KEY PARAMETERS

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Population targeted: Home delivered meal program participants

Geographic setting: Urban, rural and frontier communities

Service delivery setting: Client homes

Services offered: Care coordination, nutrition-focused home visitation and care planning

Number of staff/FTEs dedicated to innovation project: 1.35

Total grant funds received: $240,096

Total project period: Two years (2017 – 2019)

Total funding leveraged from organization (cash/in-kind): $145,862

BRIDGING HIGH QUALITY MALNUTRITION SCREENING, 

ASSESSMENT, AND INTERVENTION FOR OLDER ADULTS FROM 

HOSPITAL TO HOME: IMPACT OF NUTRITION HOME VISITATIONS

PROJECT PURPOSE

To demonstrate an evidence-based relationship of targeted nutrition home visitation assessments and care 

planning on the health outcomes of recently discharged home delivered meal (HDM) recipients at malnutrition risk. 

PROJECT LENGTH

• Two years

PROJECT COMPONENTS

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Nutrition-focused home visitation program

Care coordination and care transition services

SUCCESSES AND LESSONS LEARNED

Successes

• The development of study protocols, training in-services and resource materials were essential to the 

development and implementation of a home visitation model. Malnutrition referral protocols were devised in 

collaboration with the area agency on aging (AAA) partners as well as the University of Utah Hospital and 

Clinics, considering each partner’s unique situation. 

ORGANIZATION:

University of Utah 

School of Medicine

ADMINISTRATION FOR COMMUNITY LIVING INNOVATIONS IN NUTRITION PROGRAMS AND SERVICES CAPSTONE SERIES

ABOUT US

The University of Utah School of Medicine combines excellence in teaching, research, and clinical expertise 

to train tomorrow’s physicians for the rapidly changing world of medicine. With a faculty of more than 1,000 

physicians and researchers and 22 clinical and basic science departments, the School of Medicine trains the 

majority of Utah physicians, and is widely recognized for interdisciplinary research in the genetics of disease, 

cancer, biomedical informatics, infectious diseases, and other areas of leading-edge medicine.

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SUCCESSES AND LESSONS LEARNED, CONT.

Successes

• A home visitation model was developed, and is modifiable for implementation in diverse care settings, to 

address the nutrition care of older adults. This model includes a detailed assessment form that can easily 

be tailored to the individual site and older population receiving nutrition services. 

Lessons Learned

• Recruitment was the most significant project challenge. To gain more insight into recruitment barriers, project 

staff began to regularly attend staff meetings and gathered in-depth information and conducted detailed 

analysis of the recruitment process. Through trial and error various improvements were tested and 

implemented and, recruitment was enhanced. 

PROJECT IMPACT

• The most significant impact of this project was the improved understanding of malnutrition by health services 

workers, clients and their families and caregivers. This improved understanding included the multiple causal

factors for malnutrition and the differentiation between assessment and screening. An enhanced 

understanding of the risks and health impact of malnutrition, and the need for malnutrition assessment to 

address this risk, elucidated the need for coordinated services. 

ADVICE FOR PEERS

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The recruitment process was the most challenging aspect of administering the project. Introduction and 

incorporation of a new protocol, project staff representation at staff meetings of all partner organizations, 

required in-depth discussion and planning taking into consideration the demanding work schedules for all 

involved. Organizations are advised to develop a deep understanding of the organizational structure of each 

project partner and ensure the development and implementation of a project plan with the appropriate

distinct task allocations for optimal project coordination and oversight support. Ongoing assessment and

re-evaluation of project structure and protocols, and incremental adjustments as indicated, can optimize 

project effectiveness. 

Creation of the team-based recruitment processes that were not routine for the partner organizations required

the introduction of added staff responsibilities. This meant team input and buy-in was essential to recruitment 

success. Regularly scheduled staff meetings were found to be helpful in resolving these issues. 

This project was supported, in part by grant number 90PPNU0001 from the U.S. Administration

 for Community Living, Department of Health and Human Services, Washington, D.C. 20201

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