Essential connections: The impact of a hospital-to-community referral intervention on nutrition care and health outcomes in older adults with malnutrition: A hybrid type 2 implementation effectiveness study protocol

BACKGROUND: Malnutrition among hospitalized older adults in the United States is a growing public health concern associated with poor quality of life, increased mortality, higher readmission rates, and loss of independence. Addressing malnutrition is hindered by limited continuity of nutrition care from hospital to home and a shortage of community-based registered dietitian nutritionists (RDNs). To address these gaps, the Academy of Nutrition and Dietetics developed an enhanced referral model that supports coordinated, data-driven nutrition care after hospital discharge by securely sharing electronic health record data through the Academy's Health Informatics Infrastructure (ANDHII) with community RDNs for medical nutrition therapy and meal provision. The present study aims to: (1) assess implementation feasibility of the enhanced referral model; (2) identify barriers to and facilitators for implementing the model; (3) determine if there is an increase in the proportion of patients ≥ 60 years with malnutrition being offered MNT and meal provision in the community compared to baseline; (4) evaluate whether the enhanced referral model is effective in improving participants' quality of life, food security, and measures of malnutrition compared to usual care. 

METHODS: This study will use a hybrid type 2, implementation effectiveness, pre-post study design. Eight acute care hospitals and community meal provision organization pairs will participate. Over 35 months, sites will enroll a total of 1,120 participants; each site will enroll participants under usual care (routine clinical care and practices provided to patients at each site as the control), then transition to the enhanced referral intervention model using a step-wedge schedule. Quantitative data of descriptive statistics and effectiveness outcomes will be analyzed using SPSS. Qualitative data will be analyzed using a coding reliability approach to thematic analysis, guided by validated implementation framework, to identify barriers, facilitators, and feasibility. 

DISCUSSION: We hypothesize that adopting the enhanced referral model will improve the continuity of nutrition care, increase the utilization of MNT and meal provision, improve food security, reduce malnutrition-related characteristics, and improve quality of life in older adults. The results could provide evidence to expand RDN care for older adults in the community setting.