Food as Medicine: Examining the Role of Nutritional Assessment in Chronic Wounds

Nutrition’s impact on wound healing is well recognized by clinicians, although researchers continue to seek better understanding of the connection it has on the development of more evidence-based protocols. Research priorities of the National Pressure Ulcer Advisory Panel, the European Pressure Ulcer Advisory Panel, and the Pan Pacific Pressure Injury Alliance include almost every area of pressure injury assessment and treatment, including nutrition.¹ Until more research becomes available on the role of nutritional care for wound healing, evidence suggests the importance of screening for malnutrition, calculating resting energy expenditure and calorie needs, and monitoring intake of essential nutrients.² Hippocrates, the Father of Western Medicine, said long ago, food can be considered “medicine” when healthy eating acts as a natural drug. Through appropriate consumption of protein, calories, fluids, and vitamins and minerals, wound care clinicians can help their patients maintain (and improve) nutritional status, which will support skin integrity. While nutritional screening and intervention can help correct deficits, and therefore improve outcomes for wound patients, these services can be an increasing challenge for wound care professionals to deliver. Under healthcare reform’s value-based model, documentation of nutritional screening and intervention is often required to maximize reimbursement from Medicare. In some cases, payments for services may be completely denied without documented nutritional screening and intervention. This article will discuss the impact of overall nutrition (as well as malnutrition) on wound care and provide appropriate referral guidelines for wound care clinicians to consider when collaborating with nutrition experts.

Comprehensive Nutritional Care For Wound Healing

Nutritional screening, assessment, and care planning for patients living with pressure injuries is recommended.¹ Screening tools are recommended as part of the U.S. Wound Registry’s “Quality Measures in Wound Care,” which apply to the Physician Quality Reporting System.³ The first step in the screening process should involve implementation of a questionnaire that helps identify malnutrition or risk for malnutrition. There are several validated nutritional screening tools available,⁴ including the Nestlé Mini Nutrition Assessment (MNA^®). Nutritional screening can be implemented by any healthcare professional in any medical setting. Any individual who is found to be at risk of malnutrition, or to be actively experiencing malnutrition, should be referred to a registered dietitian — aka, registered dietitian nutritionist (RDN) — for follow up. Nutritional assessment, intervention, and monitoring and evaluation by an RDN can help correct undernutrition (including deficiencies of calories, protein, and micronutrients), dehydration, and weight loss. It can also help manage hyperglycemia, which may improve wound healing.^5,6 Many patients living with chronic wounds will also present to the clinic with comorbidities such as diabetes or renal disease that require the clinical judgment of an RDN to develop safe, effective plans for nutritional care. 

Unfortunately, many wound clinics have limited or no access to RDNs. As a result, comprehensive nutritional care may be overlooked. A lack of reimbursement for services can also be a barrier to nutritional care. However, nutritional services for renal disease, diabetes, and obesity can be reimbursed through Medicare Part B or private insurers (under specific circumstances).⁷ In many cases, comprehensive nutritional care is considered an out-of-pocket expense. It’s good standard of care for all wound care providers to collaborate with an RDN for their chronic wound patients. In the case of hyperbaric oxygen therapy (HBOT) and debridement, nutritional care could be the difference between reimbursement and denial of a Medicare claim. According to guidelines established by the Centers for Medicare & Medicaid Services (CMS), HBOT must be used in addition to standard wound care and is covered as an adjunctive therapy only after there are no measureable signs of healing for at least 30 days of treatment with standard wound therapy.⁸ Standard wound care includes “optimization of nutritional status” and “optimization of glucose control.”⁸ Referral to an RDN can help patients meet those goals. Currently, Medicare is testing prior authorization of services for HBOT in three states: Illinois, New Jersey, and Michigan. Timely and appropriate intervention and documentation of services as outlined by CMS can help prevent authorizations from being denied.⁹ For example, payers have denied payments for debridement and authorizations for offloading mattresses due to a lack of documentation of  “optimization of nutritional status” — drilling down into the definition of standard wound care. Denials for these types of services are expected to rise.

