1. Introduction

Aging processes, chronic non-communicable diseases (NCDs) and multimorbidity [1] as well as inequality in access to health care systems [2] predispose older citizens for loss of functionality, self-care capacity and therefore care dependency. This raises the demand for care services in general and long-term care in particular, especially in middle- and high-income countries [3]. Still, quality assurance within these care structures is highly inhomogeneous between and within countries. One key quality indicator in delivery of care in resident setting is access to personalized food care [4,5], as tailored nutrition plays a key role for health for older citizens residing in resident homes and long term care [6,7]. However, the level of integration of standardized nutrition care from screening to assessment to intervention and monitoring is extremely diverse across EU countries, regions and even within different care providers on local level [8–10]. Although clinical guidelines and quality standards provide guidance and instructions for evidence-based nutritional care of older adults [11,12], there is only limited implementation of integrated approaches for person-centered and inter-professional nutritional care of long-term care (LTC) residents.

This is confirmed by recent data reporting a prevalence of high malnutrition risk of 17.5% in residential care/nursing homes [13,14], and 28.7% in long-term care [14], respectively, depending on screening tool used. As a result, residents in long-term care facilities are considerably exposed to severe health outcomes, such as functional decline, prolonged hospital stays, increased readmissions and (in-hospital) mortality [15–17].

Against this background, implementing integrated care processes and services has turned out to be challenging [18]. Although implementation science is in general clearly defined as “the scientific study of methods to promote the systemic uptake of research findings and other evidence-based practices into routine practice” [19], implementation strategies are usually characterized by a concomitant complexity, ultimately leading to challenges in terms of their precise description, operational definition and measurement options [20]. In order to overcome these challenges and provide structured guidance for implementation processes, several frameworks and guidelines have been developed [20–22], raising the potential to successfully integrate the new strategies into real-world processes, enhance effectiveness and promote the practical uptake of integrated care [18,19,23,24].

It was therefore the aim of this paper to explore the development process of an evidence-based, contextualized and inter-professional nutritional care pathway for three nursing homes of the Styrian hospital trust (KAGes Ges.m.b.H.) across the province of Styria, Austria, grounded in the Expert Recommendations for Implementing Change (ERIC) taxonomy [22].

2. Materials and methods

This publication was conducted in line with the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) publication guidelines [25] and the checklist is available as Supporting information file (S3 Checklist). Nutrition care pathway development was oriented towards the framework of the European Pathway Association for developing quality integrated care pathways [26] and based on a qualitative multi—method approach consisting of sequential and constitutive sub-processes as outlined in Fig 1.

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Fig 1. Schematic representation of the multi-method research approach.

Fig 1 illustrates the multi-method research approach applied.

https://doi.org/10.1371/journal.pone.0323596.g001

Selected strategies from the Expert Recommendations for Implementing Change (ERIC) taxonomy [22] have been operationalized and contextually adapted. The following implementation strategies have been determined to methodologically support and guide the presented process: 1) Assess for readiness and identify barriers and facilitators; 2) Capture and share local knowledge; 3) Conduct local consensus discussions; 4) Involve executive boards; 5) Facilitation; 6) Promote adaptability.

3. Results

4. Discussion

The current paper describes the development and implementation process of a contextualized and inter-professional nutritional care pathway in LTC facilities in Austria, grounded in a distinct implementation science framework [22]. Nursing home residents typically represent a heterogeneous population with divergent care and nutritional needs, necessitating an inter-professional approach that bundles complementary perspectives, skills and care processes [39,40]. The pathway aims at guiding the care team around the residents to choose needs-oriented and evidence-based interventions based on a person-centered nutritional care approach.

