Interdisciplinary communication and collaboration as key to improved nutritional care of malnourished older adults across health‐care settings – A qualitative study

Abstract Background Malnutrition is a risk factor for impaired functionality and independence. For optimal treatment of malnourished older adults (OA), close collaboration and communication between all stakeholders involved (OA, their caregivers and health‐care and welfare professionals) is important. This qualitative study assesses current collaboration and communication in nutritional care over the continuum of health‐care settings and provides recommendations for improvement. Methods Eleven structured focus group interviews and five individual interviews took place in three regions across the Netherlands from November 2017 until February 2018, including OA, caregivers and health‐care and welfare professionals. Various aspects of collaboration and communication between all stakeholders were discussed. Interviews were transcribed and analysed using a thematic approach. Results Six main themes emerged: causes of malnutrition, knowledge and awareness, recognition and diagnosis of malnutrition, communication, accountability and food preparation and supply. Physical and social aspects were recognized as important risk factors for malnutrition. Knowledge and awareness regarding malnutrition were acknowledged as being insufficient among all involved. This may impair timely recognition and diagnosis. Responsibility for nutritional care and its communication to other disciplines are low. Food preparation and supply in hospitals, rehabilitation centres and home care are below expected standards. Conclusion Many stakeholders are involved in nutritional care of OA, and lack of communication and collaboration hinders continuity of nutritional care over health‐care settings. Lack of knowledge is an important risk factor. Establishing one coordinator of nutritional care is suggested to improve collaboration and communication across health‐care settings.


| INTRODUC TI ON
Currently, 19% of the total Dutch population is aged 65 years and older, and this percentage is expected to rise to 26% in 2040. 1,2 Longevity is not by definition associated with healthy ageing. At older age, the majority of older adults (OA) suffer from multimorbidity, 3 leading to increased health-care needs. Yet, Dutch health-care policy is aimed at encouraging OA to live at home as long as possible, assisted by family and health-care professionals, when necessary. 4 Herein, they are expected to coordinate their own health, relying on (remaining) physical function and self-management as much as possible. 5 Maintaining a good nutritional status plays an important role in the physical and mental well-being of OA and may be crucial to living at home as long as possible.
Nutritional risk factors seem highly prevalent among Dutch community-dwelling OA (CDOA). A recent study based on SCREEN II found that over 80% (n = 2470) of Dutch CDOA has more than one nutritional risk factor, 6 such as eating alone, difficulties doing groceries, poor appetite and mobility limitations. These nutritional risk factors are common in older age and can lead to a decreased nutritional status and eventually malnutrition. 7 Malnutrition is characterized by loss of body weight and muscle mass, resulting in immune dysfunction and increased risk of falls, slower recovery and increased risk of complications in disease and after surgery. 8 The prevalence of malnutrition is reported to range from 11% to 35% in Dutch CDOA, 9 whereby prevalence rates increase with age. 6,9 The most vulnerable patients at nutritional risk may be the ones who are in transition of care, for example from hospital or rehabilitation centre to home. 10 Furthermore, malnutrition risk factors are more likely to occur in persons with higher care complexity 11 as malnutrition is often co-existent with other geriatric symptoms such as depression or frailty. 12 Thus, optimal nutritional care and malnutrition screening and treatment should be an interplay between different health-care and welfare professionals (professionals), centred around the patients and their caregiver(s).
However, general practice proves the opposite. 13 Ideally, nutritional care and malnutrition prevention and treatment should be a continuum across health-care settings. 14

| Design
A qualitative design was used to investigate current practice and to assess possible barriers and facilitators with regard to collaboration and communication in nutritional care in Dutch OA across health-care settings. Focus group interviews with Dutch OA, their caregivers (social network; ie relatives, friends, neighbours) and professionals (ie GPs, nurses, dietitians, social workers, cooks) were held to collect all necessary information and to discover possible niches.
Between November 2017 and February 2018, focus group interviews were held in three different regions across the Netherlands: Gorinchem, Sneek and Nijmegen. These include both rural and urban regions. They were held on familiar locations, nearby the residence or working area of the respondents. SPH, a trained moderator, conducted the focus group interviews, supported by local project leaders, who made notes about non-verbal communication.
Respondents were asked to share their experiences with nutritional care across health-care settings and were encouraged to be as candid about their thoughts as possible. Focus group interviews lasted 1.5-2 hours and were audio-taped.

| Study population and recruitment
Community-dwelling OA and caregivers were recruited for participation through personal approach in community centres or with the help of OA's associations and personal contacts. No specific inclusion or exclusion criteria were applied with regard to the respondents' usual nutritional habits or risk of malnutrition. Additionally, to study communication across health-care settings, OA who stayed at a rehabilitation centre (after a hip fracture, in transition to home) were invited by local project leaders. Local project leaders approached professionals employed at hospitals, rehabilitation centres and in home care within their network, and through snowball sampling. Four focus group interviews with adults aged 65 years or older (n = 18; Table 1) and caregivers (n = 5; Table 2) took place.
After the focus group interview with OA and caregivers living in Nijmegen, it appeared that a few respondents did not feel safe of nutritional care is suggested to improve collaboration and communication across health-care settings.

