canadian malnutrition primary care knowledge exchange report · knowledge exchange could help...

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

CanadianMalnutritionTaskForceJune1,2018Toronto,Ontario,Canada

CanadianMalnutritionPrimaryCareKnowledgeExchangeReport

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

Acknowledgements

Facilitator:ProfHeatherKeller

MeetingOrganization:BridgetDavidsonandCeliaLaur

Moderators:ProfHeatherKeller,DrLeahGramlich,BridgetDavidson,VanessaTrincaandCeliaLaur

Funding:AbbottNutrition

Report:ProfHeatherKeller,DrLeahGramlich,BridgetDavidson,CeliaLaur

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

Contents1. Background 4

2. ObjectivesoftheKnowledgeExchange 6

3. Attendees 6

4. PreparationfortheKnowledgeExchange 6

5. AbbreviatedAgendafortheKnowledgeExchange 7

6. KeyPointsfromRegionalPresentations 7

7. PriorityList 9

8. KeyPointsfromPriorityDiscussions 10

9. FinalDiscussions 19

10.NextSteps 20

Boxes:

1. HospitalMalnutrition 4

2. KeyQuestionsintheSlideTemplate 6

Tables:

Table1:AprioriIssuesIdentifiedbyAttendees 9

Appendices:

Appendix1:Attendeecontactinformation 21

References: 24

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

HospitalMalnutrition:

• 45%ofmedicalorsurgicalpatientswhostay2+daysaremalnourishedatadmissiontohospital(Allardetal.,2015).

• Contributorstomalnutritionatadmissionwere:Charlsoncomorbidityindex>2,having3+diagnoses,relyingonadultchildrenforgroceryshopping,andlivingalone(Allardetal,2016).

• 2/3ofpatientslefthospitalinthesamenutritionalstateasadmittedwhile1in5weredischargedinaworsenutritionalstate(Allardetal.,2016)

• 26%ofpatientsreportweightloss30daysafterdischarge(Kelleretal2017)

• Weightlossafterdischargewasassociatedwithbeingonaspecialdietandreportingfair/poorappetite(Kelleretal2017)

1. Background

TheCanadianMalnutritionTaskForce(CMTF),astandingcommitteeoftheCanadianNutritionSociety, isagroupofclinicians,decisionmakersand investigatorswhosemission istoreducemalnutritionbypromotingnutritioncareknowledgeandoptimalpracticethroughresearchandeducation activities focusedonpreventing, detecting and treatingmalnutrition in Canadians.Between2010–2013theCMTFconductedanational study that included eighteenhospitals from eight provinces to determinethe prevalence of malnutrition in Canadianhospitals. Other data were collected todeterminewhathappenspost–hospitalizationwithrespecttonutritioncare.

Subsequenttothestudy,CMTFengagedinavariety of knowledge translation activitiesthat raised awareness of the problem inhospitals designed to bridge the knowledgetoactiongap.Activities included: theannualCanadian Malnutrition Week campaign,dissemination of tools and resources on theweb site, training and advocacy (seenutritioncareincanada.ca). There has beensubstantial success with raising awareness of malnutrition in hospital, as well as how toprevent, detect and treat the problem. Current activities include supporting hospitals acrossCanada with implementing best practices, as well as developing hospital food standards topreventmalnutritionandunderstandingtheproblemofpaediatricmalnutrition.

Inthespringof2018,CMTFdecidedtobegintofocusonnutritioncareoutsideofhospitalasitwasevidentthatmalnutritionoftenbeganinthecommunityandthatahospitalstaycouldnotresolvethiscondition.CMTFdeterminedthatanationalknowledgeexchangewouldbeagoodstarting point for developing a research and knowledge translation agenda. Specifically, aknowledge exchange could help inform our understanding of: a) the current practices fordetectingandtreatingmalnourishedpatientsinCanadiancommunities,b)thecurrentstatusofnutrition care, barriers to care andhowpatients areprioritized. CMTFplans to leverage thisknowledge into advocacy and research activities. For this initial exchange, the focuswasonPrimaryCaredefinedasthepointof‘first-contact’care,wheremosthealthconditions/ailmentsare managed or treated (University of Ottawa accessed fromhttp://www.med.uottawa.ca/sim/data/primary_care.htm) e.g. family physician or nursepractitioner practices, community health centres and community based prevention and/ortreatment programs (e.g. falls prevention). Primary Health Care, is a more encompassingconcept includingprimarycare services,aswell ashealthpromotionanddiseaseprevention,and population-level initiatives e.g. income, housing, education, illness and injury prevention(Health Canada accessed from https://www.canada.ca/en/health-canada/services/primary-health-care/about-primary-health-care.html). Although understood as relevant to our

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

understandingofnutritionrisk/malnutritionprevention,PrimaryHealthCarewasnotthefocusoftheexchange.

