Over 15 years the University of Wollongong has led applied research into identifying, preventing and treating malnutrition in at-risk groups, specifically older adults and the infirmed, in hospital settings and the community. Research has directly impacted individuals to improve health outcomes through: policy implementation of routine malnutrition screening in Illawarra region hospitals (identify); implementation of malnutrition screening in the community (Meals on Wheels/GP surgeries) (identify); changes to food service including review of food packaging (prevent/ treat) and research identifying ordering technology to maximise intake (prevent); and implementation of State and National Guidelines for nutrition standards for Hospitals and Meals on Wheels (MoW) respectively (prevent/treat).
3. Good health and well-being
Details of the Impact
UOW led research for over 15 years identifying, preventing and treating malnutrition in at-risk groups, especially older adults in hospitals and the community. In 2001 we worked with hospital dietitians to introduce malnutrition screening and assessment in Illawarra hospitals. The original work is still referenced in updates of the NSW Health Policy Directive on Nutrition Care (2011/2017 NSW DOH PD2017_041). With rates of malnutrition of 49% in at-risk groups, this directive provides a framework to improve health in our community.
Research to quantify the problems, and the early adoption of solutions, has allowed UOW dietitians in collaboration with local hospitals including Wollongong and Port Kembla (>10 publications with hospital staff since 2010) and community groups to develop impactful models to improve nutritional status of individuals, especially older adults at greatest risk (total of >50 publications). This impact is evidenced by the Australian Council of Health Care Standards evaluation of nutrition services at Wollongong Hospital reporting “excellent relationships with UOW” and “evidence that research outcomes have been translated to practice” with “capacity building…through vibrant partnerships”.
Our impact has been achieved through long-lasting connections and partnerships with hospitals and community groups, with other end-users including GP surgeries, and organisations such as Meals on Wheels (MoW), thus ensuring our research was cost-effective, timely, and translatable to practice.
After identification of malnutrition in up to half of rehabilitation patients we are hoping to help home, our team continued work on potential causes and strategies to impact health outcomes through prevention or treatment. At a policy level, we led development of the NSW Agency for Clinical Innovation Nutrition Standards for Adult Inpatients (NSW Dept of Health 2011, UOW research consultancy). These standards support every patient in NSW hospitals by the “provision of a sound nutrition basis for development of the standard hospital menu, establishing overarching principles that ensure a patient focussed food/nutrition service”.
The key to tackling malnutrition is improving intake. We tackled hospital malnutrition at a systems level to target: what is delivered (food choices), intake once delivered (quarantined meal times, tagging trays for feeding help), how a frail individual can manage (problematic packaging), what assistance they need (volunteer feeding assistance), how this might benefit the individual’s health outcomes, and the benefit to the health system through decreased length of stay and cost.
Our research on “openability” was particularly critical (>5 recent publications) with recommendations adopted by collaborators in NSW and ACT. Within NSW Health, changes included improved cheese (economical protein supplement) and cereal packaging, while in the ACT, return to use of water jugs (replacing difficult to open lids) and changes to cutlery and ward ordering systems. ACT Health also adopted policy to consider openability of products as part of the tender/product selection processes.
Canberra Hospital Dietetics’ Manager: “the value of the involvement of UOW and their students has been significant … their in-depth feedback, quality improvement suggestions, advice re compliance, training, nutritional enhancement, process change… proposals can be developed and the service improved for patients [to prevent and treat] malnutrition”.
A project at Canberra Hospital includes economic analysis of dietary intake, waste and patient satisfaction with a fully open, ready to eat meal compared to packaged foods. Having both clinical data and economic outcomes ensures changes are widely adopted in a cost effective manner, while acknowledging fiscal limitations.
We also published research showing use of bedside menu ordering systems (food explained in person, closer to meal time) increased protein/energy intake compared to traditional systems. Increased intake is linked to improved health outcomes, which is highly impactful towards adoption of new technologies - initial expenditure is outweighed by decreased costs of improved health outcomes.
We identified that where patients were admitted malnourished, any improvement must involve home interventions. Our expertise screening malnutrition in older adults (two international working party papers cited >300 times each) was applied to new screening models in GP surgeries and aged care facilities, with health economics used to critically assess cost benefits. Our research showed that the 86% of older rehabilitation patients, who 12 months after discharge have poor nutritional status, had an additional $11,500 in hospital costs from readmissions and $6500 in high level aged care costs, compared to those well-nourished.
This work was extended to the community, for example in the national advisory publications: “Managing Malnutrition at our Doorstep – A Practical Guide for General Practice” (initiative funded by Nestle) and “Coordinating Access to Food and Nutrition Services to Assist Older Australians Post Hospital Discharge” (NSW Health collaboration funded by the Dept of Veterans Affairs).