K E Y W O R D S
continuity of patient care, elderly, interdisciplinary communication, malnutrition, transitional care enough to share all their experiences during the focus group. One respondent was not able to be present during the focus group. In order to complete OA's experiences, supplementary individual interviews were held with four of the respondents of that particular focus group.
In addition, one couple from Moroccan origin was recruited from the Nijmegen area. Both respondents were not fluent in Dutch; therefore, an interpreter was present during the interview.
The interpreter was a social worker who supported the couple.
Additionally, the couple's daughter was also present during the interview. The couple indicated that they did not want the interview to be audio-taped. Therefore, notes were made and summarized, and the couple signed this summary of the interview.
The individual interviews with the couple from Moroccan origin and the four respondents from Nijmegen lasted 30 minutes to 1 hour and were also audio-taped. Baseline data of the interviews are added to Table 1.
Seven focus group interviews with professionals took place, including 41 care professionals in total. The professionals who participated in the study included different disciplines in health care and welfare ( Table 3).
All interviews were transcribed verbatim by an external party.
Respondents' names were replaced by pseudonyms to ensure anonymity and confidentiality.

| Focus group interviews
Discussion guides were developed based on Evers 16 to ensure all key-concept areas were discussed. The topics of the discussion guide consisted of two main topics including 12 subtopics, presented in Table 4.

| Ethical issues
The study was judged by the HAN Ethical Advisory Board, and they advised that no further ethical approval was necessary, as 'The study does not fall within the remit of the Medical Research Involving Human Subjects Act (WMO)'. All respondents received detailed information about the aim of the study and the content of the focus group interviews in advance. Furthermore, respondents were requested to sign an informed consent form and they were aware of the right to withdraw at any time.

| Data analysis
The interviews were analysed using a thematic approach. 17 Prior to data analysis, two authors (SPH and MHV) listened to the recorded interviews separately. They went through the data and searched for meanings and patterns to make an initial list of recurring topics, after which the formal coding process started. Both authors assigned open codes to pieces of text that had the same underlying meaning, using Atlas. were added in order to include possible niches in the analysis.

| RE SULTS
After nine of the 11 focus group interviews, saturation was consid-

| Physical decline
Physical decline was recognized as an important cause of malnutrition. Also loss of appetite and taste, the ability to take care of oneself, dementia and cognitive decline, side-effects of medication and dysphagia were frequently mentioned. These aspects were said to cause shame and fear, such as the fear of falling. This, in turn, often results in a vicious circle in which OA continued to deteriorate physically.

| Social aspects
Also social aspects were mentioned as possible causes of malnutrition. A small or shrinking network and/or loneliness were said to have a major influence on appetite and the positive experience of eating and drinking. Additionally, OA come from a generation that is reluctant to ask for help from their social network or from professionals. Another important social aspect mentioned is the importance of proper meals in relation to what they cost.
Various opportunities were mentioned in response to the social aspects described above. An important opportunity could lie within social cohesion of neighbourhoods. Social-cultural and medical facilities could improve social networks around OA and could be an easily accessible way for OA to do groceries and prepare and consume meals together. Quotes of Paragraph 3.1 are depicted in Table 5.

| Knowledge and awareness
All focus group interviews revealed that there is a lack of knowledge and awareness towards malnutrition, its causes and consequences (Table 6). Also, the importance of nutrition on health and well-being was under-recognized.
Respondents suggested that the solution may lie in giving more information: OA should be well informed about the causes, consequences and solutions to malnutrition, for example through newspapers or magazines or via the television.
Caregivers and health-care professionals wanted to be educated how they can detect signs of malnutrition and undertake adequate interventions.