CMTF Advisory Committeememberswho represent seven provinces,were asked to identifykey people they knew who had some knowledge of primary care and could link us toappropriaterepresentativestoinvitetoaone-dayknowledgeexchange.AttemptsweremadetocovermostprovincesofCanadaandinviteparticipantsfrommedical,nursing,dieteticsandpharmacydisciplines. ThePrimaryCareKnowledgeExchangewasheldon June1, 2018 from8:30a.m.-3:30p.m.atahotelclosetotheTorontoPearsonAirport.

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

KeyQuestionsintheSlideTemplate

• Howisnutritioncarecurrentlyprovidedformalnourishedpatientsintheprimarycare(community)setting?

• Whatarethegapsinyourregionfordetectingandtreatingmalnutrition?

• Whataresomenew(mal)nutritioninitiativesthatarehappeninginyourregion?

• Whatarethethreats…thingsthatmakeithardtochangethestatusquo?

• Whatcanbedonetomoveoursharedagendaofpreventingdetectingandtreatingmalnutritionforwardinyourregion?

2. ObjectivesoftheKnowledgeExchange1. TogatherknowledgeablerepresentativesfromacrossCanadatosharecurrentmodels

ofmalnutritioncareinprimarycare.

2. Todiscusscommonareasofpracticeandresourceuse,aswellasknowledgegaps.

3. TodeterminestepsthatcanbetakenbyCMTFtoimprovetheprevention,detectionandtreatmentofmalnutritioninthecommunitysector,e.g.developmentofaprimarycareworkinggroup.

4. ToidentifyopportunitiesforresearchandcollaborationacrossCanadathatcanmoveanadvocacyagendatoprevent,detectandtreatmalnutritioninprimarycare.

3. Attendees

Twenty-fourhealthcareprofessionals(2physicians,1medicalstudent,1pharmacist,2nurses,17dietitiansand2graduatestudents)attendedthesession,representingeightprovinces.Therangeofcommunityworkplacesvariedfromfamilyphysicianclinics,publichealth,homecare,toregionalandprovincialhealthauthorities(seeappendixforcontactdetails).

4. PreparationfortheKnowledgeExchange

Theparticipantswereaskedtodeveloptheirregional/provincialpresentationsusingapre-definedslidetemplatebasedonkeyquestions.

Toanswer thesequestions,participantswereaskedtocontact other provincial and community health careprofessionals to learn what was being done withrespect to nutrition risk/malnutrition care. Theexpectationwastokeepthepresentationto20minutesin length for each region. Additionally, participantssubmittedashortbiographyandaphotographtosharewith the other attendees prior to the meeting.Resources from each province were sent to thecoordinating team and assembled into a Drop-boxfolderforalltoaccess.

Theparticipantswerealsoaskedtosendinoneideaorprioritythattheyconsideredtheforemostactivitythatneeded to occur for community malnutrition to beproperly recognized and addressed. This list wascompiledwithoverlappingideascondensed,thenusedforprioritysettingduringtheknowledgeexchange.

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

5. AbbreviatedAgendafortheKnowledgeExchange

RegionalpresentationsGroup1:BC,AB,SK,MB

RegionalpresentationsGroup2:ON,QC,NS,NB

Summary/PriorityIdentification

Priorityvoting

SolutionfocusedbrainstormingonTop5Priorities

ModeratorFeedback

Wrap-up

6. KeyPointsfromRegionalPresentations

CurrentStatusof(Mal)NutritionCareinPrimaryCare

1. Malnutritionispoorlyidentifiedandtreatedinallregionsofthecountry,althoughtherearesomegroupscompletingscreeningandtreatment/serviceprovision.

2. Community-baseddietitiansarepredominatelyinvolvedinchronicdiseasemanagement(e.g.diabetes).

3. Screeningusingvalidtoolsisrare(oftenaspartofapilotorproject);exceptionswereHomeHealthandAmbulatoryCareacross6VancouverCommunityHealthUnitswhichwillberollingoutscreeninginSept2018andsomeFamilyHealthTeamsinOntario.

4. Theprevalenceofmalnutritioninthepopulationatanationallevelisunknown;someregional/singlesitestudieshavebeencompletedinprimarycareclinics(e.g.VancouverCommunityHealthCareClinics,HamiltonFamilyHealthTeametc.).

Opportunities

1. Pilotandemergingactivitiesdemonstratepotentialcapacityandinterestinmakingimprovementsin(mal)nutritioncareusingstandardizedtoolsorprocesses(e.g.riskscreening(BC),CHANGEprogram(BC),FamilyHealthTeamnutritionriskscreening(ON),StayonYourFeetprogramforfallsandnutritionscreening(ON).

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

2. Somefundingprioritieswereidentifiedthatcouldbecapitalizedtopromoteamalnutritionagenda(e.g.PrimaryCareNetworks(BC,SK),StrategicClinicalNetworks(AB),fundingforsupplementsandmealsdeliveryprograms(NB),CollaborativePracticeTeams(NS),seniors/frailty).

3. Therearediversemodelsandopportunitiesforpartnershipwithcommunityserviceprovidersthatsupportnutritionalhealth(e.g.transportation,mealprograms,recreationcentres).