Identifying Malnutrition

The definition of malnutrition (undernutrition) has changed in recent years in a way that will ultimately affect its diagnosis and treatment. In 2012, a joint consensus statement was released by the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition. The statement outlined characteristics recommended for the identification and documentation of adult malnutrition, identifying three etiology-based definitions of malnutrition:¹⁰

1. starvation-related, such as in anorexia nervosa;
2. chronic disease-related, such as in organ failure, pancreatic cancer, rheumatoid arthritis, or sarcopenic obesity; and
3. acute disease- or injury-related, such as major infections, burns, trauma, or closed head injury.

Individuals living with pressure injuries or other chronic wounds could fall into any three of these categories. The consensus statement suggests malnutrition should be identified when two or more of the following six characteristics exist: insufficient energy intake, weight loss, loss of muscle mass, loss of subcutaneous fat, localized or generalized fluid accumulation, and diminished functional status as measured by hand-grip strength.¹⁰ The consensus statement reinforces the role of serum proteins (albumin and prealbumin) as indicators of inflammation that rise and fall in response to changes in underlying acute and chronic conditions rather than indicators of nutritional status.¹¹ The identification of malnutrition using the etiology-based definition and the aforementioned six criteria is a dynamic work in progress. As it continues to evolve it will undoubtedly change the way Medicare, Medicaid, and private insurers identify and reimburse for treatment of malnutrition. Currently, a low serum albumin and/or prealbumin remain one indicator of malnutrition for many payer sources.

Referral Guidelines For Nutritional Wound Care

There are more than 89,000 RDNs in the United States,¹¹ but identifying an RDN with expertise in wound healing who is also available to support a wound clinic can be a challenge. Many RDNs in private practice develop a clinical specialty, but few specialize in wound care. When seeking the collaboration of an RDN, wound care clinicians should consider those who will provide nutritional assessment, intervention, monitoring, and evaluation. Educational counseling and take-home materials that will assist patients and their caregivers should also be made available. RDN service should provide a support system that produces a well-educated patient and medical team, leading to greater adherence to prescribed therapies and more successful outcomes. Criteria for referral to an RDN might include:

• malnutrition or the risk of it as identified by a malnutrition screening tool;
• significant weight loss in 30 or more days;
• poor wound healing or stalled wound healing;
• poor intake of food and/or fluids and/or poor tolerance of enteral nutrition; and/or
• abnormal lab values that might indicate nutritional risk.

To initiate referral services, staff in the wound care clinic may be required to produce the following information:

• physician-signed referral form; 
• patient demographic information;
• history and physical;
• laboratory results, including a comprehensive metabolic panel and prealbumin; and/or
• recent notes related to patient’s wound care.

Once referral services have been secured, clinicians in the outpatient center should anticipate the following services be provided: 

• in-depth nutrition assessment; 
• patient education with emphasis on the importance of nutrition in wound healing;
• nutritional recommendations in the form of a personalized plan based on patient-specific dietary needs; 
• clinical monitoring of wound healing progress and, when necessary, re-evaluation for enteral and/or parenteral nutrition; and
• documentation, including patient correspondence and clinical notes sent to the wound care center to satisfy CMS and accreditation requirements.

One Referral Source: Nutritional Healing

Nutritional Healing, LLC (Nashville, TN) is an available resource that provides a service in which referred patients undergo a systematic process of evaluation and care that starts with an RDN and a board-certified nutrition support pharmacist conducting an in-depth nutritional screening. Comorbidities are also evaluated and a three-day food record from the patient or family member is obtained, which allows an estimate of calorie and protein intake. An individualized patient assessment that includes an analysis of nutritional screening, history and physical, laboratory results, and wound notes is also completed. Additionally, a plan of care, which may include recommendations for changes in diet and/or oral nutritional supplements, is developed. Four weeks after recommendations for changes in diet and/or oral nutritional supplements, labs are drawn and wound notes are analyzed to assess healing progress. If the wound is not progressing, the plan of care is modified and may include recommendations for enteral nutrition or parenteral nutrition to supplement oral intake. During nutritional treatment, the RDN maintains contact with the patient and/or the caregiver to provide education and assess the patient’s ability to meet nutritional goals. The referring clinician receives a copy of the RDN’s clinical notes, including individualized patient recommendations and pertinent interactions with the patient and caregiver. Nutritional recommendations are individualized and consider patients’ lifestyle and socioeconomic status, as well as their goals of care. 

