Healthy Ageing - Nutrition. Project Report 2006

Transcription

1 Healthy Ageing - Nutrition Project Report 2006

2 ACKNOWLEDGEMENTS Healthy Ageing Nutrition is a project of Metropolitan Domiciliary Care; funded through the Department of Health s Human Services Research and Innovation Program and supported by their Health Promotion Branch and the Department of Public Health, Flinders University of South Australia. The project s chief investigators are: Dr Robert Penhall General Manager Medical Services Metropolitan Domiciliary Care Dr John Coveney Associate Professor Department of Public Health Flinders University of South Australia Ms Patricia Carter Chief Project Officer, Public Health Nutrition Health Promotion Branch, Department of Health The project work was facilitated by: Ms Leah Trotta Project Manager Metropolitan Domiciliary Care Ms Julia Overton Project Administrator Metropolitan Domiciliary Care External evaluation of the project was conducted by: Ms Gwyn Jolley Senior Research Officer South Australian Community Health Research Unit Flinders University Healthy Ageing Nutrition Project Report of 137

3 Ten groups / organisations became project partners: > Carers Association of South Australia Inc > Centre for Physical Activity in Ageing > South Australian Divisions of General Practice Adelaide North Eastern Division of General Practice Adelaide Northern Division of General Practice > Hampstead Rehabilitation Centre Block 1 Wards > Dietitians Interested in Aged Care > Meals on Wheels SA Inc > Metropolitan Domiciliary Care > Multicultural Aged Care, including: PISA Italian Meal Service Maltese Meal Service Greek Meal Service > Resthaven Inc > Royal District Nursing Service Healthy Ageing Nutrition Project Report of 137

4 The Healthy Ageing Nutrition Project Advisory Group Representatives from the above organisations, together with the project s chief investigators and an expert reference group, formed the Healthy Ageing Nutrition Project Advisory Group. Thanks to: > Alwin Chong, Aboriginal Health Council of SA > Andja Ristivojevic, Multicultural Aged Care Services > Anna Fergusson, SA Divisions of General Practice > Bob Barnard, Centre for Physical Activity in Ageing > Cam Pearce, Meals on Wheels SA Inc. > Cathy Isam, Royal District Nursing Service > Christine Morris, SA Dental Service > Debra Petrys, Council of the Ageing SA > Dianne Schnieder, Carers Association of SA > Elizabeth Kellett, Flinders Medical Centre > Ingrid Randva, Department of Veterans Affairs > Janet Skewes, Regency TAFE > Julie Dundon / Alison Shanks, Dietitians Association Australia (SA) > Lynne Daniels, Flinders University of South Australia > Mary Covernton, Office for the Aged, Department of Families and Communities > Wendy Morey, Resthaven Incorporated > Carol Smith, Adelaide Central Community Health Service, and > Marjorie Smith, Carers Ambassador, Carers Association of SA > as well as all of the other people who were regularly available to represent their organisations to support the project and provide advice. Thanks also to Dr Renuka Visvanathan, University of Adelaide and Ms Rosie Bonnin, Health Promotion Branch, Department of Heath who were both involved in the initial planning and development of the project and who have continued to provide support throughout its implementation. Healthy Ageing Nutrition Project Report of 137

5 CONTENTS SECTION 1: THE PROJECT Background Project Outline Research Approach Planning, Doing, Checking and Acting Capacity Building Action Research Approach (Doing) Project Plan and Timeframes Stage 1: Planning and Establishing Communications Planner Stage 2. Implementing Action Research Stage 3. Summary Analysis and Reporting Evaluation (Checking) Ethics What next? (Acting) Attachment 1: EVALUATION Action Research Evaluation External Evaluation The Organisations Group 1 Advisory Partners Group 2 Case Studies Carers Association of SA Centre for Physical Activity in Ageing (CPAA) Hampstead Rehabilitation Centre Interested Dietitians Meals on Wheels SA Inc Metropolitan Domiciliary Care (MDC), Day Rehabilitation Centre Multicultural Aged Care (MAC): PISA Italian Meal Service, Maltese Meal Service and Greek Meal Service Resthaven Incorporated Royal District Nursing Service of South Australia (Inc) SA Divisions of General Practice (SADI) Healthy Ageing Nutrition Project Report of 137

6 SECTION 2: EXTERNAL EVALUATION REPORT, APRIL Introduction and background Purpose of the Evaluation Project Goal and Objectives Objective Objective Objective Objective Evaluation methods Interviews with the Project Manager Interviews with Participating Organisations Project Advisory Group Review of Project Documentation Synthesis and Reporting Strengths and Limitations of the Evaluation Findings Case Study Organisations Metropolitan Domiciliary Care Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Multicultural Aged Care Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Royal District Nursing Service of SA Inc (RDNS) Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Healthy Ageing Nutrition Project Report of 137

7 Dietitian Group Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Meals on Wheels (SA) Inc (M OW) Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Centre for Physical Activity in Ageing (CPAA) Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Carers SA Inc Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey SA Divisions of General Practice (SADI), North East and Northern Divisions of General Practice Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Hampstead Rehabilitation Centre Preparing for the Journey Journey Action Plan On the Road Healthy Ageing Nutrition Project Report of 137