We also implemented malnutrition screening for MoW customers, developed long life food packages for those who cannot shop, and prepared the first national nutrition guidelines, launched by the Federal Government: “National Meal Guidelines: A Guide for Service Providers, Caterers and Health Professionals Providing Home Delivered and Centre Based Meal Programs for Older Australians”. This has national benefits with MoW delivering ~10 million meals yearly to ~50,000 Australians. UOW won this tender (>$120K) based on expertise and experience working with older adults to optimise food services and dietary intakes.
- Older adults as inpatients in hospitals, as recipients of MoW services and as patients of GP practices
- Food Service Providers (MoW and State Departments of Health)
- GP practices
- Health professionals including GPs and Practice Nurses
Approach to Impact
Summary of the approaches to impact
UOW Public and Allied Health researchers have a strong philosophy of the provision of real life solutions, enabled via ongoing collaboration with stakeholders at all levels from undergraduate and postgraduate research projects to joint publications with health services. We engage formally through the Illawarra Health and Medical Research Institute. Initiatives are supported through partnership grants, community engagement grants and Global Challenges funding. UOW has an excellent track record with health service providers such as MoW, Coordinaire, Department of Veterans Affairs, NSW Department of Health, Illawarra Retirement Trust, Primary Health Networks, and Australian Diabetes Council, to provide research services at minimal cost to these providers.
Approach to Impact
Our approach focusses on solutions in our region, finding low-cost mechanisms for embedding research and evidence-based practice in the community. The impact case study includes changes to practice and benefits arising from positive collaborations with health service providers. Specifically, we undertake small collaborations, including student research placements for piloting of work; ongoing collaboration with regional focus supported through internal grants (Community Engagement Grants, UOW Global Challenges or IHMRI); and community engagement to ensure initiatives focus on issues relevant to the region. For example, our malnutrition screening and assessment research has been supported in an ongoing manner through use of student research projects to minimise costs. Projects are further developed through the Faculty small grants program.
Initiatives extend across the breadth of Public and Allied Health. For example, our public health researchers engage with Western Sydney Local Health District (LHD) and Primary Care Network in diabetes research, changing practice through routine screening of glycosylated haemoglobin in Western Sydney (UOW Vice Chancellor’s award for Outstanding Research Partnership 2016; Award for Productive Partnerships at Western Sydney Leadership Dialogue).
UOW has developed relationships with both inpatient and community services and these are cemented with the establishment of the Illawarra Health and Medical Research Institute (IHMRI) - a joint initiative of UOW and Illawarra Shoalhaven LHD (2008). IHMRI supports health research but also builds capacity in stakeholders, just as the project in malnutrition has done over many years.
Our researchers use a range of methods to engage with end-users including qualitative methods such as focus groups (e.g. exploring experiences of nurses with renal patients regarding food packaging and dietary intakes or to explore the views of older adults regarding use of food packages), interviews (e.g. patients’ perspectives of acceptability of malnutrition screening in GPs) and community fora.
Key strategic initiatives that supported our research include:
- Strong commitment for student research providing low cost opportunities for translational research: projects commence with quality initiatives to map existing practices, initiate improvements and re-evaluate patient or community outcomes. In 2016, student projects included 17 hospital collaborations, and five within the community sector including ongoing projects to identify, treat and prevent malnutrition. Other Public and Allied Health students have worked on mental health recovery camps, driving and dementia and exercise interventions in aged care facilities.
- UOW Community Engagement Grants (CEG) devised specifically to fund projects which: address key challenges in our communities and generate measurable outcomes for specific stakeholders; build capacity for outcomes that are sustainable and extendable across a broader healthcare setting; and support the vision of UOW to ‘transform people and the world we live in’. Our initial MoW work was supported by two CEGs (2010&2013) investigating strategies to improve dietary intake and also using interviews to develop a rich audio-story of experiences of MoW stakeholders (UOW VC Community Engagement Award 2014). UOW funding provided a springboard to further (Commonwealth) funding, but specifically, small projects led to more impactful research and outcomes for the communities we engage with (in this case older adults). Other recent CEGs include investigations of available eating-out options for people living with a disability (e.g. when requiring texture modification); and a breakfast provision project at a local school utilising previously wasted foodstuffs, collaborating with All Sustainable Futures Inc. Projects also include public health initiatives such as the “Life Happens” gaming resource promoting positive decisions around sexual health.
- IHMRI grants supporting collaboration between university and clinician researchers. IHMRI’s vision is of “excellence and innovation in health and medical research supporting better health services leading to a healthier Illawarra community”. Grants include the HealthTrack Lifestyle intervention utilising diet, exercise and psychology to improve metabolic health. Malnutrition research has also been supported through IHMRI: SUSTAIN (Stopping Undernutrition and Sarcopenia Through Activities At Home): Bringing together Allied Health Services; and, “Engaging GPs to Improve Health Service Delivery to Older Patients”.