| Recognition and diagnosis of malnutrition
As stated before, lack of knowledge and awareness was recognized a factor withholding stakeholders from taking preventive measures or starting adequate interventions. Furthermore, professionals do not always know which professional should be consulted if they recognize signs of malnutrition. In order to consult the right professional, it is required to assess the cause of malnutrition. For example, malnutrition caused by loneliness needs another approach than malnutrition caused by dysphagia.
Another factor that was mentioned explaining the missed diagnosis of malnutrition is the fact that a significant group of frail OA remains beneath the radar, even when health problems arise. This group of OA tends to avoid any involvement of professionals or others because they believe they are able to take care of themselves or do not want to be a burden to others, herewith making monitoring, diagnosing and treatment unable. Quotes on recognition and diagnosis of malnutrition can be found in Table 7.

| Communication
Nutrition assistant Business manager local hospital

Gorinchem Nijmegen Sneek
Health broker VERWIJS Et al.

| Between professionals
Communication with other health-care professionals is essential once one of the health-care professionals has identified a (nutritional) problem. In this way, no duplication of work arises and the right health-care professional can be involved. Unfortunately, the interviews revealed that this is not happening yet. For example, results of nutritional screening (by nurses) are not always shared with the doctor or dietitian and no action is taken. Furthermore, it was acknowledged that lack of communication between professionals resulted in cases where patients needed to tell their personal experiences multiple times, or important information remained unknown. It was suggested that these problems could be resolved easily, by interconnecting existing electronic care systems in which professionals can share their findings. However, this is thought to be problematic, given the European General Data Protection Regulation (GDPR).

| Transfer report
Within the health-care system in the Netherlands, a transfer report is issued when a patient is discharged from an institution to home. This report includes information about a patient's disease, recovery and medication use. Unfortunately, in some cases transfer reports are not issued at all, or issued only days after discharge, causing a delay in information. In some cases, the transfer report is sent to the GP but not to other relevant professionals, or patients receive the transfer report themselves, again leading to a delay in provision of information. In addition, several respondents identified that information about a patient's nutritional status and the involvement of a dietitian or the use of oral nutritional supplement is often not mentioned in such reports.
A paper/digital 'nutritional passport', or even an overall 'health-care passport', has been suggested as a means of communication. In this case, someone should be made responsible for keeping such a document up to date. This topic relates to the theme discussed in the next chapter. Quotes of Paragraph 3.4 are depicted in Table 8.

| Accountability
During all focus group interviews, the GPs and their nurse practitioners were often referred to as being key figures in the (nutritional) care of OA: they are supposed to have all the information about a client, to know when a client is admitted or discharged from the hospital, when a client experiences (health) problems at home and which health-care professionals are involved in their clients' care ( Table 9).
The role of home care nurses also appears to be of great importance. They are expected to be able to evaluate nutritional status easily, since they visit their clients at home. However, with regard to taking action, they are limited in time to spend with their client. Formally, they can only signal and monitor nutritional status.
Preparing and assisting with meals no longer falls under their duties.
However, it depends on the individual employee or home care organization whether they will still assist in serving meals.
A 'personal (nutrition/health-care) passport' was suggested as being one of the solutions to a better communication between health-care professionals. As to whom should be made responsible for keeping it up to date, the GP, nurse practitioner and/or home care nurses were often being mentioned. Also health-care mediators and dietitians, and even caregivers were suggested as being appropriate for the job. However, a great deal of responsibility already rests on the caregivers' shoulders and this may be too much for them to handle. Lastly, it was suggested that OA themselves could be made responsible. This is in line with the previously mentioned policy of self-management. However, stakeholders doubted whether this will be feasible and effective: the current generation of OA is not used to this responsibility and they might be too vulnerable, too shy to ask for help, or even too dependent on the idea that they will be taken care of by health-care professionals or caregivers.

| Food preparation and supply
Much discussed topics are the quality of the food supply in hospitals and rehabilitation centres, the existence, quality and familiarity of meal services and ready-made meals, use and quality of oral nutritional supplements, and the enjoyment of food at an older age.
Together, these topics form the overall theme food preparation and supply.
Several OA who (had) stayed in a hospital and/or rehabilitation centre stated that the quality of the food served was poor. They lacked variation in meals or meal components and were unable to continue their own diet (Table 10)

| Interview couple from Moroccan origin
The interview with the couple from Moroccan origin revealed that they expressed themselves differently from people with a Dutch origin. They indicated that they dealt with illness differently and that care is mainly provided by their family members and caregivers. Consequently, they rely less on professionals. When in touch with health-care professionals, language barriers have been a major problem. Because of the language barrier, the couple experienced that they were not always involved in decisions about their own health care. Furthermore, they indicated that during hospital admission they were not sure whether the food was hallal. They also believed that discharge from hospital to home was too soon, the respondent was not fully recovered. Little had been arranged by the hospital, and home care was not available. At discharge, the respondent received the transfer report and it was the respondents' responsibility to make sure the report was delivered to their GP. GP: 'They say: "It's all going well doctor", but when they are admitted to hospital, they can't keep saying that, but prior to the admission, that's the answer you get'.
Sports coach: 'I can do it by myself easily'

| Suggestions
The respondents made different suggestions to optimize collaboration and communication across the continuum of health care. Table 11 includes these suggestions, summarized per theme.

