Can regular meals make a difference in well-being?
Two Texas Health Dallas nurse practitioners say that they can, but not just because of nutrition.
Stephanie Lindsey, M.S.N., R.N., AGNP-BC (above right), and Rincy Thomas, M.S.N., R.N., AGNP-BC (above left), led a pilot program to provide free Meals on Wheels to qualified patients who are about to be discharged.
The patient must be a Dallas County resident over 65, with food insecurity or unable to afford food or prepare meals, and meet criteria set by the Visiting Nurse Association of Texas (VNA), which provides the meals and the drivers to deliver them.
The pilot program is a collaboration between Texas Health Dallas, VNA and UT Southwestern Medical Center.
Once the discharged patients are receiving the hot, fresh meals five days a week, the patients also get a weekly phone call from Stephanie or Rincy.
“We want to focus on prevention,” said Rincy. “When we are calling and talking with them we can focus on something, even small things, so we can prevent them from coming back to the hospital.”
The patient gets a visit from the same Meals on Wheels driver every day.
“The driver asks the same set of questions with each delivery, and if there’s a problem the driver calls us so we can contact the patient right away,” said Stephanie.
The benchmark questions include topics such as “are you feeling better, the same, or worse than when you were discharged?” and “are you eating all of the meals?” If the patient doesn’t answer the question affirmatively, Rincy or Stephanie refer them to needed services.
The program has a clinical goal, but is also an effort to support Consumer Focus.
“We want to create a relationship with them, even after the discharge, so they feel like there is someone still caring for them even if they are not in the hospital anymore,” said Rincy. “They remember us from when they were in the hospital and we still care afterwards.”
Since the pilot started in September, 29 Texas Health Dallas patients have participated in the Meals on Wheels program. Only one has had to be readmitted, and the nurse practitioners credit the program with five “saves.”
In one “save,” a diabetic patient was experiencing nausea and diarrhea and was considering returning to the emergency room within a week of discharge.
When the patient told the Meals on Wheels driver she was not eating and was not taking her medications, a nurse practitioner stepped in
and encouraged the patient to follow up with her primary care physician (PCP). The nurse practitioner also suggested bland meals, supplemented with Gatorade, until the PCP visit. The doctor prescribed an antibiotic and adjusted the patient’s insulin. The patient’s condition improved, and she did not require a readmission.
In another case, the nurse practitioner learned a Meals on Wheels patient had been the victim of financial exploitation which drained her bank account. The nurse practitioner contacted the patient’s emergency contact and her daughters, so they could take steps to prevent future exploitation. The patient was moved to an assisted living facility.
The nurse practitioners have learned a lot from the pilot. “Not everyone eats three meals a day. That was a big eye-opener for me,” said Rincy. The patients tell me they are so glad to get these meals.”
And the program welcomes referrals from Texas Health Dallas employees if they have a patient in need.
“We hope to create a better relationship with our community partners to improve tracking of people being released from the hospital and skilled nursing facilities to improve the care continuum for vulnerable patients, especially seniors,” said Stephanie. “The aim is to reduce hospital readmission rates, improve health outcomes, and help patients age in their homes.”
Rincy Thomas, M.S.N., R.N., AGNP-BC and Stephanie Lindsey, M.S.N., R.N., AGNP-BC
by Larry DeBoever • Posted July 31, 2018