8 Arriving: Summary of Achievements Reflections on the Journey Resthaven Inc Preparing for the Journey Journey Action Plan On the Road Arriving: Summary of Achievements Reflections on the Journey Themes from Interviews with Project Manager Project Implementation and Management Getting Commitment from Participating Organisations Starting Change Keeping the Project on the Agenda Action Research Approach Website Links Support Key Achievements Sustainability and future directions Organisational interviews Distribution of clients Number of clients Number of workers (paid and volunteer) Service type Structural and Personnel Change in Organisations between Interview Rounds Working with the Healthy Ageing Nutrition Project Enablers and Barriers to Beginning Action Communication Strategies and Activities Action Planner and Achievements Will the achievements make a difference at an organisational level? Any other comments about the organisation s involvement in the project? Contribution to Achievement of Project Objectives and Goal Sustainability of Achievements and Changes Healthy Ageing Nutrition Project Report of 137

9 3.4. Project Advisory Group Role of the Advisory Group Diversity of Group Influence on the Project Quality and Effectiveness of Project Management Action Research Approach Enablers and Barriers to Change within the Project Enablers and Barriers in the Broader Environment Achievement of Objectives What would you like to see happen next? What is likely to happen? How can the achievements be sustained? Other Activities Contact with other organisations Community Affairs Senate Committee ATSI worker forum Web links Conferences Funding applications Discussion Achievement of Objectives Action Research Approach Project Reach Achieving Change Figure 1: Organisational Change Enablers Figure 2: Organisational Change Challenges Sustaining Change Conclusion Appendix 1: Round One Interview Guide Appendix 2: Round Two Interview Guide Appendix 3: Healthy Ageing Nutrition Reference Group Meeting 26 th October Appendix 4: Project Manager Interview Question Guides Healthy Ageing Nutrition Project Report of 137

10 SECTION 1: THE PROJECT Background Our population is ageing. Australian population projections indicate that the proportion of the population aged over 65 is increasing and South Australia currently has a higher proportion of older people than the national average. 1 Australia s over 65 population is expected to increase from 12.8 per cent in 2002 to 24.5 per cent in In 2012, the proportion of the population aged over 85 is expected to have grown from 1.5 per cent to 1.9 per cent, and is projected to grow to around 4.3 per cent by By 2006, it is estimated that more than a quarter of a million South Australians will be over the age of 65 years. 3 Healthy ageing is therefore a significant public health issue for Australia, and particularly South Australia. Nutrition and physical activity are the two main areas identified by the World Health Organisation (WHO) for prevention of the chronic disease burden and in improving healthy ageing. The WHO has called for urgent action in this area. 4 Health care costs increase sharply with age, and many of these costs are incurred in treating diet related problems. A WHO 5 Report found that the cost to the world of the current and projected epidemic of chronic disease related to diet and physical inactivity dwarfs all other health costs. Poor nutrition can lead to an increased risk of falls, fractures and infections, poor wound healing, poor recovery from surgery and longer hospital stays. Malnutrition may also lead to decreased appetite, dental problems, depression, apathy and even dementia. 6 Proteinenergy malnutrition can be hidden as a cause of weight loss when present with other factors such as cancer, chronic airways disease, Alzheimer s disease, Parkinson s disease, diabetes, depression and particular medications. Nutritional intervention has been 1 ABS Statistics Basic Community Profile ( 2001) 2 Australian Government Budget Overview accessed online Nov 2005 at (2005) 3 ABS Statistics Basic Community Profile ( 2001) 4 WHO Report of a Joint WHO/FAO Expert Consultation Expert Report on Diet, Nutrition and the Prevention of Chronic Disease, Geneva WHO Report of a Joint WHO/FAO Expert Consultation Expert Report on Diet, Nutrition and the Prevention of Chronic Disease, Geneva NHMRC Dietary Guidelines for Older Australians (1999) Healthy Ageing Nutrition Project Report of 137

11 proven to be helpful. 7 polypharmacy and social isolation. 8 The main nutritional risk factors are acute or chronic disease, It is now thought that 25 to 30 per cent of independent older people are at risk of nutritional problems and that this proportion increases from 41 to 57 per cent in those where frailty or illness has led to the need for support services or hospitalization. 9 Clinical studies have shown that appropriate nutrition has the potential to reduce the number of hospital admissions; shorten hospital stays and improve outcomes from community managed care. Good nutrition is particularly important for older people to maintain an independent lifestyle for as long as possible and to minimize morbidity and premature death. Poor nutrition is one of the main reasons why people become frail and dependent, reducing quality of life and increasing the cost of health care for the individual and the community. A study carried out at Hampstead Rehabilitation Centre, Adelaide in 2003, identified and validated a simple screening procedure to quickly and inexpensively identify older people who are at risk of under-nutrition. It indicated that under-nutrition among sub-acute care patients was high and that patients who were undernourished had significantly worse discharge outcomes than their well-nourished counterparts. 10 Further research with community based elderly clients within Metropolitan Domiciliary Care in Adelaide, found that use of this simple screening process by health workers identified 38.4 per cent of clients were at risk of malnutrition and these people had significantly worse outcomes than well nourished people when followed up at 12 months 11. There is evidence that nutritional intervention can produce good effects in later life, extending the years of healthy life for older people MilneAC, Potter J, Avenell A Protein and energy supplementation in elderly people at risk of malnutrition. Cochrane Database of Systematic reviews. 2002:CD Position of the American. Dietetic Association Nutrition, Ageing and the Continuum of Care, ADA Vol 100 No MilneAC, Potter J, Avenell A Protein and energy supplementation in elderly people at risk of malnutrition. Cochrane Database of Systematic reviews. 2002:CD Visvanathan, R, Penhall, R, Chapman, I, Nutritional screening of older people in a sub-acute care facility in Australia and its relation to discharge outcomes, Age and Ageing 2004; 33: Visvanathan, R., McIntosh, C, Callary, M, Penhall, R, Horowitz, M, Chapman, I The Nutritional Status of Older Australian Recipients of Domiciliary Care Services and Its Association with Outcomes at 12 Months JAGS 51: , Wahlquist M, Savage G Interventions aimed at dietary and lifestyle changes to promote healthy ageing. European Journal of Clinical Nutrition 2000;54 Suppl3:s 148-s156 Healthy Ageing Nutrition Project Report of 137