| D ISCUSS I ON
To our knowledge, this is one of the first qualitative studies into bar- Causes of malnutrition was identified as an important theme.
Causes of malnutrition include physical and mental decline, mainly caused by ageing itself. This is not a novel finding. The decline in the ability to taste and smell, decreased appetite, effects of medication, metabolic changes and many other problems are known to influence food intake and uptake at an older age. 18,19 Additionally, social aspects such as small social networks, loneliness, absence of external stimuli and financial issues are known causes for malnutrition among OA. 20,21 Hence, a number of respondents, both OA and professionals, suggested to create more social and medical facilities in order to solve many of these social problems. In sharp contrast, the interviews also revealed that a large number of facilities already exist, but that OA and health-care professionals are mostly unaware of these. Solutions might therefore not lie into organizing new facilities, but into promoting existing facilities and making sure they are known among OA and health-care professionals.
Knowledge and awareness towards malnutrition in OA was the second theme that arose, and has been found to be low among both OA and caregivers and professionals. This could undermine timely recognition and treatment. These findings are in line with a previous studies. 13 CG: 'With regard to older adults, one often speaks about older adults but rarely with older adults. That's the thing throughout the entire civil world and also in the field service and so on, they think they know what's good for us and for some older adults, but not all older adults are already senile and that is often forgotten. So participation is a nice term but if you indeed want to join in the discussion at a given moment, then they are completely upset because then they no longer know what to do'

Quote 12:
GP's nurse practitioner: 'the moment you see a patient for the first time, there are sometimes things that you think, what would that be like and then if you then have a follow-up appointment with that patient you will see that you get a bond and that you get more information'

Paragraph 3.4.3
Transfer report

Quote 13:
GP: '[…] sometimes you receive the report four days after a vulnerable older adult returns home, you would say that four days would be acceptable, but a lot can happen. In my opinion, I should receive that report before the patient is at home'

Quote 14:
Nurse: 'I also think that with regard to the transfer from the hospital, in our practice nutrition isn't included in the transfer report. There is no specific focus on that' improve identification of OA at risk of malnutrition. This could be done through initial curriculae or through in-service training on this topic, preferably addressing a multi-professional group (eg a community nurse, welfare professional and GP from a municipality).
Additionally, professionals, but also caregivers, should be aware of the steps that need to be undertaken when a malnourished OA has been identified. They need to know which professional to contact in case malnutrition is suspected. This strongly relates to the following theme, communication.
Communication was a frequently discussed topic during the focus group interviews, both between health-care professionals, with OA and their caregivers, and issuing the transfer report. As stated before, when (nutritional) problems are suspected by one professional, it is crucial that is communicated with other professionals.
In short, in addition to knowledge about recognition of (signs of) keeping the GDPR 30 in mind.
Regarding communication with OA and their caregivers, the results of this study showed that OA themselves often feel ignored by professionals. This is in line with previous studies, 28,31 showing that patients are often not involved in the decision making of their treatment, while involving the patient in for instance discharge management showed positive results on several patient outcomes. 32

TA B L E 9 Quotes Paragraph 3.5 'Accountability
Quote 15: Occupational therapist: 'not to put the responsibility on the shoulders of the GP, but he has the overall picture' Respondent: 'That's what you're hoping for, he actually remains the gatekeeper for everything'

Quote 16:
Occupational therapist: 'Yes, we also kinda always come back to the GP's nurse practitioner, because he/she also has the function, they are busy with working that out, there is already a part of where our question simply can be added and he/she can bring all the information together and pass it on to other health care professionals if needed, and can also provide feedback to the GP, and the GP will of course know that immediately. This can all be done in one system'

Quote 17:
CG: 'In my opinion, the nurse from the home care organization can very well evaluate the nutritional intake of the older adults'

Quote 18:
Nurse: 'What I do find difficult in home care, is that you cannot force anything. So you are always dependent on the clients' goodwill. Also, you're not always there, so you can only stimulate, motivate and monitor whether someone is not losing weight or becoming dehydrated or whatever, and that is already a big step, isn't it?'

