Skip Allen drives throughout the Wilmington, North Carolina, area trying to solve a problem we’ve all heard of but may never notice.

Many people can’t afford to buy food. So, Allen, an outpatient dietitian at Novant Health New Hanover Regional Medical Center, reaches into the back of his car when he encounters someone who needs help.

“I try to never show up empty-handed,” he said. “I bring patients a food box, if they need it, which includes three to five days of food.” Those boxes, compiled and stored at the hospital, contain peanut butter, spaghetti, canned vegetables and other simple, ready-to-eat or easy-to-prepare foods.

“They’re designed for that 70-year-old who lives alone and doesn’t have a way to prepare food,” Allen said.

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Allen’s work is just one piece of a years-long effort at New Hanover Regional Medical Center to reduce food insecurity and malnutrition in the region. And thanks to all that hard work, today, the medical center is considered a national leader in the area of food insecurity and malnutrition.

Community partners are helping expand the effort, which began in 2016. Food Lion and Novant Health recently began a two-year pilot program at New Hanover to offer a “food pharmacy” to patients in need.

Through the program, Novant Health will provide qualified participants with as-needed access to free, nutritious food – donated by Food Lion – and educate patients on nutrition and healthy living.

Some patients aren’t just lacking food. They’re literally malnourished – meaning they lack sufficient nutrients and can face a variety of physical and mental impairments. It’s a disease state that places a great burden on patients, clinicians and the entire healthcare system.

“Malnutrition is an incredible risk factor for poor health outcomes,” Allen said. His role, which began as a grant-funded position (through The Duke Endowment) in 2019, became permanent in 2020.

When Allen says he meets patients where they are, he means it. He’s met his patients in pricey homes by the beach, in hotel rooms, by the woods and in a forested area behind a movie theater. In cases like those, they give him a landmark so he can find them.

Angela Lago
Angela Lago

“This is a unique position for a dietitian,” said team leader Angela Lago, clinical nutrition manager at New Hanover Regional Medical Center. “It’s not something just anyone can do. It takes a specific type of person because you’re meeting people in a variety of settings, from $2 million, oceanfront homes to wherever someone who’s homeless might live – including on the edge of the woods. And you have to do both with confidence.”

A related issue: Food insecurity

Some patients with malnutrition are also food insecure, meaning they lack consistent access to food. Through education, connections to community partners and short-term access to food – like those food boxes – Allen addresses both issues.

Patients diagnosed with malnutrition are referred to Allen by the inpatient registered dietitians when discharged from the hospital. He ensures they’re able to follow the discharge care plan they get when they leave.

“When a patient is discharged with malnutrition, they’re twice as likely to be readmitted to the hospital than a patient who’s not malnourished,” Allen said. “Their length of stay also goes through the roof,” which also adds to the cost of health care.

Allen’s primary goal with home visits is to address malnutrition and prevent a patient’s further weight loss, but “if a patient cannot get the food they need, we have to address that first, or nothing else makes sense,” he said.

The work Lago, Allen and their teammates do is highly specialized. “The areas we cover are things dietitians are specifically licensed and trained to do,” Allen said. “You couldn’t just replace the role with, say, a paramedic or community health worker because that malnutrition piece is so targeted to our skill set.”

A tremendous need, a tremendous effort to address it

In North Carolina, about 14% of the population is food insecure, meaning they’re not sure they can feed their family that day. Each month, an average of 3,000 Novant Health patients is determined to be food insecure.

Food insecurity is a serious public health issue that’s associated with birth defects, diabetes, high blood pressure, poor sleep and mental health conditions.

Dr. William Hammill, a pediatric cardiologist at Novant Health Pediatric Cardiology - Elizabeth in Charlotte, is leading the systemwide effort to address the need. Launched last January, Novant Health Nourishes begins with a couple of questions patients are asked during an office visit.

One question: Do you have enough food for today? If not, they’re given an emergency food pack that could feed them up to four days. There’s even a ready-to-eat, pop-top option for people without access to a microwave or cooking element.

The effort doesn’t stop there. The team makes referrals to food pantries that can provide more sustainable access.

Getting a diagnosis

Diagnosing a patient with malnutrition begins at hospital admission. Nurses screen for it within 24 hours of a patient’s arrival.