12 At the commencement of the Healthy Ageing Nutrition Project, widespread use of general assessment tools including a nutrition component or specific nutrition assessment and intervention tools in South Australia was not found. It could be anticipated though, from available evidence, that many older people live with malnutrition, or with significant nutritional risk. In South Australia and in fact, throughout Australia, many older people remain living in their own homes or in the community as they age. Accessing appropriate nutrition at home, or in the community may be an issue for some, or many. It is estimated that 68 per cent of people receiving Home and Community Care (HACC) support could not live alone without meal assistance. According to the HACC minimum data set there were over 60,000 people using HACC services (aged over 55 years) in South Australia. Over 8,000 clients used social support service (which may include assistance with shopping); over 4,000 clients received centre-based meals, and almost 300 received assistance in the home with cooking/preparation of meals (other food services). It is estimated that more than 5,000 people receive home delivered meals each week through HACC Programs (predominantly through Meals on Wheels, but also smaller ethno-specific meal providers). For those living in residential care the provision of appropriate nutrition is guided by the Accreditation Standards for Aged Care Homes, administered by the Aged Care Standards Agency and Accreditation Agency Ltd 14. Both the Accreditation Standards for Aged Care Homes and the Guidelines to the Home and Community Care Program 15 are broad, with no specific requirements for nutrition assessment or interventions, although both are inherently supportive of these concepts. A national and state political environment, which was favourable to healthy ageing initiatives, existed in the lead up to the project. For example, the Australian Government s National Strategy for an Ageing Australia 16 in 2001 called for more 13 accessed on-line Nov 2005 at 14 accessed on-line Nov 2005 at 15 accessed on-line Nov 2005 at 16 accessed on line Nov 2005 at Healthy Ageing Nutrition Project Report of 137

13 research, collaborative action and improved practice initiatives for healthy ageing. Furthermore, Eat Well Australia 17 was endorsed in 2001 by the Australian Health Ministers Conference, and provided a coherent national approach to the underlying causes of the preventable burden of diet-related disease and early death. An introduction to Eat Well Australia 18 states that there is irrefutable evidence that good nutrition can enhance quality of life and contribute to health and to a general sense of wellbeing. The Government of South Australia responded to this document and process with Eat Well SA a state action plan. The South Australian Strategic Plan has an objective focused on Improving Wellbeing of South Australians. Within this objective, emphasis is given to prevention, early intervention and health promotion and to strengthening primary health care services. This includes opportunities for general practitioners, allied health workers and nurses to work together to provide easier access to their services. 19 The plan aims to improve health services for the most vulnerable people, including the frail and aged. The Healthy Ageing Nutrition Project has synergy with this. As part of Eat Well South Australia, the South Australian Community Research Unit (SACHRU) has conducted a review of the literature on effective models of workforce development (with a focus on nutrition). The review identified both capacity building and competency-based approaches as a key part of multi-strategy workforce development. Strategies suggested by an expert Australian dietitian for successful implementation of national and local strategies for prevention of nutrition related illness include: leadership, effective communication, functioning alliances and an enabling environment accessed on-line Nov 2005 at 18 accessed on-line Nov 2005 at 19 South Australia s Strategic Plan The Government of South Australia. Accessed on line Nov 2005 at 20 Woods.B. Identifying and planning assistance for home based adults who are nutritionally at risk. Vic. DHS2001 Healthy Ageing Nutrition Project Report of 137

14 Project Outline Healthy Ageing Nutrition is a project of Metropolitan Domiciliary Care; funded through the Department of Health s Human Services Research and Innovation Program and supported by their Health Promotion Branch and the Department of Public Health, Flinders University of South Australia. The project was funded for a two-year period, from March 2004 until March As a collaborative action research project the Healthy Ageing Nutrition Project aimed to develop workforce capacity through increased awareness and the use of an early intervention strategy to improve the nutritional health of older people in South Australia. The project proposed to increase knowledge and skills in the use of simple screening tools and early intervention for the older population by the health workforce. There were four objectives: > To increase awareness and knowledge of the food and nutritional needs of older people among carers and professional groups - the workforce; > To increase knowledge and skills of the workforce in early identification of nutritional risk by the use of simple assessment and screening tools; > To increase the use of appropriate nutrition early intervention strategies; and > To increase intersectoral collaboration in addressing food and nutrition needs among organizations and groups who support healthy ageing. The Healthy Ageing Nutrition Project has focused on groups and organisations and their action in building capacity toward the set objectives. Ten key groups and organisations oriented on different aspects of the aged care services sector have become project partners and have developed actions specific to their own needs and experiences. These project partners are: > Carers Association of South Australia Inc > Centre for Physical Activity in Ageing > South Australian Divisions of General Practice Adelaide North Eastern Division of General Practice Adelaide Northern Division of General Practice > Hampstead Rehabilitation Centre Block 1 Wards Healthy Ageing Nutrition Project Report of 137