4. Thereispotentialandinterestininterprofessionalcaretoaddresscommunitymalnutritionand/ornutritionrisk.Therewasrecognitionthatadietitianmaynotalwaysbethepreferredoravailableoptiontomeettheneedsofclientsandaddressrootcausesofnutritionriskormalnutrition.

5. Somemodelsofmalnutrition/nutritionriskscreeningandsubsequentcarehavebeenpiloted(BC,ON)andtherewastheviewthatafeasiblepathwaywouldgoalongwaytopromotingnutritioncare.

6. Thereisrecognitionthatlocaldataonprevalencewillstimulateinterestintheissueofmalnutritionand/ornutritionrisk.

Challenges

1. Workforceshortages(includingdietitians)thataffectcapacitytomeetcurrentneedsormoveintonewareassuchasmalnutrition.

2. Shiftinggovernanceandtransformationofhealthservices;closingofservices(e.g.Emergencyrooms(NS)).

3. Emergenceofcompetingunregulatedhealthcareproviders.

4. Knowledgegapwithrespecttohealthcareprovidersandpatientsontheimportanceofmalnutrition;attitudesandperceptionsontheimportanceofmalnutrition.

5. Geographyformanyregions(ruralandremote)resultsinlimitedorvariedservices,includingcommunityservicesthatareavailabletomeetnutritionneeds(e.g.transportation,grocerystores).

6. Diversemodelsofprimarycare,evenwithinaprovince;uncoordinatedcare.

7. Themultifactorialnatureofmalnutritionandbarrierstopreventionandtreatment(e.g.poverty,isolation,foodskillsorcapacity),healthinequities.

8. Communicationwithinandbetweenhealthsectorsforaparticularpatientthatismalnourished.

9. Malnutritionterminology.

10. Reluctancetobereferredtoadietitian.

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

7. PriorityList

A priority list formore detailed discussionwas created before the Knowledge Exchange andexpandedduringthemeeting.Theinitial list includedtheissuesorproblemsidentifiedbytheattendeespriortothemeetingthat,ifresolved,couldmoveaheadtheagendaforpreventing,detectingandtreatingnutritionriskand/ormalnutritioninthecommunity.Theseissuesweresynthesizedintoalistthatwasthebasisforvotingpriortotheafternoondiscussion.Afterthemorningpresentations,attendeeswereaskedtoaddanyfurtherissuestheythoughtshouldbediscussed (the last5 in the following list). Itemsthatarebolded in the listbelowwerevotedmosthighlybyattendeesandbecamethebasisfortheafternoondiscussion.

Table1:Aprioriissuesidentifiedbyattendees.Itemsvotedashighestprioritiesarebolded.

Lackof…• Interprofessionalmodelforpreventing,detecting,andtreating

malnutrition/nutritionrisk

• Healthprofessionalandcommunityserviceproviders’awareness/educationofmalnutrition/nutritionriskprevalenceanditsconsequences

• Physicianawareness/educationofmalnutrition/nutritionriskprevalenceanditsconsequences

• Awarenessamongthegeneralpopulation(i.e.,patients)aboutmalnutrition/nutritionrisk

• Capacitytomakenutritioncarepartofroutinepractice(e.g.,intakeforcommunityservices/programs;routinelycompletedinprimaryhealthcare)

• Accesstoprimaryhealthcaremodelsthattargetpotentiallyatrisk/malnourished(e.g.,seniorshousecallprogramwheremorepatientsarelinkedpost-discharge).

• Incentives(billingbonus)toaddressmalnutrition/nutritionrisk

• Accesstodietitians

• Integrationwithcommunitybasedservicestoprovidesolutions(e.g.programsofferedbypublichealthunitstoincreasefoodpreparationskills)

• Relevanceoftheregistereddietitian

• Research.

• Policy

• Systematicdatacollection

• Understandingontheimportanceof(mal)nutrition;whyshouldotherpeoplecare?

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

Theseissueswerethenrestatedasquestionsforattendeestoidentifypotentialsolutionsduringasmallgroupactivity.

1. Howdowegethealthpractitioners/serviceproviderstocareaboutnutrition

risk/malnutritioninthecommunity?

2. Howdowebuildcapacityfor(mal)nutritioncareinprimarycare?

3. Whatdoesaninterprofessionalmodelofcaretoaddressnutritionrisk/malnutritionlooklike?

4. Howdowegetpatientsinvolvedandawareoftheirnutritionrisk?

5. Whatarekeyresearchquestionstoadvancea(mal)nutritionagendainprimarycare?

Attendeeswereassignedtooneoffivetablestopromotediversityofideasandsolutions.Eachtablewasassignedoneoftheabovequestionstodeveloppotentialsolutions.

Astep-wiseprocess(e.g.,AffinityDiagram)wasusedtogeneratepotentialsolutions,categorizeanddevelop labels for these solutions. The teams thengenerated specific ideas for activitiesthat could move this solution into action in the next 6-12 months. Each group workedcollectivelytowardsthisgoalandthenpresentedhighlightsfromthediscussiontothegreatergroupforfurthersolutionideasandactivities.Onlythefirstsolutionthemediscussedwiththerespective6and12monthactivitygoalsisprovidedinthisreport.8. KeyPointsfromPriorityDiscussions

1. Howdowegethealthpractitioners/serviceproviderstocareaboutnutrition

risk/malnutritioninthecommunity?