Quote 19:
Nurse: '[…] and that's when it gets debatable, that health insurances say that nutritional care is not part of personal care, so you almost immediately get financial problems. In our organization we decided that we will do it, we are not going to literally feed someone, but we will heat meals and serve breakfast and so on'.

Quote 20:
Nutrition assistant: '[…] many health care professionals are involved with nutritional care and when talking about a nutritional passport, you would want someone to be responsible, who manages it and that's the question, who is going to manage, to all those things, we all do different tasks and I am wondering who would be responsible for this. Would this be the dietitian who can set the lines and how someone's diet should look like and engage everyone, or should this be a medical specialist, someone's care taker, it can be anyone, but someone should monitor, should it be a GP? […]'

Quote 21:
CG: '[…] you could also make sure that older adults themselves keep all adequate data and make clear they are in charge, so you could also leave that to older adults themselves, I don't know..'

Quote 22:
OA1: 'It remains true that the whole principle of self-sufficiency of your health care and that it is, because if you cannot do that, then you won't get it either. That is the essence of the problem, if you cannot do that, there will be gaps'OA2: 'That is the nasty thing about that whole political load behind that, that we've been called back since two years, well we, but not me, the self-management in health care and those people have been completely pampered since World War II, a great deal has literally been pre-chewed, even with regard to meals, with the television and all other comforts and then from 2014 onwards they are expected to self-direct everything […]'

Quote 23:
Interviewer: 'What I hear is that you have to be very empowered to be able to state things and I don't know if you think, with regard to the other older adults at the rehabilitation unit, would everyone be empowered enough?'OA: 'No, there are people who cannot do that, they are too sad, or unstable' Health-care professionals should learn how to involve patients in the decision making regarding (nutritional) care, in order to make them feel involved in their own care process. This requires new competences, in approaching the client as a person, not as his disease.
Lastly, the transfer report was a frequently discussed topic. In many cases, transfer reports were delayed or never reached the proposed recipient. Additionally, nutritional information was often not included in the report. It is suggested that such reports should be issued in all cases and that there should be a fixed format, including nutrition(al problems) and possible steps undertaken and to be taken. A previous study investigated the effectiveness of transitional care and already concluded that, in order to reduce short-term readmissions, transitional care should consist of communication between the primary care provider and the hospital. 33,34 Nutrition is one of the most important aspects in life. Besides the physical need of nutrition, social aspects play a major role. Herewith, nutrition is a topic that appeals to everyone. Contrarily, our study shows that no specific professional feels responsible for coordinating nutritional care. This is said to be caused by a lack of knowledge and/or It was suggested that besides the OA, one specific, or even several professionals should be (made) responsible. These results are in line with a previous qualitative study among 22  One of the regions included in the interviews is a multicultural neighbourhood. Therefore, it was found important to also include OA with a non-Dutch origin. Unfortunately, due to limited time and resources, only one couple with a non-Dutch origin was included in the study, and no data saturation has occurred. However, the interview did reveal important results. Namely, the couple from Moroccan origin identified the language barrier and cultural differences (eg social relations, eating habits) as two of the largest barriers. As a result, they experienced that they were not always included in the decision making of their treatment. These findings are in line with a previous study which already showed that language and cultural barriers are severe barriers to putting shared decision making into practice. 35 The results of this study imply that physicians should improve their Theme Suggestions  Lastly, further research is needed to fully study the view of elderly immigrants.

Causes of malnutrition
The results of this qualitative study will be used to improve communication and collaboration of nutritional care across the continuum of health-care settings, by developing a personal nutrition passport. Furthermore, suggestions will be made to improve transfer reports, including at least a patient's disease, recovery, medication use, nutritional status, use of oral nutritional supplements and involvement of other professionals and timely availability of the report. 37,38 In summary, this study identified barriers and facilitators towards communication and collaboration of nutritional care across the continuum of health-care settings. Many stakeholders are involved in the nutritional care of OA. Suggestions are given for improvement, such as nutritional education, improving possibilities for social coherence and establishing one coordinator of nutritional care.

ACK N OWLED G EM ENTS
We would like to thank Ad den Dekker, Jolanda Dircks and Annie Dijkstra for their support in organizing and co-chairing the focus group interviews and personal interviews. Additionally, we would like to thank Joost de Beer for sharing his experience in and knowledge on performing qualitative research. Last but not least, we would like to thank all participants for sharing their personal experience and view on nutritional care across the continuum of healthcare settings.

CO N FLI C T O F I NTE R E S T
None of the authors declare a conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available for privacy or ethical restrictions.