15 > Dietitians interested in aged care > Meals on Wheels SA Inc > Metropolitan Domiciliary Care > Multicultural Aged Care, including: PISA Italian Meal Service Maltese Meal Service Greek Meal Service > Resthaven Inc > Royal District Nursing Service Their experiences in reorienting their organisations and clinical systems toward the project s objectives have been recorded as case studies. Additionally, South Australian training providers from the tertiary and vocational sectors have partnered the project. > Regency Institute of TAFE - Community Food Services > Flinders University of South Australia - Dietetics > Flinders University of South Australia - Public Health In the application for funding, potential project benefits were described as: > Raised awareness of the food and nutritional needs of older people in the system, community and workforce; > Increase in the inclusion of food and nutrition in aged care assessments across South Australia; > Increase in the workforces competency in the use of simple screening and assessment tools; > Increased competency in the use of early interventions and health promoting program resources; > Increased number of food and nutrition programs available in community and institutional settings; > Increased communication and partnerships within sectors; and > Coordination and collaboration across sectors. Healthy Ageing Nutrition Project Report of 137

16 Research Approach Planning, Doing, Checking and Acting The Healthy Ageing Nutrition Project has taken a multi-faceted approach to research. Principles arising from the established fields of capacity building, action research and quality management have been blended in a complementary approach to workforce development. Aspects of each facet of the approach are seen in the activity, language and relationships associated with the project. A basic tenet of the project s approach has been the Plan Do Check Act (PDCA) or Deming Cycle, as first described by American business analyst and consultant W. Edward Deming. The cycle was developed in the 1930s and later known throughout the world as the Deming Cycle, or PDCA cycle. Regardless of its name, it involves a four-step process for quality improvement. These steps are: plan to improve a product or process, do what is planned, check the results, and act on what has been learned so that the process can be repeated and continuously improved. 21 Deming's PDCA cycle can be illustrated as follows 22 : 21 W. Edwards Deming (1982) Out of the Crisis, reprinted 2000, MIT Publications, USA. 22 Accessed on-line Nov 2005 at Healthy Ageing Nutrition Project Report of 137

17 Today, this cycle is known by many organisations and embraced in various forms as a part of quality approaches and management systems. In organisations that are already working on quality improvement, total quality management or are familiar with certain models of workforce development, the thinking which underpins the PDCA or Deming Cycle is familiar. This understanding has made this a useful approach to planning change in the Healthy Ageing Nutrition Project. Following Deming s thinking, it can be accepted that quality improvements in organisations are progressive and beneficial and can be made in two ways; through improvements in processes or in improvements in outcomes by modifying existing approaches. The project s action focussed on both ways. Capacity Building Capacity building is now an accepted method of organisational development and of helath promotion, and has been extensively detailed by New South Wales Department of Health in their document, A Framework for Building Capacity to Improve Health 23. It is an approach which is known to build independence 24, value different ways of approaching problems and takes account of context at all times 25. A capacity building approach has been employed through the Healthy Ageing Nutrition Project in order to improve project sustainability, value diversity among groups, organisations and individuals and to facilitate progress toward the project s objectives. Hawe et al, who have written extensively on capacity building, promote capacity building as an approach which will support the development of sustainable skills, structures, resources and commitment to health improvement in health and other sectors to prolong and multiply health gains many times over New South Wales Department of Health (2001) A Framework for Building Capacity, Sydney 24 Eade, D. (1997) Capacity-Building An Approach to People-Centred Development, Oxfam, Great Britain, in New South Wales Department of Health (2001) A Framework for Building Capacity. 25 New South Wales Department of Health (2001) A Framework for Building Capacity., Sydney 26 Hawe P, King L, Noort M, Jordens C, Lloyd B (2000) Indicators to help with Capacity Building in Health Promotion, NSW Department of Health, Sydney. Healthy Ageing Nutrition Project Report of 137

18 Five elements of capacity building have been used to designate the types of activity that groups and organisations have undertaken through the project. > Organisational Development; > Workforce Development; > Resource Allocation; > Partnerships; > Leadership. Additionally, a further category, Policy Development, was used to descibe changes that were incorporated into policy within organisations or in other settings. Each organisation or group participating as a project partner of the Healthy Ageing Nutrition Project was offered a copy of New South Wales Department of Health (2001) A Framework for Building Capacity, to assist with planning change in relation to the project s objectives. Discussions were held between the groups or organisations and project staff to help with understanding capacity building if it was requested by groups, organisations or individuals in the course of the project. The document offered examples of strategies that could be used to influence each of the capacity building elements listed above. Action Research The overall methodology in this workforce development project has been action research. This is a process whereby groups and organisations with a common problem collaborate in planning, implementation and on-going reflection and evaluation to identify new knowledge and put it into practice. The benefit of this problem-solving approach is that it: > Recognises and takes advantage of existing knowledge and skills; > Builds in flexibility of design to accommodate different settings; > Promotes commitment to overall process; and > Encourages ownership of outcomes. Action research acknowledges different but complementary skills within the research partnership. Healthy Ageing Nutrition Project Report of 137