As care pathways are regarded as complex interventions being designed with the intent to function within a complex system, understanding the care context in which care is provided is an important prerequisite for effective and sustainable care pathway implementation [26]. The European Pathway Association (EPA) provides a framework that guides care pathway development and application in relation to care context, amongst others [26]. As part of this study, analysis of the respective care contexts was conducted within a preceding maturity assessment, depicting strengths, weaknesses, opportunities and threats of nutritional care provision across all three nursing home locations, taking into account inner and outer organizational factors that shape the operational context [41,42] and outline feasibility of pathway implementation. Interestingly, our data demonstrated a huge variety in context related care ecosystems already within three LTCs involved, although all three units are run under the umbrella of one trust. This observation, once more, underlines the importance and value of the first step also recommended by the European Pathway Association (EPA) framework [26].

In addition to this, the implementation strategies from the Expert Recommendations for Implementing Change (ERIC) project [22] provided further valuable methodological guidance for tailoring and executing the nutritional care pathway development process. Several strategies were particularly instrumental in supporting a contextual and flexible approach. First, the strategy to “assess for readiness and identify barriers and facilitators” [22] – consistent with the first step of the EPA framework [26] - was applied through the initial maturity assessment, allowing for a structured understanding of contextual enablers and challenges across the three LTC facilities. Second, the strategy to “capture and share local knowledge” [22] was realized within focus group sessions where key participants shared local knowledge on how to effectively execute nutritional care in everyday practice in their specific setting. Third, “consensus discussions” [22] were held within the co-creation process of the care pathway development, ensuring appropriate design of the innovative care pathway. Fourth, executive boards [22] have been involved throughout the whole process, with the management board of the Styrian hospital trust KAGes m.b.H. acting as governing structure and being in charge of final approval of the results. Fifth, the strategy of “facilitation” [22] was applied by engaging in interactive solution finding based on the needs recognized in the initial maturity assessment. Finally, recognizing the dynamic nature of implementation, the “promote adaptability” [22] strategy was key in allowing for iterative adjustments based on ongoing feedback and contextual needs. Employing the ERIC framework [22] helped to develop an individual multicomponent approach towards integrated nutritional care implementation, as the discrete strategies presented within the compilation serve as solid methodological pillars for implementation science.

In general, the nature of integrated care is characterized by its diversity of methods, models and processes within and across different care settings. This directly impacts assessment and quality assurance frameworks related to integrated care processes [43,44]. The challenge of evaluating and measuring the impact of integrated care initiatives and interprofessional collaborative practice has been thoroughly discussed in literature [45–48], both for hospital as well as nursing home care processes [40]. From a conceptual perspective [49], nutritional care delivery and its quality needs to be evaluated from the side of structural and outcome indicators [40]. The study presented in this publication focused on integration of nutritional care delivery in the LTC facilities involved in the project within implementation of the innovative integrated care pathway shown in the Supportive Information files of this paper. Generally speaking, evaluation results reveal a positive impression of the integrated nutritional care initiative. However, one have to bear in mind that the results reflect perspectives from different professional silos that are characterized by pre-existing opinions and experiences. Moreover, working routines that are embedded in pre-established structures or frameworks and may be difficult to adapt or change further pose a factor that needs to be considered in terms of care integration initiatives. This is also reflected in the literature, as engagement of staff is regarded crucial when designing nutritional interventions in healthcare settings [50]. Corresponding to this, evaluation results reveal that long-term implementation into practice routine is regarded a major challenge. Still, valuable lessons learned emerged that may facilitate scaling-up aspirations for integrated care initiatives. One major condition for success is to maintain a flexible approach that fits the contextualized integration strategy and allows for adaptations and corrections along the road. In this sense, a continuous improvement process is made possible that ensures achievements and avoids losing track within a too rigid procedure. Moreover, as previous integrated care implementation experiences confirm, more clearly defined and smaller changes exhibit a higher probability of successful implementation [51].

As implementing changes in health and social care organizations encompass planned as well as unplanned measures [51], another essential scaling-up recommendation is to early engage in a method of barrier or challenge identification [52]. Within such assessment, a deeper understanding of potential impacts and influences will be gained and integrated care progress may be secured more easily.