They do that using a simple Malnutrition Screening Tool (MST) comprised of just two questions:

  • Have you lost weight unintentionally?
  • Do you have poor oral intake due to a decreased appetite?
  • If they score a 2 or higher on that validated screening tool – which has a matrix of possible responses that carry different weights – an inpatient dietitian sees them within 48 hours. The MST is 93% effective in determining if someone is at risk for malnutrition.

    New Hanover is staffed to care for a number of malnourished patients; the hospital employs 20 dietitians. Twelve provide inpatient care, and seven are outpatient dietitians. But Allen is the only one who makes “house calls.” Their goal, Lago said, is “to bridge the gap from hospital to home.”

    New Hanover’s malnutrition diagnosis rate is 11% – and Lago believes the number of malnourished patients is actually much higher. Research indicates that between 20% and 50% of patients admitted to hospitals nationwide are either malnourished upon admission or at risk for becoming malnourished.

    During the first two days of a patient’s hospitalization, a dietitian collects a nutrition history and performs a hands-on, nutrition-focused physical exam. They’re looking for fat and muscle loss from the temples down to the calves. “Five years ago, dietitians traditionally didn’t do hands-on assessments,” Lago said. But doing a head-to-toe physical exam is an important part of diagnosing malnutrition.

    Lago’s team uses approved, national guidelines to make their malnutrition diagnoses. ASPEN (American Society for Parenteral and Enteral Nutrition) and the Academy of Nutrition and Dietetics have issued malnutrition diagnosis criteria.

    The causes of malnutrition might surprise you. It’s not always a lack of money.

    Often, it stems from substance abuse. Or it could be a disability or cognitive impairment that led to it. “Malnutrition may be an acute or chronic illness, and it can be related to environmental factors or be a disease-related illness,” Lago said. “But almost always, the person feels it was out of their control.”

    Anyone living within about 30 miles of the hospital who’s diagnosed with malnutrition, taking oral nutrition and discharged to a home setting is eligible for a home visit.

    Now, the work begins

    Allen strives to visit his patients within a week of discharge. He’ll see them as many times as they need, but traditionally his next visit is three weeks later and then again within another month or two.

    “For most patients, we need to get them food, stat,” he said. (Hence, the food boxes – and supplemental oral nutrition – in his car.)

    His goal is to get them on a path to better health – one they feel equipped to stay on. Once he’s sure they have access to healthy food, he educates them on making good choices. If a patient has diabetes, he educates them on that, too.

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    Allen’s patients welcome his visits. He thinks his Raleigh, North Carolina, roots help him make a connection and earn patients’ trust. “I've been all around this area. With every patient I meet, there's a thread of familiarity. But the real reason for the warm reception is this is usually the most chaotic experience of patients’ lives. They’re scared, and having someone come in, sit down and comfort them is a real gift.”

    Once he understands the root cause of a patient’s malnutrition, he works to solve the underlying issue. Perhaps someone needs help applying for food stamps? Allen will initiate that process. And there are other options, from Meals on Wheels to nearby senior centers and food pantries.

    Last December, Allen won Novant Health’s Sunshine Award for his lifesaving work. He’s humble about it. “It was flattering,” he said. “But the best part is that now some of the physicians who didn't know who I was are sending me referrals. It really expanded our department’s reach.”

    A national model

    Lago built New Hanover’s malnutrition program from the ground up. When she started working on the effort, it was uncharted territory. A conference she attended gave her the first tool she needed.

    She learned about the MQII (Malnutrition Quality Improvement Initiative) at a symposium in 2017 and brought it back to her team.

    MQII is a platform that allows hospitals to create their own malnutrition programs. Under Lago’s leadership, New Hanover was an early adopter of MQII. “They were helping us as we evolved this innovative process, but we were helping inform their data,” Lago said.

    The program has become a model of success. Novant Health clinicians in Charlotte and the Winston-Salem area are now screening for food insecurity and distributing emergency food boxes to patients in need.

    When Lago first started this effort, there were about 50 hospitals in the U.S. participating in MQII. Now, there are more than 300. “We’ve been the main poster child for MQII,” she said. “We’re showing hospitals across the country what’s possible.”

    Allen added: “Malnutrition is resolvable. Nutrition is one of the few things a person can control. We’re giving patients that power.”