19 Action research is a form of self-reflective enquiry undertaken by participants in social situations 27. It can be utilized as a catalyst for transforming social relationships and structural problems that exist in organisations and work groups 28. Negotiation, conflict resolution, debate, discussion, reflection, advocating, admitting, asserting, problem solving and many more skills are inherent in the process of enacting authentic action research. 29 The process of action research follows the Deming cycle closely and involves continual reflection on practice in stages of planning, doing, checking and acting. It accepts that within an organisation or group practices are shaped by the historical, cultural and structural characteristics of the context in which they take place as well as by the biographies, skills and dispositions of the practitioners who implement them. 30 Action research can accept and be inclusive of different values and view-points and this certainly was the case for the Healthy Ageing Nutrition Project. The project demonstrated a consistent value for and commitment to learning, developing workforce knowledge, promoting and facilitating progressive changes to practice, encouraging social justice based practice, and developing connections between groups and organisations wherever possible. Each group or organisation connected to the project also had a set of unique and highly developed values embedded in an organisational or workforce culture. No research is neutral and through an action research approach, it has been possible to develop an environment in which organisations, groups and individuals could participate in developing the approach and outcome, while exploring, discussing and purposefully accepting or changing their own biases and preferences. Inclusiveness and acceptance was essential to progress. 27 Henry C, and Kemmis, S (1985) A point-by-point guide to action research for teachers, The Australian Administrator, vol. 6, no. 4, August Kemmis S, McTaggart R. ed. (1988) The Action Research Planner, 3rd edition, Geelong, Vic: Deakin University Press. 29 Wilkinson M, Ehrich, C Action research revisited: Can it assist organisational cultural change? Action Learning Action Research Journal Vol 5 No 1 April 2000 (3) 30 Stevenson, S. (1995) Teaching teachers technology. NetTeach News, April/May Healthy Ageing Nutrition Project Report of 137

20 Approach (Doing) So how was it done? The Healthy Ageing Nutrition Project operated for a two-year period. A project plan of three stages was devised to assist with the timing of the project s implementation. The plan outlined the action for each stage as follows: Project Plan and Timeframes Stage Date Planned Action 1. Planning and Establishing 2. Implementing Action Research March 04 to September 04 October 04 to October 05 > Establish management and advisory groups > Create contact register > Establish baseline measures > Plan forum and other promotion strategies > Establish evaluation plan > Establish action research framework and tools > Collate supporting information for screening tool > Identify and document existing intervention strategies > Identify target groups from workforce > Establish communication plan with workforce > Develop support materials for workforce > Implement, support, monitor and evaluate action research within case study organisations from the target groups. > Develop / collect and distribute resource materials as required to participating workforce groups. > Continually review action research plans against the project objectives > Communicate with workforce > Conduct forum and other promotion strategies Healthy Ageing Nutrition Project Report of 137

21 Stage Date Planned Action > Identify and support opportunities for establishing links between workforce groups > Identify and support opportunities for sustainability of project outcomes 3. Summary Analysis and Reporting October 05 to March 06 > Collate, analyse and prepare report on findings from action research phase > Conduct external evaluation of project activity > Prepare final reports > Disseminate findings Stage 1: Planning and Establishing Initially a contact register was established and included those who had been involved in the conceptual planning and support of the project and those involved in seeking funding. A search through networks, general knowledge and the Australian Government s Commonwealth Carelink 31 system was also carried out to determine which groups and organisations existed locally that had a link or potential link to the nutritional health of older people. From this contact list, many discussions and interviews were conducted, seeking information on issues such as: > Who are the workers who provide nutrition services or information to older people? > Who are the workers who do not currently provide nutrition services or information to older people, but may be well placed to do so? > How are such workers and organisations linked? > How are they funded? > What are they already doing to improve the nutritional health of older people? > What else could be done? > What capacity exists to improve practice? 31 Accessed on-line Nov 2005 at Healthy Ageing Nutrition Project Report of 137

22 Based on this activity, a number of groups and organisations were identified as project targets and were re-approached and asked to become partners of the project. Partnering the project meant making an organisational commitment to the project s objectives and agreeing to reorient some services toward them during (and possibly) beyond the life of the project. All of the organisations that were approached agreed to do this. Baseline measures were then established, recording details of the group or organisation and their level of activity in relation to the project s objectives. The project officer s and organisations view of their capacity to reorient toward the stated objectives was noted. The baselines were then negotiated and agreed as a formalization of the beginning of the action research. The project s management group consisted of the chief investigators and the Healthy Ageing Nutrition Project workers. An advisory group was established to bring together representatives from each of the partnering organisations, as well as a broader group of industry experts, the project workers and chief investigators. This involvement was seen to be essential to the commitment the project made to a participatory method and to action research. The project s methods have been constructed as empowering, enlightening and progressive, mobilising ideas and knowledge to action wherever possible. Facilitation by the project staff, participation by the partnering groups and organisations and continual marketing and communication of the project s ideals and objectives have assisted with this. A formal plan for communicating with the workforce was drawn up and although not followed unfailingly, provided guidance for the project s communications activity, beyond the expected daily interactions. The planner outlined below identified who the key targets of the communication would be and methods and reasons for communicating with these targets. Forums, a project newsletter, contribution to specific newsletters and a website were identified as methods for communicating, as well as postcards for specific event advertising eg launch of the project website. Healthy Ageing Nutrition Project Report of 137

23 Communications Planner Who Interested service Key people in Case Study Workforce of case study providers and HACC Organisations identified in and other action-taking funded meal service and formal evaluation process organisations shopping support or other (eg meal service nutrition service providers managers, CEOs, project contact people) When 3-monthly Continually and in-line with key project events As per organisation s own communications plan How Healthy Ageing Nutrition Newsletter and 2005 Forum and 2005 Forums. Website and Postcards re specific events. Organisations own newsletter and other communiqué. What Information regarding the Resource provision for Contextualised and project, the issue, action research specific information to screening, current and component of project plan meet organisations own potential intervention and promotion of specific goal within the project by options, organisation project events providing information profiles, best-practice regarding the project, the stories issue, screening, current and potential intervention options, organisation profiles, best-practice stories or other as agreed with the organisation Why Raise awareness Increase knowledge and provide specific information about project and events Raise awareness and prompt action Healthy Ageing Nutrition Project Report of 137