Implementing and scaling-up integrated care efforts does not require to “reinvent the wheel”, in fact it is about finding, planning and realizing an individual and contextualized approach within the guidance of prevailing frameworks. The presented initiative has been deployed using the developed methodology from the EU-funded VIGOUR project (Grant Agreement Number 826640) [53], however, interested parties will find several different guiding frameworks that comprise the building blocks for integrated care development in the literature, such as the Rainbow Model of Integrated Care [54], the (expanded) Chronic Care Model [55] or WHO’s Innovative Care for Chronic Conditions Framework [56], amongst others. The purpose of these frameworks is to navigate through the integrated care system and simultaneously allowing room for contextualized practical implementation addressing emerging care needs.

A significant context orientation lies in the nature of implementation science, as research not only takes into account individual patients or subjects, but has to carefully analyze settings, facilities, organizations, communities and even the macro level of policy environment or health care systems as well [57,58]. In this regard, another prerequisite for successful implementation research is the high degree of participation of individuals and integration of structural conditions. As implementation research targets innovation and intervention at structural level where key stakeholders are operating as local experts, their participation is essential for successful implementation [59].

The present multi-method pathway development process displays strengths and limitations.

The implementation of integrated care measures, such as the inter-professional nutritional care pathway described in this paper, requires procedures, structures and mechanisms that are tailor-made, addressing contextualized issues and circumstances [60]. The inter-professional nutritional care pathway presented here, is a custom-made tool for integrated nutritional care of LTC residents, approaching issues and routines explicitly for the three LTC facilities of the Styrian hospital trust KAGes.

By applying a concept of co-creation including all stakeholders in health and social care, shared commitments towards improvement of nutritional care in long-term care are made possible. Co-creation in health and social care serves as a promising methodological approach enabling cross-fertilization among stakeholders and shedding light on perspectives and attitudes transcending individual and isolated frames of references [61]. The methodological approach presented is grounded in implementation science, utilizing the ERIC taxonomy [22] to achieve sustainable and contextually meaningful outcomes.

However, although an iterative, multi-stakeholder design process was applied, patients’ perspectives are still lacking. There is growing evidence that patient and/or consumer participation are relevant for dealing with current challenges in health and social care provision and enables them to actively contribute on their individual care journey [62,63]. Valuable patient involvement shows the potential to increase and reinforce project outcomes in health care research, as patients are equipped with unique expertise when it comes to their own health and individual experiences in their healthcare journey [64]. Furthermore, patient or service user involvement and engagement helps to bridge research and practice, to identify issues and enables a greater needs orientation and co-production of care services [65,66]. One essential prerequisite in this regard is a mutual understanding of the concept and dimensions of patient-centered care provision [67]. There are several guidelines and recommendations addressing policy and researchers alike to foster inclusion, empowerment and participation of patients [64,65]. In this sense, important key factors are for example the right to involvement, resources and capacity building [64]. Burgher et al. presented more specific recommendations for public involvement in care home research. As a result, a successful approach towards patient and public involvement (PPI) comprises of five main subjects: 1) appreciating stakeholders’ perspectives; 2) being aware of the multi-dimensional research context; 3) secure inclusiveness and transparency; 4) stay flexible and able to adapt; 5) make use of resources and extended support [68].

Finally, evaluation results of care pathway implementation, giving insight into outcomes, effects, sustainability and necessary adaptations of the intervention [69], are still pending. Further evaluation research is needed in this regard in order to present comprehensive long-term results underpinning the method applied. Furthermore, deeper understanding about the dynamic nature and impact of this context-specific innovation will be generated, enriching the current evidence base within the field of implementation science [57].

5. Conclusion

The present study gives insight into a collaborative approach to develop and implement an inter-professional, evidence-based nutritional care pathway, bridging health and social care around the complex needs of older residents in three LTC facilities across Styria, Austria. Early evaluation results show promising effects, however, further in-depth evaluation is required to consolidate and eventually adapt integrated nutritional care provision in the context of a long-term quality assurance approach.

Supporting information