The FREER Pilot Study (Family in Rehabilitation: EmpowERing carers for improved nutrition outcomes)

Intervention approach: By integrating formal and family care for malnourished rehabilitation patients, family carers will be empowered to improve the efficacy of their individualised nutrition support. We have applied the four-step systematic approach for using the theoretical domains framework to develop and establish the feasibility of the FREER intervention strategies. This was done through systematic and narrative (examining qualitative aspects of interventions) reviews, a qualitative study of support needs and preferences, a pilot of intervention acceptability and qualitative impact (n=4 carers; unpublished), and stakeholder engagement (n=20 health care staff; unpublished). This project now proposes to establish the preliminary efficacy of the FREER intervention through a pilot trial. FREER intervention components will be delivered by a Research Assistant (an Accredited Practising Dietitian; herein referred to as the “study dietitian”) and will use three individualised and needs-based strategies. These are: 1. Nutrition counselling during rehabilitation admission: The family carer will be engaged as an essential part of the nutrition care team for the malnourished patient by the study dietitian. The carer will be involved with: patient assessment; one or more collaborative nutrition counselling and education sessions; and discharge planning. Guided by evidenced-based practice guidelines (Watterson et al. 2009) the sessions will be focused on improving patient nutrition status, The frequency and duration of the inpatient sessions is individualised based on need and length of rehabilitation admission. There will be a minimum of 1 session with no maximum number of sessions. It is estimated the initial session will be approximately 30-60 minutes, with follow-up sessions 10 - 30 minutes duration). The first session will take place within one week following admission, and the last session within one week of discharge (if patient discharge is planned within one week of the first session, there will be only one session acting as both initial intervention and discharge intervention). Nutrition counselling will provide a nutrition care plan which provides highly individualised nutrition support strategies used to treat malnutrition, which are usually targeted towards enabling the care-recipient to consume appropriate high protein-high energy foods. Counselling will also involve recommendations of strategies and resources that assist in overcoming the individual’s nutrition-related barriers (e.g. low appetite, food aversions, fatigue, poor dentition). The nutrition care plan will utilise a food-first approach; however, oral nutritional supplements may be provided if patients are unable to consume sufficient protein and energy by food alone. The intervention will be delivered by standard menu changes and additions via the rehabilitation food service as well as foods/beverages brought in by carers. Carers will also be linked to other existing rehabilitation services as needed, such as speech pathology for modified food textures, or occupational therapy for modified eating utensils. Carer engagement strategies will apply the theory of planned behaviour to increase an individual’s ability to make recommended changes through goal setting, problem solving and contingency planning. Ideally, the carer will attend the rehabilitation site to participate in the collaborative nutrition counselling; whereby paper-based resources will be provided. However, if the carer is not able to attend the facility at the required time, they will be engaged via telephone and the resources will be a) left at the patient bedside for them to collect at next visit, b) mailed to them by post, or c) emailed, according to carer preference. Any referrals made to other health staff during rehabilitation admission will be made via the existing electronic referral system. Referrals to services or professionals outside of the rehabilitation site will be made according to the existing referral system. All intervention, referrals and contacts will be recorded in patients’ electronic medical records by the study dietitian. Adherence to the intervention will be monitored through food service records (consumption/acceptance of supplements and/or specially ordered foods and 24 hour recall). 2. Telehealth follow-up: The patient and family carer will receive a minimum of four 15-30min telephone consultations from the study dietitian focussed on patient nutrition support for a period of 12-weeks post-discharge from rehabilitation. Consultations will be as needed, but will be at least every three weeks. These telehealth consultations will either a) involve both the patient and carer, or b) be provided separately if patient and carer cannot attend the call together (patient consulted first). Consultations will be individualised, follow a semi-structured plan, and apply the theory of planned behaviour. Consultation content will be centred around nutritional monitoring, food and nutrition-related problem-solving, modification of the individualised nutrition care plan for the patient, and linking with further supportive services such as home-delivered meals, provision of oral nutritional supplements, or referral to other allied health professionals. Adherence to intervention will also be monitored through 24-hour recall. 3. Resources: A resource pack will be provided to and discussed with, family carers to support their day-to-day caregiving (during and following rehabilitation) and for reference to topics discussed during telehealth follow-up consultations. This pack will include written educational material on appropriate foods and hydration for older adults with malnutrition. Items included will be: 1) High Protein High Energy Diet (NEMO* Resources), which includes a weight monitoring calendar, 2) Individually written meal plans/goals using the FREER Meal Plan & Recommendations form. Additional NEMO Resources from the NEMO website will be selected to suit the individual patient’s needs. The meal plan & recommendations form will be updated for each dietetic consultation, and additional resources provided as needed. Any additional resources required during telehealth sessions will be mailed to the participant and carer following the telehealth appointment. *Nutrition Education Materials Online (NEMO) is a website with nutrition resources suitable for use by clinical dietitians, coordinated by the Royal Brisbane & Women’s Hospital, with contributions from dietitians across Australia. It includes a range of resources for various conditions including malnutrition and dysphasia which are unaltered to ensure consistency, and have undergone a process of quality assurance. They are available freely from health.qld.gov.au/nutrition. Oral nutritional supplements: Supplements will be provided to participants on a case-by-case basis. If they are provided during the rehabilitation admission this will be via standard procedures whereby supplements are ordered as part of the food service. The supplements chosen will be subject to food service stock availability and participant preference. Upon discharge, if supplements are recommended for an individual to consume at home or during an aged care admission, they will be provided by the study researchers using products supplied in-kind. The type, flavour, and dose will vary according to individual needs and availability. If participants require a new supplement to commence once they are discharged, it will need to be collected from the rehabilitation site. Once the study has concluded, if patients require ongoing nutrition support and ongoing supplements, they will be referred to the Murwillumbah community dietitian to access dietetic outpatient services and discounted supplements.