• Integratenutritionintohealthpractitionereducation(formalandwhenpracticing)o Embedmalnutritionintomedicalschool,nursingandpharmacyundergraduate

educationo Integratenutritioncoursesregardingmalnutrition(causesandtreatment)into

medicalprograms,nursing,physiotherapy,occupationaltherapyandothercurricula

• Developkeymessages(“whatneedtoknow”)o Foodismedicineo Showinequities(e.g.,access)o Identifyspokespersoninthecommunity,andsharewithpeersandcolleagues,

etc.o Discusssavings($)andpatientflowinthehealthcaresystemifmalnutritionis

addressedinthecommunity

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

o Showthefinancialimpactsofmalnutritioninhospitalandinthecommunityo Showtheconsequencesof(mal)nutritionthroughdiseasesandconditionsthat

arecomorbidormalnutritionisapotentialcause(e.g.falls)o Focusmessageonteamapproachtomanagemalnutritiono Involveprofessionalassociationstobuildawarenesso Peoplewhodonothaveaccesstofoodcannotgetbetter

• Developingthestandardorgoal(“whatisdesiredpractice”)

o Conductmoreresearchonmalnutritioncareactivities(e.g.prevalence,gapsincare,outcomesofuntreatedmalnutrition)andcarryoutknowledgetranslation(whichwillinfluencekeymessages)

o Researchshowingdataonbestpractice(whichwillinfluencekeymessages)o Engagegovernmentorregulatorybodiesindevelopingstandardo Linkingittoincentives(financialorother)

• Developinganintegratedcommunicationstrategy(“howtocommunicate”)

o Picknursing,physicianandpharmacychampionso Developmalnutritionawarenessintomediacampaigno Involvearockstarorvocalwell-knownfigureintheissueo RaiseawarenessthatmalnutritionexistsinCanadainpeopleofallageso Encouragechampionstotalkwithteams,colleaguesandpatientso Text,email,sharemalnutritionresearch,evidenceandeffortso Healthcarepracticeawarenesscampaign,anddisseminatekey

statistics/prevalenceo DevelopdocumentariestobebroadcastonnationalTVonmalnutrition,the

research,costsrelated,andinterventionso Integrate(mal)nutritionawarenessintoexistingcommunityprogramssuchas

cookingclasses,lifestyleclasses,healthylivingclasseswithasectiononmalnutrition

o Conferencesforhealthpractitionerso Sharepatientstorieso Shareoutcomedataonmalnutritionscreeningo Targetfamilymembersandpatientcommunitiestoidentifynutritionriskand

supporttreatmento Createadepotofresources/evidencetoshareo Createadvocacycampaigntargetingclinicians,government

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• Havingthesolutionprocessor“nextstep”readyafterawarenessoftheissuehasbeenraised

o Systematicassessmentgiventohighriskgroupse.g.olderadultso Evaluateresearchandprocesso Researchonhowtoscreeno Whatisthetrade-offifstartingsomethingnew?

• Buildingpartnershipswithbuy-in

o Proximity,interprofessionalclinicworko MeetingsbetweenRDandserviceprovidero Linkkeygroups(HealthQualityOntario,OntarioCollegeFamilyPhysiciansetc.)o Linkwithotherprovincialandcommunitygroups(e.g.mealprogramproviders)o Createmalnutritionnetworksforclinicianso “Sell”ofworko Includepublic/patientvoiceo Involvepractitioners(otherthandietitians)tospeakaboutmalnutritiono Shareresearchfindingsatnon-dietitianconferences,exhibitionsandmeetings

TopPriority 6-MonthActions 12-MonthActionsDevelopkeyhealthpracticemessages

• Reviewmessagesfromotherkeyorganizationsfocusedonprimarycaremalnutrition

• Developcommunicationsstrategicplan→developmessages,andtoptargetsforcommunication

• ComebacktoCMTFPC-KEmembersforinput,andtonarrowdownkeymessages

• GatherCanadianinsightsfromhealthpractitionersonhowtotargetmalnutrition,whattheyneedtohearandhow/whattheyalreadyknow

• Reviewoftheevidence(potentiallyjustCanadianevidence)