For example, a patient who requires additional protein and has a limited income might receive low-cost ideas to increase the protein content of his/her diet. In other cases, oral nutritional supplements might be the best option to meet increased needs. Because the relationship between the clinics and the RDNs is part of a wound care center’s “continuum of care,” there are no special requirements related to HIPAA, and no patient consent forms or signatures are required for services. This may also eliminate the need for business associate (BA) agreements, depending on the nature of the business relationships involved. For example, if the relationship is between the patient and the RDN, there is no BA relationship between the RDN and the clinic. If the relationship is between the clinic and the RDN, a BA relationship may be triggered. (For more clarification, consider consulting with a HIPAA compliance consultant.) Nutritional screening assessment services are not billed to the patient, clinic, or payers. The process is designed to meet payer qualifications for potential revenue-producing therapies (eg, enteral feedings, durable medical equipment, infusion services), which are covered by most payers, including Medicare. According to Mark DeLegge, MD, FACG, CNSP, AGAF, FASGE, a board-certified gastroenterologist with a specialty in nutrition, some patients appear to be consuming adequate protein but still live with nonhealing wounds — possibly related to the inability of the liver to synthesize protein or absorb it during the inflammatory process.¹² In these cases, he considers alternate feeding regimens (such as enteral or parenteral nutrition) as a useful adjunct to oral nutrition in some individuals.

Over time, DeLegge has come to believe the benefits of supplemental nutrition therapy can outweigh any risks related to enteral nutrition or temporary parenteral nutrition. The gut is the preferred route to treat malnutrition, but a small percentage of patients don’t absorb nutrients and can benefit from supplemental parenteral nutrition. For those patients, targeted nutritional therapy is something that can make a difference in the healing of wounds.

Summary

Most healthcare experts agree food can be used as “medicine” to correct nutritional deficiencies and, as a result, to assist in healing wounds. Nutritional screening can help identify nutritional problems, improve patient outcomes, and maximize payments from Medicare for reimbursable procedures. Comprehensive nutritional assessment and intervention by an RDN should be individualized and take into account comorbidities, lifestyle, and socioeconomic status. Barriers to good nutritional care for patients living with wounds include lack of direct reimbursement for nutritional services and lack of access to RDNs. There are resources available for wound care clinicians to partner with nutritional care services. 

Liz Friedrich is a registered dietitian nutritionist and president of Friedrich Nutrition Consulting, Salisbury, NC. Stephen G. Bergquist is the medical director of a wound management center in Jackson, TN. He is also a section editor for WOUNDS research journal in addition to being an active speaker and educator. He may be reached at drb@nutri-heal.com.  

References

1. Haesler E. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Cambridge Media: Perth, Australia; 2014.

2. Little MO. Nutrition and skin ulcers. Curr Opin Clin Nutr Metab Care. 2013;16(1):39-49. 

3. U.S. Wound Registry. CDR 20: Process Measure: Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers Process Measure: 2016. Accessed online: www.uswoundregistry.com/specifications/uswr%2020.pdf 

4. Dorner B, Posthauer ME, Thomas D, National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. Adv Skin Wound Care. 2012;22(5):212-21. doi: 10.1097/01.ASW.0000350838.11854.0a.

5. Tsourdi E, Barythe A. Rietzsch H, Reichel A, Bornstein SR. Current aspects in the pathophysiology and treatment of chronic wounds in diabetes mellitus. BioMed Res Int. 2013. Epub 2013 Apr 7.

6. Lioupis MD. Effects of diabetes mellitus on wound healing: an update. J Wound Care. 2005;14(2): 84-6.

7. Academy of Nutrition and Dietetics. Who Pays for Nutrition Services. Accessed online: www.eatrightpro.org/resources/practice/getting-paid/who-pays-for-nutrition-services

8. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Hyperbaric Oxygen Therapy (20.29). Accessed online: www.cms.gov 

9. Gelly H. Understanding and responding to prepayment reviews for hyperbaric oxygen therapy. TWC. 2015;9(9):12-3. 

10. White JV, Guenter P, Jensen G, Malone A, Schofield M, Academy of Nutrition and Dietetics Malnutrition Work Group. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). J Acad Nutr Diet. 2012;112:730-8.

11. Commission on Dietetic Registration. Number of Registered Dietitians by State.  Accessed online: www.cdrnet.org/certifications/number-of-registered-dietitians-by-state 

12. Friedrich L, Bergquist SG. Oral interview. Mark DeLegge. 6 Sept 2016