24 Complementary to the communication planner, a project image was devised with the assistance of a marketing agency and Department of Health s Media and Communications Unit and their colleagues in Department of Premier and Cabinet. This image was replicated across all of the project s communications as well as being printed on calico document bags which were used for providing information packs through project forums and other contexts in partnering organisations. Having a project image provided an opportunity to give the project an identity with the aim of making it highly visible in workplaces, and identifiable when seen by workers on repeated occasions, thus aiming to reinforce the project s message. It was also thought that having a recognizable and professional image, backed by the state government s logo, would give the project a credible look and feel. In the initial stages of the project a large body of technical and research-based information and evidence was collected and collated. This provided well-evidenced supporting information to workers on nutritional needs and health of older people, use of nutritional screening tools and strategies for early intervention. Much of this was linked to the project s website, and some was retained in the project office and provided to individuals, groups and organisations on a needs basis. The project s website was conceived as a low-cost, low-maintenance method of communication which would support action research. The website, provided a mechanism where the workforce could make decisions about and then explore and access information to best meet their own needs and goals for action. The website was constructed with numerous links to other sites providing information which informed the project s objectives. Through the website, an on-line feedback form was provided so that those accessing the site could interact, requesting new or different information, or commenting on the existing links. This offered the opportunity for users of the site to participate in the project through production and ownership of knowledge Rice PL, Ezzy, D (1999) Participatory Action research pp Qualitative Research Methods, Oxford University Press Healthy Ageing Nutrition Project Report of 137

25 During the project s planning phase, the South Australian Community Health Research Unit was engaged and collaboratively, an evaluation plan was established. Evaluation was an integral part of the project s design. Compelled by the action research method, evaluation became an on-going task for all involved in the project. Evidence in various forms was routinely collected. Action-research is open-minded about what counts as evidence (or data) it involves not only keeping records which describe what is happening as accurately as possible but also collecting and analyzing your own thoughts, judgments, reactions and impressions about what is going on. 33 Stage 2: Implementing Action Research Following the planning and establishment of the project, there was a need to move the locus of control of the project information out of the project office and toward the groups and organisations - the workforces partnering the project. Prior to this, a significant amount of time was spent on working with key managers or key contacts within the groups and organisations to eliminate real and perceived risks to the organisation. These risks were in relation to confidentiality, how information might be disseminated or publicised, and how particular organisational practices or details could be shared, but remain anonymous. Time was spent on negotiating entry to groups and organisations, understanding reciprocity, clarifying roles, procedures, protocols and limitations. Establish rapport in the field, shaping the role of the project workers and that of the participants was universally important. Paying selective attention to what was observed in organisations was also important, and emphasis was placed on assuring trustworthiness. Being selective about strategies and approaches for different settings and taking a progressive focus assisted partners to be able to be safely involved in the project. 33 Kemmis S, McTaggart, R eds (1992) Introduction. The Nature of Action Research pp5-28 The Action Resaerch Planner, Deakin University Press, 3 rd ed. Healthy Ageing Nutrition Project Report of 137

26 Once relationships were established between the project workers and the project s partners, a forum was planned and carried out. This forum was dubbed and promoted as the Moving into Action Forum - the name describing its intent! The first forum was held on 1 st October 2004 for key contacts within the workforce. Eighty people were invited to attend and approximately 60 people from more than 12 organisations (case-study organisations and affiliates) attended for all or part of the day. Advisory group members were also invited to attend or to send a representative. The purpose of the forum was four-fold: > To launch the action research phase of the Healthy Ageing Nutrition Project; > To promote the project, its objectives and its concepts to critical members of the workforce in each of the partnering organisations; > To provide an opportunity for networking between workforce members of case study organisations; and > To collect information from the workforce to help shape the delivery of support during the action research phase. The day-long forum took a multi-disciplinary approach to healthy ageing and particularly, of course, nutritional needs of older people. The program was as follows: Screening Issue, evidence and experience > Recent evidence in Adelaide > Bob Penhall (Royal Adelaide Hospital) > Different tools, different settings > Julie Dundon (Dietitians Association Australia) > Initiative in practice > Catherine Painter (presented by Bob Penhall) (Hampstead Rehabilitation Centre) Healthy Ageing Nutrition Project Report of 137

27 Intervention Issue, challenges and examples from the community meal service setting > Moving toward the future Peter Radcliffe (Meals on Wheels) > Challenges for Dietitians Anne Schnieder (Dietitians Association Australia) > The changing face of demand (ethno-specific food preferences) Andrea Dunkley (student Flinders University of South Australia) Physical activity and nutrition: partners in wellbeing > Encouraging physical activity Bob Barnard (Centre for Physical Activity in Ageing) > Falls Prevention Ruth Brunt (Best Foot Forward Project, Dept of Health) A view to the future > Where to from here? Leah Trotta (Metropolitan Domiciliary Care) > Vignettes for thinking A dietitian s view Alison Shanks (Repatriation General Hospital) A carers view Marjorie Smith (Carers Association) Following the presentations, forum attendants were invited to participate in a facilitated planning session. Participants were asked to engage in discussion about the current and possible future situation regarding nutrition for the ageing population and whether there were benefits that could be enhanced or issues that needed to be addressed. Healthy Ageing Nutrition Project Report of 137

