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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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 [email protected]
PauleBernier PresidentoftheOrdreprofessionneldesdiététistesduQuébec
RD QC [email protected]
WendyCarew PopulationHealthLead,NorthEastLocalHealthIntegrationNetwork
SystemPlanner
BridgetDavidson
CMTFDirector RD ON [email protected]
RupinderDhaliwal
DirectorofOperations,MetabolicSyndromeCanada
RD ON [email protected]
ColleenEinarson
RegionalManagerofCommunityNutritionfortheWinnipegRegionalHealthAuthority
RD MB [email protected]
ColleenEnns ExecutiveDirector,PacificNorthwestDivisionofFamilyPractice
RD BC [email protected]
CarinaFolgering
RegisteredDietitian–SeniorsHouseCallsPrimaryHealthCare
RD SK [email protected]
NanetteGiswold
RegisteredDietitian-ExtraMuralProgram
RD NB [email protected]
LeilaGoharian RegisteredDietitian RD BC [email protected]
LeahGramlich CMTFCo-chair
ProfessorofMedicineatUniversityofAlbertaandProvincialMedicalAdvisorforNutritionServicesinAHS.
MD AB [email protected]
VictoriaGray RegisteredDietitian-NovaScotiaHealthAuthority
RD NS [email protected]
HeatherKeller SchlegelResearchChairinNutrition&Aging;Professor,Kinesiology,UniversityofWaterlooResearchScientist,Agri-foodfor
RD ON [email protected]
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2018CanadianMalnutritionPrimaryCareKnowledgeExchange
Name Role Profession Province E-mail
HealthyAging,Schlegel-UWResearchInstituteforAging
CeliaLaur PhDcandidateintheSchoolofPublicHealthandHealthSystems,attheUniversityofWaterloo
Student ON [email protected]
AimieLavoie RegisteredDietitian RD QC [email protected]
MicheleMacDonaldWerstuck
NutritionProgramCoordinator,HamiltonFamilyHealthTeamAssistantProfessor,DepartmentofFamilyMedicine,McMasterUniversityChair,DietitiansofCanadaOntarioPrimaryHealthCareActionGroup
RD ON [email protected]
MelissaMercier
RegisteredDietitian RD QC [email protected]
RoseannNasser
CMTFCo-chair
ResearchdietitianintheSaskatchewanHealthAuthority
RD SK [email protected]
OnuoraOdoh FamilyphysicianandoneofthephysiciansleadingCHANGEBCprograminBC
MD BC [email protected]
CynthiaRichard
ClinicalLecturer,UniversityofWaterlooSchoolofPharmacy
Pharmacist ON [email protected]
SarahRoss RegisteredDietitian-ManitobaHIVProgram
RD MB [email protected]
CarolineSheppard
MedicalschoolattheCummingSchoolofMedicineinCalgary,Alberta
MedicalStudent
AB
VanessaTrinca ResearchAssistant-UniversityofWaterloo
Student ON [email protected]
VanessaVerkerk
ManagerPrimaryHealthCareNetwork,NorthRegina
Nurse SK [email protected]
LeslieWhittington-Carter
PublicRelationsManager—HealthSystemsforDietitiansofCanada
RD ON [email protected]
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2018CanadianMalnutritionPrimaryCareKnowledgeExchange
InviteesUnabletoAttend
Name Role Profession Province E-mail
MargAlfieri RegisteredDietitian;ChairoftheInterProfessionalHealthCouncilofAssociationforFamilyHealthTeamsofOntario(AFHTO)
RD ON [email protected]
EricaMessing RD BC [email protected]
CarolineRheaume
Medecin-chercheur MD,PhD QC [email protected]
IngridVerduyn HomeHealthandPrimaryCareRavenSongCHC
RD BC [email protected]
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.