Development of Outpatient Nutrition Risk Prediction Tool to Prevent

Diabetes Related Hospitalizations

Brittnee Williams, Dietetic Intern, James A. Haley Veterans’ Hospital
Chelsey Armendinger, RD, LD/N, Ambulatory Care Nutrition Section Chief, James A. Haley Veterans’ Hospital

Background Project Aim and Purpose Conclusions and Recommendations

Ambulatory Care Sensitive Conditions (ACSC) are conditions for
which early intervention and quality outpatient care can potentially
prevent disease complications and hospitalizations. Hospitalization for
complications of ACSC is therefore an indicator used to examine the
quality and accessibility of health care1. The Agency for Healthcare
Research and Quality maintains a list of 13 Prevention Quality Indicators
that can be used with hospital inpatient discharge data to identify quality
of care for ACSC1. The Veteran’s Health Administration uses 12 of these
sets of measures for their ACSC model2, three of which are directly
related to complications of diabetes mellitus (DM). Just as diabetes
affects a disproportionately large percentage of the Veteran population,
diabetes related ACSC hospitalizations are responsible for a significant
section of ACSC admissions3,4. Therefore, this area has been identified
as an opportunity for increased efficiency at James A. Haley Veterans’
Hospital (JAHVH) and Veterans Integrated Service Network (VISN) 85.
Early identification and proactive care for those at increased nutritional
risk can help to lower hospital admissions associated with ACSC, raise
quality of care indicator and improve the health and quality of life
outcomes for the Veterans served by JAHVH.
The aim of this project was to identify characteristics and themes
among Diabetes-related Ambulatory Care Sensitive Conditions to
reduce the number of inpatient admissions by proactively assisting
Veterans in managing their diabetes in the outpatient nutrition setting.
The purpose of this project was to use characteristics and themes
identified among Veterans hospitalized for diabetes complications for
the development and implementation of a proactive risk prediction tool.
Methods
• A retrospective chart review was conducted from October 2017 to
January 2018.
• There were a total 211 ACSC diabetes related hospitalizations of
JAHVH Veterans from July 1, 2016 to July 1, 2017.
• ACSC hospitalizations were defined as hospital discharge diagnosis
codes relating to complications from uncontrolled Type 1 or Type 2
Diabetes.
• An interactive tool was then created by our Data Acquisition &
Analytics Service to be implemented in the outpatient nutrition setting.
• Identification of high risk patients seen at routine primary care
appointments increases Veteran access to care.
• By using this tool, the team Dietitian can quickly evaluate all
patients scheduled to be seen in the clinic for prioritization and
coordination of same day, walk-in appointments with the dietitian.
• Encounters with a dietitian in the outpatient setting can aid the
Veteran in managing their diabetes or pre-diabetes and potentially
prevent future complications and associated hospitalizations.
• Early identification of nutrition intervention opportunities related to
disease management provides for more proactive, timely and
focused nutrition care with improved outcomes and better access to
care.
• Tool training and implementation is scheduled to begin May 2018.
• Validation of this tool is needed to help to assess its effectiveness in
improving patient access and outcomes.
• Future analysis of individual encounters may also help to identify
the most effective nutrition interventions for the management of
diabetes and prevention of diabetes related hospital admissions.

Outpatient Dietitian Diabetes Nutrition Risk Identification Tool

Appt Date of Last Blood
Patient Name Age Appointment Type Existing Diagnoses Associated with Diabetes Risk of Hospitalization A1c BMI LDL
Date/Clinic Appointment Pressure
1/5/2001 Nutrition Individual Appt (123) Anemia Atherosclerosis/cardiomyopathy
5/14/2018 Nutrition Group Appt (124) Diabetes Mellitus/Prediabetes Heart failure
MOVE! Group Appt (373) Malnutrition Peripheral vascular disease 29.5
Last, First 65 MOVE! Individual Appt (372) Overweight/Obesity Chronic obstructive pulmonary disease 9% H (overweight/ 131/84 H 101 mg/dL H
PCA-Alpha 1/5/2001 Diabetes (306) Hypercholesterolemia/hyperlipidemia Gastroparesis obese)
Clinic Hypertension Cirrhosis of liver
Findings Chronic Kidney Disease Patient's noncompliance

ACSC DM Admission Details References

Prevalence of Diabetes at JAHVH
Top Discharge Diagnosis Codes % of admissions Age (yrs) Uniques Admissions 1. Prevention Quality Indicators Overview. AHRQ - Quality Indicators.
https://qualityindicators.ahrq.gov/Modules/pqi_resources.aspx. Accessed September 28, 2017.
20-29 2 2 2. Ambulatory Care Sensitive Conditions. Veterans Health Administration Office of Productivity, Efficiency & Staffing.
No Diabetes
T2DM w/ Hyperglycemia 34% 30-39 7 13 http://opes.vssc.med.va.gov/ACSC/Pages/default.aspx. Accessed Sept 28, 2017.
Diabetes 28% 3. Diabetes Latest. Centers for Disease Control and Prevention. https://www.cdc.gov/features/diabetesfactsheet/.
40-49 10 14 Published June 17, 2014. Accessed September 29, 2017
34% 4. Management VHAM. Veterans Health Administration. Close to 25 percent of VA Patients Have Diabetes - Veterans
T2DM w/ hypoglycemia w/o coma 12% 50-59 32 41 Health Administration. https://www.va.gov/health/NewsFeatures/20111115a.asp. Published November 15, 2011.

Prediabetes 60-69 68 76 Accessed September 29, 2017.

5. Strategic Analytics for Improvement and Learning Report. Veterans Health Administration VISN (Veterans Integrated
T2DM w/ foot ulcer 10% 38% 70-79 44 48 Service Network) Support Services Center.
http://reports2.vssc.med.va.gov/ReportServer/Pages/ReportViewer.aspx?%2fMgmtReports%2fVATR%2fSAIL_Prod%
80-89 14 15
Other 44% 2fSAIL&rs:Command=Render Accessed September 28, 2017.
90-99 2 2
Thank you to our Data Acquisition and Analytics Service for their support and assistance throughout
Total 179 211 the duration of this project!