28 Open space planning methods were used at the forum and then subsequently in a followup planning day and again with specific groups and organisations on a needs-basis following the forum. Information gathered provided an information base for the project workers to draw on in planning and facilitating action with the workforces, and also in the project s broader context. Although the project s method provided an outlook for the project, ultimately the action of the project has been problem-driven rather than method driven. This has allowed research and development to take place in an autonomous and natural setting for each workforce. Social complexities and the need to be flexible and responsive to organisational needs and conditions have needed to be taken into account in order for workforces to reorient their services toward the project s objectives. A tool for each organisation to use in discussing and recording their action or planned was provided. The proforma was as follows: Action Research Achievement Task / Action Measurement Who & When Capacity Development We hope to In order to We ll know when This change is achieve: achieve this we this is achieved a: will: because: Policy Development We ll reflect on Organisational this by: Development Workforce Development Resource Allocation Leadership Partnerships Healthy Ageing Nutrition Project Report of 137

29 Project staff facilitated by these action plans worked with the organisations and groups in ways which were mutually agreed to be beneficial to the outcome and which would promote sustainable changes. In carrying out their various action plans, many groups and organisations found opportunities and benefits in working collaboratively, increasing intersectoral exchanges and building beneficial networks. Some organisations also welcomed the assistance of final year Bachelor of Nutrition and Dietetic students from Flinders University in carrying out discreet aspects of their plans. The benefits in this were reciprocal, with organisations benefiting from the student s time, knowledge and enthusiasm, and the students and their peers benefiting from increased knowledge about aged care. In discussing the objectives and potential outcomes of the Healthy Ageing Nutrition, many instances arose where overlap into other aspects of healthy ageing were inevitable. Concurrently with the Healthy Ageing Nutrition Project, a number of other healthy ageing initiatives were evolving with a concern about the health of older South Australians. Often these were raised in discussion as organisations embarked on action. Topics included the relationship between nutrition and falls prevention, nutrition and medications management and nutrition and physical activity. Collaborative activity was undertaken on a number of occasions, with reciprocal benefits with projects such as Best Foot Forward 34 falls prevention project, Home Medications Review 35 and Home Activity Monitoring Program (HAMP) physical activity project The Best Foot Forward project in the northern metropolitan area aimed to develop and test a systems approach to falls injury prevention and harm minimization among older people to build capacity in services and communities to reduce the incidence of falls and falls injuries. Best Foot Forward was funded by the Health Promotion, Department of Health for two years during which time the Project Coordinator engaged with organisations and professionals who work with older people in the development and implementation of community strategic plans. Accessed on line Nov 2005 at 35 Home Medicines Review (HMR) is a service to patients living at home in the community. The goal of Home Medicines Review is to maximize an individual patient's benefit from their medication regimen, and prevent medication-related problems through a team approach, involving the patient's GP and preferred community pharmacy, with the patient as the central focus. In South Australia, two organisations involved in supporting this have worked to collaborate with the Healthy Ageing Nutrition Project; The Pharmacy Guild of Australia - SA Branch and The Adelaide Northern Division of General Practice. Accessed on-line Nov 2005 at 36 Accessed on-line Nov 2005 at Healthy Ageing Nutrition Project Report of 137

30 In addition to the project s expected activity, a number of initiatives specific to Adelaide s indigenous population were undertaken in collaboration with the Aboriginal Health Council of SA Inc. This included relationship building activity with Aboriginal Health workers and key community members in Adelaide s north and culminated in a forum. The forum was focused on Healthy Ageing Nutrition and jointly arranged by the Aboriginal Health Council of SA, the Healthy Ageing Nutrition Project of Metropolitan Domiciliary Care, the Northern Divisions of General Practice and the Northern Metropolitan Falls Prevention Strategy and the Best Foot Forward project auspiced by Central Northern Adelaide Health Service The forum aimed to raise the awareness and knowledge of Aboriginal and Torres Strait Islander (ATSI) workers about important holistic health issues so that they can inform and assist their clients to access appropriate regional services; to build a rapport and trust with the workers so that they will access the presenters and their organisations for information and staff training; to provide information about services within the region, and link aboriginal workers to mainstream workers so that they will access services more broadly within the region. Stage 3: Summary Analysis and Reporting In the project s final stage, time was spent on exiting the research field. This involved communicating with organisations about a change in relationship with the project, and the need to move into a phase of collation, analysis and preparation of findings from the action research phase. Contact was however maintained over this time. During this phase, the final external evaluation of project activity was conducted by SACHRU and those findings were disseminated through the final forum, which took place on 24 th May 2006 and was called Completing the Loop. Evaluation (Checking) Checking of the project s progress was continual throughout the project and is best described through the project s evaluation plan. Refer to Attachment 1. Healthy Ageing Nutrition Project Report of 137

31 Ethics The Healthy Ageing Nutrition Project was focused on organisations and their action in building capacity towards set objectives. Information was collected about organisations and recorded documentation provided in a negotiated document agreed by the project workers and organisation s delegate. There was no study of individuals involved in the project, and there were no individuals identified or adversely affected by the objectives of the project. The project focused on organizations and groups taking action in their own context. Any information collected was done only within the organization and was collected according to the organizations own practices and processes. No individual information was collected. What next? (Acting) There is recognition in the health promotion and public health literature that initiatives built on cooperative partnerships have the best chance of sustainability. From the outset, the Healthy Ageing Nutrition Project has had commitment at a high organisational level from each project partner which augers very well for sustainability of effort and outcomes. Moreover, the action research framework which has underpinned the development of the project actively builds cooperation leading to increased project sustainability. There have been many examples of project partners working together on their shared visions through the project and as such have built collaborations and have transferred knowledge about solutions. The case-studies developed through the evaluation process demonstrate ways in which the project outcomes can be used by other agencies in a variety of settings. Throughout the project it has been apparent that the particular combination of actionresearch and capacity-building that has evolved through the project has been a useful and progressive method of workforce development. The method used in the project has also attracted attention from health care providers from other parts of Australia seeking information about how the method might be developed for their specific research and development needs. Healthy Ageing Nutrition Project Report of 137

