Not your grandfather's hospital food: Health systems make meals part of population health

Visitors to New Milford (Conn.) Hospital don't need to ask for directions to the hospital's newly renovated cafeteria because the healthy food eatery opens right into the main lobby.

The lobby and cafeteria were relocated and redesigned when the 85-bed hospital completed renovation of its emergency department in late 2014. Hospital leaders set out to make the cafeteria a focal point of nutritional wellness for the entire community.

The cafeteria's chefs tout their “Plow to Plate” approach, serving healthy, locally sourced meals. They have eliminated processed and fried foods, and regularly consult with local farmers and suppliers to create seasonal menus.

“I see people come in for lunch and breakfast who are regulars because the food is so good,” said Damon deChamplain, administrative director at New Milford Hospital. They “just know it's a good hot meal that's very reasonably priced.”

As more care is shifted to outpatient settings, New Milford is one of a growing number of hospitals seeking new revenue opportunities by making food service operations appealing to the broader community rather than only to people visiting patients.

And in another important shift in food service operations, hospitals send chefs and dietitians into the community to help improve residents' health and assist with the management of post-acute patients.

Health systems are introducing the innovations partly to maintain customer volume for food service operations as they face pressures to shift care to lower-cost outpatient settings and find new revenue sources. Administrators say their inpatient meal volume has remained largely unchanged so far. But they recognize that will change as outpatient care grows. That means attracting more retail customers for dining.

“The shift from inpatient to outpatient really required us to create a world-class retail experience with recognizable brands,” said Gary Crompton, president of Healthcare Hospitality at Aramark, a provider of healthcare food services. “Our approach to the retail space in this new world is actually to be better, from a value and quality standpoint, than what (the public) can get on the street.”

Aramark is not alone. Sixty-four percent of food service operators surveyed in FoodService Director magazine's 2015 Hospital Census said their hospital retail-meal counts had increased during the past two years.

Hospitals served an average of more than 1,000 retail meals a day last year, up 2.9% from the year before. Those meals accounted for 58% of all meals served at hospitals that reported offering both retail and patient food services.

At New Milford, the new cafeteria and its locavore philosophy seems to be paying off. So far, the hospital has exceeded its retail revenue projections by 12%, said Tim Bouchard, vice president of the Healthcare Culinary Group at Unidine, which operates New Milford's cafeteria as well as food service operations at about 30 hospitals across the country.

Boston-based Unidine has been growing at a rate of about 24% over the past five years, thanks in large part to retail growth, Bouchard said.

Hospital food service operations are also playing a growing role in population health management. They are deploying dietitians into the community, using dietary education to reduce the risk of heart disease, diabetes and other conditions.

Unidine hosts a variety of events, including farmers markets, chef demonstrations, wellness seminars and community meals for the elderly and disadvantaged in the communities served by its client hospitals.

Bouchard said his company's dietitians have also organized grocery-store tours to help community members learn how to shop for healthier food.

“We're switching to a more community-based program,” Bouchard said. “From a clinical perspective, you see more teaching needing to be done, not just at the bedside, but also in the community.”

When the Cleveland Clinic closed Huron Hospital in East Cleveland in 2011, it replaced the hospital with an outpatient facility—the Stephanie Tubbs Jones Health Center, which features an “Iron Chef” teaching kitchen. There, patients and community members learn how to cook meals using less salt, sugar and fat.

Every cooking class at the new health center includes a nutritional education component that focuses on the importance of reducing ingredients like saturated fats and carbohydrates and their impact on heart disease, diabetes and other chronic conditions. From 2012 to 2014, the Iron Chef kitchen hosted 36 classes with nearly 600 participants, according to a Cleveland Clinic spokeswoman.

The kitchen is also used for healthcare research. This past year, it was the site of a six-week study examining whether dietary education, culinary classes and other lifestyle programs can delay or prevent the progression of pre-diabetes to diabetes.

At Intermountain Healthcare, the system's dietitians and chefs regularly teach healthy cooking in local TV news segments and at community events, said Laura Watson, director of patient support services at the 22-hospital system based in Salt Lake City. That's part of Intermountain's community wellness initiative called LiVe Well.

Retail-oriented food services at Intermountain's hospitals also have been an effective vehicle for community dietary education, Watson said. Hospital chefs create healthy plates accompanied by recipe cards so that visitors can make the dishes at home.

“It's been a nice platform for us to support the mission of the system with great, healthy food and education and training about nutrition,” she said.

There is evidence that New Milford Hospital's Plow to Plate sustainable-food education initiative, launched in 2006 by pediatrician Dr. Diane D'Isidori, has improved the health of local children. A study of 148 kids begun in 2012 found that after they were involved in the program for three years, the percentage who were obese or at risk of obesity dropped.

Health system leaders are also emphasizing the key role dietitians can play in outpatient care.

Intermountain has shifted many of its dietitians to outpatient and primary-care settings to enable them to provide dietary counseling quickly after patients receive a diagnosis that requires them to change their diet, Watson said.

The Academy of Nutrition and Dietetics has called on healthcare leaders to better integrate dietitians into emerging delivery models such as patient-centered medical homes. “The overall health of our population depends on the nutrition community taking actions and providing coordinated and comprehensive care that focuses on the needs of the individual,” Bonnie Jortberg, a registered dietitian and professor of family medicine at the University of Colorado-Denver, and Dr. Michael Fleming, chief medical officer at home health and hospice provider Amedisys, wrote in an article in the December 2014 Journal of the Academy of Nutrition and Dietetics.

Registered dietitian nutritionists, they continued, “are uniquely experienced and positioned to be one of the critical healthcare professionals in our U.S. healthcare model of today and the future.”

Dietetics is one of several comprehensive services that should be added to the primary-care settings of the future, said Amy Gibson, chief operating officer of the Patient-Centered Primary Care Collaborative, an advocacy group for the patient-centered medical home model. A value-based health system will put more focus on non-physician services that can help patients manage their conditions. “Dietary is usually a big issue when it comes to chronic conditions,” she said.

In hospitals, dietitians generally do not have the opportunity to provide the continuous care that is needed to prevent readmissions, said Theresa Han-Markey, a dietetics administrator at the University of Michigan in Ann Arbor. “When we're talking about trying to change someone's diet, it takes more than a 10-minute conversation with them,” she said. “It's about follow-up. Dietitians in a hospital don't follow up with a patient when they get out of the hospital.”

With that in mind, the U-M Health System has doubled its staff of ambulatory-care dietitians in the past two years, with 60 dietitians now working in clinics, Han-Markey said. Those dietitians meet with patients during post-discharge medical appointments and monitor patients' nutrition status via follow-up phone calls.

U-M dietitians are participating in a study of care for patients with congestive heart failure, a target group with frequent hospitalizations. They are hoping that putting patients on a low-sodium diet will improve their heart health and keep them out of the hospital.

“Patients with heart failure know what they're supposed to do,” Han-Markey said. “But there hasn't really been somebody devoted to working with them on how to make it a reality.”