Managing postacute malnutrition (undernutrition) risk.

Although a direct correlation between poor nutrition status and increased risk of readmission has yet to be established, it is reasonable to assume that patients who are identified as undernourished while hospitalized would be "at increased risk of adverse outcomes" following discharge. Also, the evidence that links nonadherence to dietary prescriptions after discharge, with increased readmissions in patients with heart failure (HF), is fairly robust. Nutrition screening prior to discharge should be mandated, just as it is at admission. However, the criteria to assess a patient's ability to adequately and appropriately nourish themselves after discharge are very different from those used to diagnose and treat malnutrition on admission or during a hospital stay. The U.S. healthcare environment germane to the readmissions rates policy that was adopted for implementation in October 2012 by the Centers for Medicare & Medicaid Services is characterized. Factors critical to the successful development and implementation of a post-acute nutrition care plan are described. Nutrition-related contributors to readmissions in HF are delineated. Transitional care models that could be adapted to enhance nutrition care plan efficacy are identified, as is the need to adopt a multidisciplinary approach to nutrition in transitional care that includes care coordination and routine follow-up. An evidence-based systematic approach to determine those patients in whom palliative vs restorative nutrition care is appropriate needs to be developed.