• Identifythe“what’s”tocommunicatefromtheevidence

• Developaknowledge,attitudesandpractices(KAP)surveyforprimarycareproviders

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

2. Howdowebuildcapacityfor(mal)nutritioncareinprimarycare?

• What:o Bringawarenessofimportanceo Bringknowledgetokeystakeholderso Elevatetheimportanceofmalnutritionamonggeneralpractitionersthrough

socialmediao Educateconsumersonmalnutritionprevalencewiththeirfamilyphysiciano Developapublicrelationscampaigno Useavarietyofknowledgedisseminationstrategieswithinandacrossdisciplineso “Brand”(mal)nutritiono Uselocal/nationaldatatotellastoryo Digestdata.Donotshowerotherswithdatao Tiedatatoactionsoropportunitieso Demonstratethefinancialimpactofmalnutritiono Showtheimpactofnutritioncare(research)o Usedatathatisthereandapplytoyourrealityo Find“what’sinitforme”foreachpublicaudienceo Providefundingforservicesandpersonnel(e.g.moreFTEregistereddietitians)o Advocateattheprovinciallevelfortheimportanceofnutritioncareo Amulti-facetedpublicrelationscampaign(evidenced-based,varietyof

knowledgeusers;includingpublichealthcareprofessionalsanddecisionmakers)• How:

o Developworkstandardstoaddressmalnutritiono Nutritionscreendonebymultipleprofessions(e.g.pharmacy,nursing,MD,RD,

etc.)o Createstandardlistofresourcesinthecommunityo HavequalityindicatoraboutnutritioncareinLongTermCare(LTC),acutecare

andthecommunityo Developasimpletoolkitforscreeningandnutritioninterventiono Educatepublic/healthcareworkersontheconsequencesofmalnutritiono Identifyandspecifyscreeningstandardsformalnutritiono Teachlearners(e.g.students,residents)onnutritionservicesavailableand

potentialtoimprovemalnutritionbothinclassandinpracticeo Teachmultiplehealthcareprovidersaboutnutritionserviceandcareo Startsmallthenspreadsuccesso Focusonhighriskpopulations(e.g.seniors)o Identifyvulnerablepopulationso Usetop-down-bottom-upstrategieso Havemandatorypolicyforsafermalnutritioninhomecareo HaveaministrypolicyforscreeningandtreatingmalnutritioninLTC

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

o Haveministrypolicyforpatientsafetybasedonmalnutritioninacutecareo Haveministrypolicyforpatientsafetybasedonmalnutritioninthecommunityo Providefinancialincentives(orotherincentives)forprovidingnutritioncareo Createtool-kit–screening,communityresources,strategiesinsupportofpolicy

andidentifyvulnerablepopulations• Who

o Actlocal,thinklocal(buildingnationalcapacity)o Sharegoodideasandpracticeso Buildonexistingcapacity,orcurrentactivitieso Workwithanationalcommunityofapproacheso Identifytargetaudiences/publico Findpatientrepresentativesaschampionso Findhealthcarechampionso Developprogramsthatbringpeopletogetherformealso Buildandappointchampionsforchangetodriveaccountabilityo Getprofessionalcollegesinvolvedo Targetapproachestodietitianso Targetapproachestodoctorso Targetapproaches(messages)forleaders/managerso Identify/mobilizethecommunityofpractice,withauniquefocuson:RDs,MDs,

decisionmakers,andotherhealthcareprofessionals,andalsodefinechampions/roles

TopPriority 6-MonthActions 12-MonthActionsPublicrelationscampaigntomobilize

• Gatherinformationinprimarycareregardingcodeofpractice

• Brand• Defineandrefinecodeof

practice• Createpull/need• Politicalawareness• Identifyknowledgeusers

• Createneed• Disseminatelectureseries

o CanadianMalnutritionWeeko Localinserieso Mixnationalandlocal

3. Whatdoestheinterprofessionalmodelofcaretoaddressnutritionrisklooklike?

• Settingthestagewithstakeholderengagement/whatdoeseachstakeholderbring?

o Determinestakeholderstoincludeinthemodelo Establishpatient-centredcareasoverallpracticeo Buildmodelwithstakeholderso Determinewhomakesuptheinterprofessionalteamo Understandwhetherthemodelwillbeusedbystakeholders

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

o Definetargetaudienceformodel(whatriskwillweaddress?)o Decidehowsuccesswillbemeasuredo Definethegoalofcarethattheteamshareso Communicateregularlywithwholeteamthroughouto Createbuy-infortheprocess–whyshouldtheycareo Educatingallteammembersonnutrition(whyitmatters)o Determinewhichtools/initiativesinprimarycarecanbebuilton(orstartfresh)

§ E.g.CHANGEorINPACorOntarioalgorithmo Decidewhowillleadtheinitiativeo Gethighlevelsupportandapprovalo Confirmtheroleofeachmemberastheyseeit,andhowtheyperceiveit(gap

analysis)

• Nationallydefinethecomponents/tool-kitdevelopmento Identifynutritionriskscreeningtooltouse(e.g.,SCREENII)o Whowillscreenthepatients(patientvs.familyvs.healthcareprovider)o Screeningatintakebyanyprovidero Simplifystandardassessmento Embednutritionquestionsintoallproviders’careo Usestandardquestions/formso Connectpatientstocommunityresourceso Communityparticipationandprogramso Standardreferralprotocolo Educateallteammembersonprocesso Decidewhatlevelofeducationothersprovidevs.whatanRDprovideso Createawarenessofmalnutritionriskwithteamo Prioritizemalnutritionriskassessmento Educateteamarounddiseaseconditionso Makeincorporatingnutritionriskinbasiccaremandatoryo Availabilityandaccessibilityofdietitiansontheteamo Provideevidencethatanutritionriskmodelisbestpracticeo Whatevidence-basedpracticesshouldoccurafterscreeningo Developtoolstosupportnutritionalinterventions

