Overcoming rural barriers to good health and nutrition is an important policy focus area, with rural areas facing greater nutrition risks. More than 1 in 5 older Americans live in rural areas, spanning from Appalachia and the Mississippi Delta to the Oklahoma Panhandle and Native reservations. A new article in OBM Geriatrics outlines how quality malnutrition care can help improve rural health outcomes and health equity for older Americans so they can enjoy a high quality of life in their later years by staying active and fully engaged in life.

Rural hospitals provide essential care and can be a connection point for services. More than half of all US hospitals are in rural areas and a large portion of primary care occurs in rural hospitals as there are fewer primary care providers--3/4 as many--as in urban areas. Many older adults prefer to stay in their homes as they age, but many rural areas lack capacity to connect rural older adults to their needed services. For example, there are more limited  transportation options compared to urban areas, which can limit options for buying fresh and affordable food and accessing other services. Older adults in rural communities are at a higher risk of malnutrition too as they have higher rates of poverty, multiple chronic health conditions, and more disabilities vs older adults in urban communities. Unsurprisingly, the highest rate of hospitalization for malnutrition occurs in rural areas.

Malnutrition is linked to health disparities and the US Centers for Medicare and Medicaid Services (CMS) has commented, "One factor contributing to the burden of malnutrition is health disparity across racial and ethnic groups." The needs of people in rural communities are as diverse and broad as their populations, with 60 of the 100 most marginalized counties being rural ones on Tribal lands or in Southern regions with large Black populations. Additionally, 9 out or 10 of the top 10 US counties with the highest food insecurity rates are rural.

Malnutrition Quality Measurement can help address health equity in rural areas

Many of the health and nutrition obstacles faced by rural health care providers and their patients are unique but addressing malnutrition through quality measurement can yield benefits in health outcomes and health equity. Starting this year, a Global Malnutrition Composite Score is included in the Centers for Medicare & Medicaid Services' (CMS) Hospital Inpatient Quality Reporting Program. This health-equity focused measure can help address healthcare disparities in and outside the hospital. The Composite measure will be available for hospital reporting in 2024. The Composite measure was included in the National Quality Forum's most recent key rural health measures list to advance rural health priorities. The Composite measure could also help rural hospitals meet The Joint Commission's new requirements to reduce health care disparities.

The Global Malnutrition Composite Score measure is made up of 4 components of the nutrition care process—malnutrition screening, nutrition assessment, malnutrition diagnosis, and a nutrition care plan and is supported by the Malnutrition Quality Improvement Initiative tools and resources. This measure was developed by the Academy of Nutrition and Dietetics and Avalere Health to measure quality malnutrition care delivered to patients ages 65 and older in the inpatient setting. Implementation of the Composite measure starts with initiating malnutrition quality improvement. In a rural setting this process can be enhanced by taking a collaborative approach, gaining administration buy-in, education, and tackling care transitions.

Local Community Partners for Action

With each rural area requiring a unique approach, community partners have the critical knowledge to best understand the community and help address malnutrition. Partnerships can be particularly successful if a rural hospital takes a creative approach in seeking solutions to overcome access limitations. One approach is partnering with community health and wellness organizations. For example, Cooperative Extension professionals have identified the need to work with hospitals and doctor's offices to support improved health and local county Cooperative Extension Offices are often one of the few programs in rural communities to provide public education on healthy eating and nutrition. To address food access issues, there may be opportunities for rural healthcare providers to establish stronger partnerships and referral systems with local food banks. Other national programs that can help support improved nutrition for older adults across communities include:

• Commodity Supplemental Food Program (provides food packages to income eligible older adults through local agencies)
• Older Americans Act (OAA) congregate/home delivered meals programs (not income specific)
• Medicare Advantage programs which may offer coverage of home delivered meals for specified time periods post hospital discharge
• Rural PACE (Program of All-inclusive Care for the Elderly) programs which may include meals in the services provided

With the many pressures rural healthcare providers must address, it may seem there is a limited bandwidth for improving malnutrition quality care. The MQii and the Global Malnutrition Composite Score measure can help ease the burden of providing care with frameworks for developing malnutrition quality improvement programs in rural healthcare. With the unwinding of the Public Health Emergency and the reduction of SNAP benefits, these frameworks will be essential to identifying and intervening for those at malnutrition risk. The Defeat Malnutrition Today coalition is developing a range of resources in 2023, to help enhance community partnerships to improve malnutrition quality care. You will see more news about these opportunities in the coming months.

Suzanne Fleming, MS, RDN, LD, Clinical Dietitian at McPherson Hospital

Bob Blancato, MPA, National Coordinator at Defeat Malnutrition Today