- Research clusters such as our Health Impact Research Cluster (HIRC). The vision of HIRC is to improve the health of whole communities by conducting research that informs and transforms clinical practice and health policy. HIRC includes health researchers from indigenous health, nursing, medical and exercise science, graduate medicine and nutrition and dietetics and includes projects with the Illawarra and Southern Practice Research Network. These collaborations maximise impact through specific strategies, targeting problems such as renal disease where the LHD region has significantly higher prevalence than the national average.
- UOW Global Challenges funding to support interdisciplinary research to address complex, real-world problems “transforming lives and regions”. Our malnutrition research was initially funded as two seed projects on food “openability” in older adults, but subsequently became a project grant with ACT Health measuring the economic benefits of improving food service systems, to extend our impacts nationally and globally.
UOW supports researchers to engage in our community, supporting small projects to provide real life solutions which as a result of their change to practice in health systems, both embed research in the community they serve and improve health outcomes in a fiscally responsible manner.
Targeting high risk groups, we led projects in food fortification, assistance with packaging and feeding assistance with South East/Illawarra Health. Initially this focussed on strategies with foods already provided. For example, a health services evaluation project measured the outcomes of increased protein/energy intake in older patients to show improvements with assistance in feeding by caregivers. Older adults struggle with manual dexterity to open packages and so significant resourcing is now directed at simple changes to food service to increase food intake (Walton Dietetics/Bell Social Sciences).
Extension of malnutrition screening logically progressed to outpatient settings including GP surgeries where many elderly patients visit regularly (Walton/Charlton 2013). We have funding to extend malnutrition screening across 12 practices, achieving behavioural outcomes in health practitioners, sustainable without ongoing research funding.
Similarly, those unable to prepare food, such as MoW recipients, were key targets with our screening showing many at risk. Policy development of MoW (5 Dietetics academics 2016) and NSW DOH nutritional guidelines (Williams/Walton 2011), targeted systems changes to assist practitioners with implementation in their settings, such that the reach of UOW is wider than the individual communities we collaborate with. Identifying the savings associated with improving nutritional status (Dietetics/Social Science collaborations 2016) was key.
1. Beck, E.J., Patch, C.S., Milosavljevic, M., Mason, M.L., White, C., Carrie, A., Lambert, K. (2001) Implementation of malnutrition screening and assessment by dietitians: malnutrition exists in acute and rehabilitation settings. Australian Journal of Nutrition and Dietetics, 58, 92-97.
2. National Meal Guidelines: A Guide for Service Providers, Caterers and Health Professionals Providing Home Delivered and Centre Based Meal Programs for Older Australians. Australian Meals on Wheels Association. http://mealsonwheels.org.au/wp-content/uploads/2016/10/NationalMealsGuidelines2016.pdf
3. Bell A, Walton K & Yoxall A (2017). Measure for Measure: Pack Performance versus human dexterity and grip strength. Packaging Technology and Science; 30(4):117-126
4. Bell AF, Walton KL & Tapsell LC (2016). Easy to open? Exploring the 'openability' of hospital food and beverage packaging by older adults. Appetite; 98: 125-132.
5. Charlton K, Hamirudin A, Walton K, Bonney A, Albert G, Hodgkins A, Ghosh A, Potter J, Milosavljevic M & Dalley A (2016). Implementation of nutrition screening for older adults in General Practice: Patient perspectives indicate acceptability. Journal of Aging: Research and Clinical Practice; 5(1):7-13.
6. Huang C, Dutkowski K, Fuller A & Walton K (2015). Evaluation of a pilot volunteer feeding assistance program: influences on the dietary nutritional intakes of elderly hospitalised patients and lessons learnt. Journal of Nutrition, Health and Aging; 19(2):206-210.
7. Hamirudin A, Charlton K, Walton K, Bonney A, Potter J, Milosavljevic M, Hodgkins A, Albert G, Ghosh A & Dalley A (2014). Feasibility of implementing routine nutritional screening (MNA-SF) for older adults in Australian General Practices: A mixed-methods study. BMC Family Practice; 15:186. http://www.biomedcentral.com/1471-2296/15/186
8. Hamirudin A, Walton K, Charlton K, Carrie A, Tapsell L, Milosavljevic M, Pang G & Potter J (2017). Feasibility of Home-Based Dietetic Intervention to Improve the Nutritional Status of Older Adults Post Hospital Discharge. Nutrition & Dietetics; 74(3): 217-223. DOI: 10.1111/1747-0080.12305
9. Manning F, Harris K, Duncan R, Walton K, Bracks J, Larby L, Vari L, Jukkola K, Bell J, Chan M & Batterham M (2012). Adding feeding assistance improves the energy and protein intakes of hospitalised elderly patients - A Health Services Evaluation. Appetite; 59:471-477.
10. Charlton KE, Nichols C, Batterham M, Bowden S, Lambert K, Baronne L, Mason M, Milosavljevic M. (2012). Poor nutritional status of older rehabilitation patients predicts clinical outcomes and mortality at 18 months of follow up. European Journal of Clinical Nutrition; 66, 1224–1228.