• Evaluateandpublish

o Identifypatientgoalsforcareo Patientvoiceandeducationonmalnutritiono Provideguidancetohealthprofessionalsonadditionalstepsifriskcontinueso Decidehowsuccesswillbemeasuredo Collectdatausingagreed-onmethods

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

o Pilotmodel(withprimarycareproviders)o Enablebuildingandgeneratingstrategieso Brainstormpossibilitiesforimplementationo Communicateregularlywithteamregardingsuccess/failures/barrierso Validatemodelo Standardfollow-upofclientsindifferentsettingso Buildawarenessofexistenceofamodelo Createbuy-infortheprocess,whyshouldtheycare?

TopPriority 6-MonthActions 12-MonthActionsEngageandconvincestakeholders

a. Definecomponentsofamodel

b. Developtoolkit,evaluateandpublish

• Collecttools• Gapanalysis• Pooltoday’sfindings

(fromPCKE)• Develop“strawdog”tool

kit

• Convenenational,interprofessional/publicgroupsofstakeholders

4. Howdowegetpatientsinvolved,andawareoftheirnutritionrisk?

• Educationofpatientso Showthemlocalstatistics/incidenceo Educationregardingthebenefitsofnutrition(increasedhealingtimes,decreased

hospitalstayetc.)o Educatepatientsonrolenutritionplaysandhowitcanreducerisko “MeetyourRD”–explaintheroleofthedietitian

• Engagingalliedhealth

o Integratingnutritionintoclinicalcarepathways(e.g.CHF,COPD)o Settingpatientcentredgoalsaspartoftheircareo Includingnutritionaspartoftheirhealthmanagementplan/careplano Createopportunitiesforfollowuptoseeprogresso InvolvetheirfamilyMD(oralliedhealth)whocaninfluencepatientso SimplifyprocessforfamilyMDsto“nudge”patientso Provideeasytouseresourcestoassessrisk

• Removestigma

o Removestigmaaround“mal”nutritiono Removestigmabyclarifyingtheroleofnutrition

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

o Change“malnutrition”toapositivewordo Createaburningplatformthatshowswhyhealthyeatingisimportanto Sharepatient(s)stories

• Connectingwithexistingorganizations

o Identifypotentialareaswherepatientcanfallthroughthesystemo Createcommunityorvolunteerpartnershipsforongoingsupporto Workwithmultiplepartnerstoprovidebettertransitionofcareo Starttheeducationwithnutritioninschools.Startwithyoungpeople

• Empoweringpatients/patientengagement/questionsforpatientsusetoasktheirMD

andRDo Empowerpatientsonhowtheycanmakeadifferenceo Encouragepatientstoadvocateforthemselveso Createpatient-ledrevolutiontofocusonaddingyearstoliveso Understandingwhatpatientprioritiesareo Createpatientfriendlytoolstoeducatethemo Useoftechnology(app)totrackriskovertime

• Increasingpublicawareness/communicatingtothepublic

o Usepatientstorieso OfferpublicawarenessadsonnutritionduringNutritionMonth(similarto

Participaction)o Socialmediastrategyo Publicawarenessthroughsocialmediao Createeducationcampaignregardingnutrition(similartosmokingcessation)

TopPriority 6-MonthActions 12-MonthActionsEducatingandempoweringpatients

• Developa“tagline”(motivationalandpersonal)

• Identifyasnapshotofwhatisavailable,andwhathasbeendone

• Askpatientswhatmatterstothem• Identifyprivateandpublic

partners(beingawareofpotentialconflictsofinterest)

• Findphysicianchampions• Workwithrelevantpartners• Developacommunicationplan• Developingideasforwaysfor

patientstoadvocateforthemselves

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

5. Whatarekeyresearchquestionstoadvancea(mal)nutritionagendainprimarycare?

• Riskfactors,prevalenceandpopulationsaffectedbymalnutrition

o Whatistheprevalenceofnutritionrisk/malnutritionbyprovince?o Whatdoesnutritionrisk/malnutritionlooklike;whatarethecharacteristicsof

patients?o Whataretherootcausesofnutritionrisk/malnutritionincommunityliving

individuals(lowintake,lowincome,etc.)?o Whatarethecurrentresearchgapsin(mal)nutritioncare?Systematicreviewof

theliteratureo Whoismostatriskofmalnutrition(keyriskfactorstotargetscreening)

• Perceptionsofmalnutrition

o Healthprofessionals’perceptionofmalnutritiono Whataretheperceptions,behavioursandattitudesofprimarycarephysicians

towards(mal)nutrition,screeningandintervention?o Howdogenderrolesand“profiling”playaroleinphysicianscreeningand

interventionfornutrition?

• Who,whenandhowtoscreeno Wheredowescreen?(e.g.ERs,familyphysician’soffice)o Whenshouldscreeningbedone?o Wherewouldbethebestplacetodonutritionrisk/malnutritionscreening?

