Impact of implementing a Rapid Access Dietetic Service to Care homes during COVID-19

ABSTRACT

Background: In the UK, 38% of people residing in care homes are estimated to be at high risk of malnutrition1 and it is known now that nutritional status can further be negatively affected by COVID-19 not only directly through medical complications but also social factors such as social isolation, staffing issues, increased anxiety and low mood2. Our aim is to evaluate the clinical and cost effectiveness of direct dietetic input (Rapid Access Dietetic Service) to care homes during the COVID-19 pandemic. Methods: During the first wave of the Covid-19 pandemic, a rapid access service to support care homes was set up, accepting referrals directly from the care home staff and offering a remote dietetic assessment within 1 week of referral. Patients at high risk of malnutrition / on ONS were followed up as part of a 12-week care pathway. The 12-week pathway consisted of initial and last telephone/video consultation by the dietitian and monthly telephone follow ups in between by the dietetic assistant. Care home staff were provided remote training on ‘Food First’ malnutrition management and ONS prescribing. Outcomes audited were MUST, clinical outcomes (number of falls, pressure sores, chest and UTI infections, hospital admissions, A&E attendance in the last 3 months) pre and after 12-week pathway. Cost benefit analyses were performed on both clinical outcomes and ONS changes. Service evaluation was done by requesting GP / care staff and community dietitians’ feedback. Results: 54 patients were referred by the care homes staff/GP, 24 of those because of medium/high risk of malnutrition, 30 referred for ONS review. Out of the patients who were medium/high risk (n = 24) and were onboarded onto the 12-week care pathway, the number of patients with MUST of 0 (low risk) increased 8-fold, patients with MUST of 1 (medium risk) increased 2.3 times and patients with MUST of 2 or above (high risk) declined by half after the 12-week care pathway. Cost benefit analysis on clinical outcomes showed combined estimated cost savings of £26,061 (Table 1). Out of the patients on ONS, 11 prescriptions were changed, 5 were stopped, 13 were continued resulting in a total ONS annualised savings of £12,753 / £425 per patient. The service was evaluated by the community dietitians, care staff and GPs and positive feedback was provided. [Formula presented] Discussion: Despite being an existing service, significant adaptations were made in order to continue providing care throughout the COVID-19 pandemic. All interactions and engagement with GPs and care home staff were conducted remotely in place of the usual in-person service. Despite this change, marked improvements in patient malnutrition status were seen during the 12-week care pathway. Cost benefit analysis show a combined annualised cost saving of £38,814 during the 6-month intervention from the ONS changes and clinical outcomes. This equates to an annualised cost saving of £77,628 and £718.7 per person referred. The service was highly valued by the care home staff, GPs and community dietitians as evidenced by the positive feedback received. Limitations include other possible factors may have influenced the results e.g. medications/other HCP involvement. Annualized savings for ONS changes and clinical outcomes were estimated based on savings achieved in the 6 months over the service was running. The cost of dietitian was not included as a pre-existing service was altered during the pandemic months prioritizing care homes. Conclusion: The new rapid access service for care homes resulted in residents being seen quickly and appropriately treated for malnutrition where identified. The service also resulted in significant cost savings for ONS prescriptions and avoidance of healthcare costs associated with malnutrition. Continuation of this new service model should be considered to reduce the incidence of malnutrition and effectively manage those identified as malnourished. References 1. Nutrition Screening Survey in care Homes in the UK A report based on the amalgamated data from the four Nutrition Screening Week surveys undertaken by BAPEN in 2007, 2008, 2010 and 2011 C A Russell and M Elia on behalf of BAPEN and collaborators 2. Azzolino D, Saporiti E, Proietti M, Cesari M. Nutritional considerations in frail older patients with COVID-19. The journal of nutrition, health & aging. 2020 Jul;24696-8. 3. National Schedule of Reference Costs 2017/2018 4. Dealey C, Posnett J, Walker A. The cost of pressure ulcers in the United Kingdom. J Wound Care. 2012 Jun;21(6)261-2, 264, 266. 5. British National Formulary – National Institute for Health and Care Excellence -