(Transmural) cooperation and transfer

Responsibility for identifying and treating malnutrition does not lie with one (healthcare) professional or professional group. Patients/clients with (risk of) malnutrition often involve more complex (disease) problems and often several (healthcare) professionals are involved. Multidisciplinary collaboration is therefore essential in the prevention and treatment of malnutrition.

In view of the shortening duration of admission, for example in the hospital and rehabilitation center, and the transfer of care to home, it is also of great importance to ensure a good transmural transfer and follow-up of the nutritional advice and the implemented policy.

Multidisciplinary collaboration

In general, the division of tasks below applies to all care sectors when identifying and treating malnutrition. In primary care, professionals from the social domain can also have a task in identifying. Within an organization or setting, other or more specific collaboration agreements may be described. For complex patients/clients with nutritional problems, it is recommended to have regular multidisciplinary consultations about the treatment policy.

Division of tasks

The nurse/carer coordinates the care, nutrition is part of this. He/she identifies problems with eating and drinking by, among other things, screening for malnutrition, being alert to unintentional weight loss, and observing whether the intake of food and drink is sufficient. In case of nutritional problems, he/she takes follow-up actions such as offering an energy- and protein-enriched diet and referral to a dietician. But also motivating the patient/client and helping them to eat well. In addition, he/she offers support in evaluating and implementing the nutritional treatment plan in consultation with the dietician and other stakeholders.

The dietitian  is responsible for nutritional treatment. He/she diagnoses malnutrition, draws up the treatment plan in consultation with the patient/client and, if necessary, caregivers, formulates the treatment goals with the patient/client, evaluates the treatment and coordinates nutritional care with the nurse/carer and other involved parties.

The (GP) doctor identifies nutritional problems and integrates the nutritional treatment (objective and implementation) into the total medical treatment.

The speech therapist  offers prevention, care, training and advice regarding swallowing and chewing oral functions.

The other (para)medical disciplines (such as occupational therapist, physiotherapist, dental hygienist and dentist) have a signaling function and pass on suspected problems to the main practitioner or dietitian. Based on their own expertise, they can also contribute to reducing or remedying underlying causes of malnutrition such as impaired functioning, reduced mobility and/or dental problems.

Social domain: professionals working in the social domain such as domestic help, case managers, social welfare consultants, welfare workers can have a signaling function and pass on suspicion of problems to, for example, a neighborhood team. This is particularly important for target groups that are not visible to healthcare professionals.

Continuity and transmural transfer of (under)nutrition care

When a client/patient with malnutrition moves from one setting to another, it is important to ensure the continuity of the nutritional treatment plan. For example, if someone is discharged from the hospital to the nursing home or from the rehabilitation center. In that case, each professional involved ensures a timely transfer to care providers in the other setting.

Nurses and carers state in the nursing transfer at least when they were last screened for malnutrition the results of this screening, which nutritional advice/diet applies to the client/patient and whether a dietician and/or speech therapist is involved.

The doctor or general practitioner states in the medical transfer that there is a (high risk) of malnutrition and that a dietician has been engaged or has yet to be appointed.

The dietician, if involved, ensures a transfer of the dietetic care and nutritional treatment plan.

The speech therapist, if involved, ensures a transfer of the speech therapy care and treatment.

Below is an example of a transfer form for dieticians and a sample letter to inform the GP.

Transmission in malnourished children after hospitalization

In view of the short average length of stay of children in hospital and the relocation of care for sick children to the home situation, it is of great importance to ensure a good transmural transfer and follow-up of the nutritional advice and the policy applied upon discharge from the hospital.  The transfer of nutritional care at hospital discharge can be considered complete if:

  • Current height and weight (absolute and SD score) are listed in the discharge letter and discharge/transfer form.
  • Nutritional advice (including treatment goal/target weight) drawn up by a dietician or attending physician is stated in the discharge letter and/or discharge/transfer form and is also given to the parents and child.
  • Nutritional care is transferred to a healthcare professional in the first, second or third line.

The Nutrition Passport: improving transmural (under)nutrition care

Good transmural cooperation and transfer is essential for the client/patient with (high risk of) malnutrition. In the project ‘The Nutrition Passport’, on the initiative of the Knowledge Center Malnutrition, a blueprint has been developed for (improving) transmural cooperation and nutritional care for vulnerable elderly people.

The project was carried out with support from the Ministry of Health, Welfare and Sport and resulted in:

  • Guide to the Nutrition Passport: an extensive description of the method by which continuity in nutritional care for (vulnerable) elderly people can be improved in a regional partnership
  • The national concept of Nutrition Passport: a (digital) notebook and handy tool to support the elderly, in which the most important data and agreements about nutritional care can be recorded together with the informal carer and involved professionals.

With the help of the guide, the instruments and the examples from three pilot regions, care providers in their own region can improve the continuity of transmural (nutritional) care for the elderly.

Regional approach Nijmegen ‘Care for Nutrition’

In the pilot region Nijmegen, the Canisius Wilhelmina Hospital (CWZ), district nurses and social district teams collaborated during the Nutrition Passport project to develop a transmural care path for the target group: vulnerable (older) patients with an increased risk of malnutrition with causes in the social domain.

The core of the transmural care pathway is that if the dietitian determines during admission to hospital that the cause of/risk of malnutrition stems from a social problem, the district nurse will be deployed in an accessible manner when discharged home. The district nurse then connects the right professionals from the care and social domains so that the cause of the (imminent) malnutrition is tackled optimally.

On the right, see more information for the flow chart of the care path and a document with an explanation of the working method and mutual agreements.

(Transmural) networks and care pathways

Dietitians in different regions have established a transmural network to promote collaboration and transfer between dietitians in different settings. There are also several regions where multidisciplinary care pathways aimed at identifying and treating malnutrition have been set up. Here are some examples. Is the website of your regional network or care path not listed? Let us know via the contact form.