About one in five participants in Older Americans Act (OAA) programs may be at risk for malnutrition, based on a recent analysis of data from the 2022 National Survey of Older Americans Act Participants.
That survey screened for malnutrition risk (MR)—specifically, risk of protein-calorie malnutrition (PCM)—using the Malnutrition Screening Tool, which is based on self-reported unintentional weight loss and decreased food intake due to poor appetite. The community-based Older Americans Act Nutrition Program (OAANP) helps to reduce malnutrition risk by providing congregate and home-delivered meals, as well as additional referrals for nutrition services and health-related social needs to millions of older adults nationwide. However, stronger connections are needed to better identify older adults at MR and improve links to appropriate nutrition and health services.
Why Identify Malnutrition Risk?
The substantial societal and indirect costs of PCM in older adults include increased morbidity and disability, lower quality of life, higher healthcare costs, and more. Addressing malnutrition is important for the Food is Medicine movement as well because appropriate nutrition is fundamental to maintaining overall well-being, preventing and managing various diet-related diseases and conditions, and reducing the need for medical care.
In the United States, some OAANPs are making progress in forging stronger connections between existing community-based programs and clinical health services.
Community-living older adults with MR often go unrecognized due to lack of existing standardized malnutrition screening methods, which limits further assessment of PCM, and if it is present, development of a person-centered plan with interventions directed at root causes. Other limitations include gaps in coordinating nutrition care across clinical and community settings. For example, patients at malnutrition risk often leave the hospital or rehabilitation facility without receiving guidance on addressing their nutrition at home. Appropriate nutrition assessment, individualized nutrition interventions and community-level follow-up are vital to ensure MR is addressed.
Community Nutrition Services Are Underused
Malnutrition can result from lack of adequate food but also is often disease-related, requiring interventions beyond a home-delivered or congregate meal, such as medical care and nutrition counseling. According to federal reporting for FY2022 only 1% of the total OAANP participant population received dietitian-provided nutrition counseling and 48% of States/Territories reported that their OAANP had no individuals receiving nutrition counseling.
Thus, despite findings that PCM may exist in approximately 20% of OAANP participants and nutrition counseling services that yield positive results among older adults in the community, such services appear to be underused.
Models for Strengthening Malnutrition Risk and Care Connections
The Center for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (DHHS) has approved an inpatient malnutrition quality measure, which follows evidence-based guidance to support malnutrition care in the hospital. Yet the United States still lacks a national, formal framework that connects MR and care across clinical and community settings.
Several countries have developed robust community-based malnutrition identification and treatment pathways that could serve as models. One of these is from Canada, which has developed evidence-based nutrition care pathways and guidance linking institutional clinical services to primary care providers and community programs.
Here in the United States, some OAANPs are making progress in forging stronger connections between existing community-based programs and clinical health services. One source for such models is the DHHS Administration for Community Living (ACL) grant projects. ACL projects, some of which are described below, leverage community program infrastructures to implement and coordinate innovative and responsive malnutrition care pathways linking to clinical expertise and to launch other initiatives such as unique IT systems to help fill gaps and resolve disconnects. Note: MR identified across these projects may include PCM as well as other types of malnutrition.
- CONNECT Study, Academy of Nutrition and Dietetics (2023–2028): This project aims to establish a replicable model to provide coordinated post-discharge nutrition care by a Registered Dietitian Nutritionist (RDN) who follows older adults from the hospital to home, in coordination with local OAA programs, to improve dietary intake, reduce malnutrition, and enhance health outcomes. Data is transferred from the hospital’s electronic health record to the Academy of Nutrition and Dietetics Health Informatics Infrastructure (ANDHII) portal.
- Addressing Malnutrition in Community Living Older Adults, Toolkit for Area Agencies on Aging, Maryland Department of Aging (2019): This project outlines a stepwise approach for OAA Area Agencies on Aging to identify and manage older adult MR by offering free or low-cost community programs to address the root causes of malnutrition, providing access to Medical Nutrition Therapy, and by establishing partnerships with healthcare organizations that provide funding for community-based service delivery.
- Health and Hospital Corporation of Marion County Indiana (2023–2028) This is a project to develop a customized toolkit for OAA Area Agencies on Aging to address malnutrition in older adults living in the community by including screening for and addressing social determinants of health, communicating effectively with healthcare partners regarding MR, and ensuring robust sustainability of the project.
The results of the projects to date suggest that stronger malnutrition care links are feasible and can be successful, and that existing OAANP assets can be leveraged for broader implementation across the aging services network. They highlight opportunities for OAANP and healthcare organizations to catalyze public/private resources and implement evidence-based service approaches to combat MR and provide optimal malnutrition care among older adults living in the community.
The problem of poorly coordinated and non-standardized approaches to dealing with MR and medical care in community-living older adults can be solved. Steps taken today to build stronger collaborations and funding supports between key partners in the community and medical care services and to develop nationwide pathways of MR identification and care will have positive impacts on health and may also lower healthcare costs.
Judy Simon, MS, RDN, is a consultant with the National Association of Nutrition and Aging Services Programs and Defeat Malnutrition Today; Shirley Chao, PhD, RDN, LDN, FAND, is the principal at FoodPolicy Insights; Laura Borth, MS, RDN, CD, is director of policy with the National Association of Nutrition and Aging Services Programs and Defeat Malnutrition Today; Lydia McGrath, MS, RD, LDN, is a clinical dietitian at Brigham and Women’s Hospital; Jaime Gahche, MPH, PhD, is director of the population studies program with the National Institutes of Health (NIH) Office of Dietary Supplements; Johanna T. Dwyer, DSc, RDN, is senior nutrition scientist, ICF (contractor to the NIH Office of Dietary Supplements), professor of Medicine and Community Health at the Schools of Medicine and Nutrition and senior scientist at the Jean Mayer USDA Human Nutrition Research Center at Tufts University; and Mary Beth Arensberg, PhD, RDN, LDN, FAND, is director of Health Policy and Programs at Abbott Nutrition, a division of Abbott.