(hospital,homecare)o Whoshoulddothescreening?o Whoshouldbescreened?o Howcan(mal)nutritionstatusbetrackedatanationallevel?Flagofcharts

enteredinCIHIo Whattoolshouldbeusedtoidentifyorscreenformalnutrition/riskinprimary

care?o Whattools/resourcescurrentlyexist(national/international)thataresuccessful?o Whatarethemosteffectivemethodsforincreasing/implementingpractice

changeinprimarycare?Interviewsandauditso Whatcommunityresourcesexist?

• Effectiveinterventionstopreventandtreatnutritionrisk/malnutrition

o Howcanmedicaleducationbeimprovedtopromote(mal)nutritionscreening?Intervention?

o Howcanongoinggapsinnutritioncarebeidentifiedovertime?Implementationofauditandfeedbackinprimarycare

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

o Whatsupports/resourcesdopeoplewhoaremalnourishedfeeltheyrequire?o Whatshouldbedonewhennutritionriskand/ormalnutritionisidentified?o Whatarethemosteffectiveinterventionsfortreatingmalnutrition?o Whatarethemosteffectiveinterventionsforpreventingmalnutrition

upstream?o Howmuchwouldwesavethehealthcaresystembydecreasingnutrition

risk/malnutrition?o Whatisthecost-effectivenessof(mal)nutritionscreening?

TopPriority 6-monthActions 12-monthActionsRiskfactors,prevalenceandpopulationsaffectedbymalnutrition

• Systematicreviewofcurrentliteratureo Scopingreviewlookingat

prevalence(primaryoutcome)andriskfactorsandpopulations(secondaryoutcome)

• Subgroupanalysistodeterminemethodsusedbyothercountriestodetermineprevalenceandriskfactors

• Determinegapsinliterature,andmulti-stakeholderworkinggroups

• Conductamulticentrepilotproject(includingruralandurbanareas)forprevalence,riskfactorsandpopulationsaffectedacrossCanadao Fromthis,alsodetermine

costsofnutritionrisk/malnutritiononhealthcare,andhowmuchmoneycanbesavedthroughprevention.

9. FinalDiscussions

Aseachgrouppresentedtheirsolutionsandpotentialearlyactionstoaddresstheproblemtheywereassigned,furtherideasarose.ItwasnotedthattargetingCMTFeffortstoprioritygroupsinthepopulationmightbeagoodplacetostartwithapplyinganyoftheidentifiedsolutions.Specifically,patientsjustdischargedfromhospital,olderadults,andcurrentprimarycareclinics(e.g.memory clinics, falls prevention clinics etc.) were considered good areas to focus earlyattentionwith respect to preventing, detecting and treatingmalnutrition. Itwas also notedthattheInterRAIincludesnutritionitemsandthisstandardizedassessmentandcareprogramisbeingmandatedforuseinhomecareinmanyregions.ThisraisedtheopportunityofworkingwithInterRAItodevelopscreeningtriggersformalnutritionbeyondthecurrentitemsthatareavailable.

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

10. NextSteps

Thefollowingstepswillbe/weretakenasaresultoftheCMTFPrimaryCareKnowledgeExchangemeeting:

1. Attendeesandinviteeswereprovidedacopyofthisreport.Theyprovidedfurtherclarificationorfeedbackonaspectsofthereportresultinginthisfinalversion.

2. CMTFwillestablishaprimary/communitycareworkinggroupin2018/2019tobeginworkingtowardssomeoftheprioritiesidentifiedintheknowledgeexchange.

3. Theorganizingcommitteewillspearheadapeerreviewedpublicationbasedontheknowledgeexchangeresults.

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

Appendix

AttendeesoftheCanadianMalnutritionPrimaryCareKnowledgeExchange

Name Role Profession Province E-mail

MarlisAtkins NutritionServicesDirectorinAlbertaHealthServices

RD AB Marlis.Atkins@albertahealthservices.ca

PauleBernier PresidentoftheOrdreprofessionneldesdiététistesduQuébec

RD QC pbernier@opdq.org

WendyCarew PopulationHealthLead,NorthEastLocalHealthIntegrationNetwork

SystemPlanner

ON wendy.carew@lhins.on.ca

BridgetDavidson

CMTFDirector RD ON bdavidson@cns-scn.ca

RupinderDhaliwal

DirectorofOperations,MetabolicSyndromeCanada

RD ON rupinder@metsc.ca

ColleenEinarson

RegionalManagerofCommunityNutritionfortheWinnipegRegionalHealthAuthority

RD MB ceinarson@wrha.mb.ca

ColleenEnns ExecutiveDirector,PacificNorthwestDivisionofFamilyPractice

RD BC cenns@divisionsbc.ca

CarinaFolgering

RegisteredDietitian–SeniorsHouseCallsPrimaryHealthCare

RD SK carina.folgering@saskhealthauthority.ca

NanetteGiswold

RegisteredDietitian-ExtraMuralProgram

RD NB Nanette.Giswold@horizonnb.ca

LeilaGoharian RegisteredDietitian RD BC Leila.Goharian@vch.ca

LeahGramlich CMTFCo-chair

ProfessorofMedicineatUniversityofAlbertaandProvincialMedicalAdvisorforNutritionServicesinAHS.

MD AB lg3@ualberta.ca

VictoriaGray RegisteredDietitian-NovaScotiaHealthAuthority

RD NS victoria.gray@nshealth.ca

HeatherKeller SchlegelResearchChairinNutrition&Aging;Professor,Kinesiology,UniversityofWaterlooResearchScientist,Agri-foodfor

RD ON hkeller@uwaterloo.ca

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

Name Role Profession Province E-mail

HealthyAging,Schlegel-UWResearchInstituteforAging

CeliaLaur PhDcandidateintheSchoolofPublicHealthandHealthSystems,attheUniversityofWaterloo

Student ON cvlaur@uwaterloo.ca

AimieLavoie RegisteredDietitian RD QC aimie.lavoie.ciussscn@ssss.gouv.qc.ca

MicheleMacDonaldWerstuck

NutritionProgramCoordinator,HamiltonFamilyHealthTeamAssistantProfessor,DepartmentofFamilyMedicine,McMasterUniversityChair,DietitiansofCanadaOntarioPrimaryHealthCareActionGroup

RD ON mmwerstuck@gmail.com

MelissaMercier

RegisteredDietitian RD QC melissa.mercier.ciussscn@ssss.gouv.qc.ca

RoseannNasser

CMTFCo-chair

ResearchdietitianintheSaskatchewanHealthAuthority

RD SK Roseann.Nasser@saskhealthauthority.ca

OnuoraOdoh FamilyphysicianandoneofthephysiciansleadingCHANGEBCprograminBC

MD BC nicod.prayer4sure@yahoo.ca

CynthiaRichard

ClinicalLecturer,UniversityofWaterlooSchoolofPharmacy

Pharmacist ON c25richard@uwaterloo.ca

SarahRoss RegisteredDietitian-ManitobaHIVProgram

RD MB sross4@exchange.hsc.mb.ca

CarolineSheppard

MedicalschoolattheCummingSchoolofMedicineinCalgary,Alberta

MedicalStudent

AB

VanessaTrinca ResearchAssistant-UniversityofWaterloo

Student ON vtrinca@edu.uwaterloo.ca

VanessaVerkerk

ManagerPrimaryHealthCareNetwork,NorthRegina

Nurse SK vanessa.verkerk@saskhealthauthority.ca

LeslieWhittington-Carter

PublicRelationsManager—HealthSystemsforDietitiansofCanada

RD ON leslie.whittingtoncarter@dietitians.ca

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

InviteesUnabletoAttend

Name Role Profession Province E-mail

MargAlfieri RegisteredDietitian;ChairoftheInterProfessionalHealthCouncilofAssociationforFamilyHealthTeamsofOntario(AFHTO)

RD ON margalfieri@icloud.com

EricaMessing RD BC Erica.messing@viha.ca

CarolineRheaume

Medecin-chercheur MD,PhD QC Caroline.rheume@fmed.ulaval.ca

IngridVerduyn HomeHealthandPrimaryCareRavenSongCHC

RD BC Ingrid.verduyn@vch.ca

FourguestsfromAbbottNutritionalsoattendedtheKnowledgeExchange:AnneDumas,SeniorManagerMedicalAffairs;CharlesAddington,SeniorProductmanager;NadiaDubuc,Marketingmanager;MariaKarounis,DirectorofMarketing.

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2018CanadianMalnutritionPrimaryCareKnowledgeExchange

References

Allard,J.P.,Keller,H.H.,Teterina,A.Jeejeebhoy,K.N.,Laporte,M.,Duerksen,D.etal.Factorsassociatedwithnutritionaldeclineinhospitalisedmedicalandsurgicalpatientsadmittedfor7dormore:aprospectivecohortstudy.BJN.2015,114(10),1612-1622.

AllardJP,KellerH,JeejeebhoyKN,LaporteM,DuerksenD,GramlichL,PayetteH,BernierP,VesnaverE,DavidsonB,TerterinaA,LouW.Malnutritionathospitaladmission:contributorsandimpactonlengthofstay.AprospectivecohortstudyfromtheCanadianMalnutritionTaskForce.JParenterEnteralNutrition.2016;40(4):487-97.

CurtisL,BernierP,JeejeebhoyKN,AllardJP,DuerksenD,GramlichL,LaporteM,KellerH.Costsofhospitalmalnutrition,ClinicalNutrition.2016.doi.org/10.1016/j.clnu.2016.09.009

KellerH,AllardJ,VesnaverM,LaporteM,GramlichL,BernierP,etal.Barrierstofoodintakeinacutecarehospitals:AreportoftheCanadianMalnutritionTaskForce.JHumNutrDiet.2015;28(6):546-557.

KellerH,LaporteM,PayetteH,AllardJ,BernierP,DuerksenD,GramlichL,JeejeebhoyK.Prevalenceandpredictorsofweightchangepostdischargefromhospital:astudyoftheCanadianMalnutritionTaskForce.EurJClinNutr.2017Jun;71(6):766-772.