32 The problem-solving process which works within the action-research methodology helps organisations to highlight areas for further development. Some common themes for further research emerged: > Dementia and good nutrition > Nutrition issues for older indigenous South Australians > Food preferences among older people > Obesity prevention in older people > Healthy weight maintenance in older people > Food security and older people Further progress, beyond the sustainable action devised by the partnering organisations, is dependent upon further funding. Healthy Ageing Nutrition Project Report of 137

33 ATTACHMENT 1: EVALUATION The following information on evaluation design for the Healthy Ageing Nutrition Project was prepared in the planning phase of the project. It was prepared jointly by Leah Trotta, Metropolitan Domiciliary Care and Gwyn Jolley, South Australian Community Health Research Unit. The design of the Healthy Ageing Nutrition Project determines that there will be two main mechanisms of evaluation. Firstly, there is an intrinsic approach to evaluation that is a part of the action-research methodology that the project has adopted. Taking an Action-Research approach means entering a continual cycle of planning, implementing and evaluation, before reflecting and then planning a new approach to implement, evaluate and learn from. This type of evaluation will occur continually throughout the project and will be evident in activity such as: > The project team documenting its findings and approaches in terms of the actionresearch cycle and the subsequent production of summary reports at regular intervals. > The case study organisations (partnering organisations) documenting their experience in managing the changes that are the objectives of the project. Secondly, a formal external evaluation will be conducted by the South Australian Community Health Research Unit (SACHRU) with the purpose of: > Triangulate processes and outcomes of the project; i.e. to contribute other sources of data/ perspective and/or use other methods to obtain information about project processes and outcomes > Assess the strength of the action research process and progress towards project objectives. Encouraging organizations and groups toward change will be done in the context of the project s goals and objectives. Action will be focused on progress towards project objectives. Healthy Ageing Nutrition Project Report of 137

34 Action Research Evaluation 1. Collecting baseline information in relation to an organisation s current activity and capacity within the scope of the Healthy Ageing Nutrition objectives. Face-to-Face interviews will be conducted with group / organisations which are actively involved in screening or intervention which relates to the objectives of the Healthy Ageing Nutrition Project. The purpose of the interviews is to scope the activity of workforces which are active, or have the potential to be active, in contributing to the nutritional outcomes of older people. This process will be supported by the collection of published information from the organisations (such as annual reports, web-page information and client information packs). Baseline information will be collated in a template format and referred back to the organisation for negotiation and response before a final copy is filed. At the time that this information is collected, discussion will be conducted with groups/ organisations about their possible commitment to participating in action research. Up to 10 organisations (those considered to have the capacity for development within the timeframe of the action research and with an interest in participating) will be selected by the project management group for the development of formal case-studies to be externally evaluated, based on their a) willingness to participate b) potential role in the context of the project and c) perceived capacity for change based on the baseline data collected. 2. Planning and recording a) the intended action of organisations; b) the organisation s approach to making the intended change; and c) how, when and by whom the intended action will be measured. Intended action against the Healthy Ageing Objectives for each group / organisation will be initially discussed between the group or organisational representatives in terms of what is likely to be achievable. Change and results of this discussion will be recorded on a three-monthly action research planner, for a period of 12 months. Healthy Ageing Nutrition Project Report of 137

35 Monitoring of the planner with the group or organisation and some support (in the form of advice, monitoring and discussing progress and provision of reference materials) will be provided by the project team during this phase. The NSW Health document, 2001 A Framework for Building Capacity to Improve Health will be provided to participating groups / organisations as a discussion starter about the types of changes that might be aimed for in line with the Healthy Ageing Nutrition Project objectives. Other information pertaining to the recommended screening tool, action research and healthy eating for older Australians will also be provided to all participating groups / organisations. 3. Describing the journey that organisations have taken in the quest for change in relation to the Healthy Ageing Nutrition Project objectives. An analysis of the action research planner will be conduced periodically (approximately every three months for a 12 month period) for each group / organisation. The analysis will be written into a case study format, along with the baseline information and a summary at the end of the action-research phase. The case studies will become a part of the external evaluation of the project. External Evaluation 1. Progress towards meeting the Healthy Ageing - Nutrition Project objectives Individual case studies (maximum of 10 workforces/organisations) will be developed. Early in the project, baseline data will be collected re current practices that support Healthy Ageing Nutrition Project objectives (e.g. screening and nutrition interventions for older people) initial thoughts about how these could be strengthened by participation in the Healthy Ageing - Nutrition Project, and anticipated actions and outputs/outcomes. A summative assessment will document progress towards the Healthy Ageing - Nutrition Project objectives, relevant to the specific workforce/organisation. Healthy Ageing Nutrition Project Report of 137

36 2. Strength of the action research (and competencies) approach to workforce development in progressing the objectives of the Healthy Ageing Nutrition Project Individual case studies will focus on the extent to which an action research approach is accepted, implemented, resourced and sustained by agencies and how this impacts on progress towards project objectives. There will be a strong emphasis on the learning that is achieved across a range of initiatives and considerable diversity in the type of workforce, the project objectives that are most relevant for specific workforces, organisational resources, communication channels and established processes and infrastructure for workforce development. 3. Reach of the project, in terms of workforce participation, coordination and collaboration Other workforce initiatives that address one or more of the project objectives but are not sufficiently developed, or exceed the number of case studies that can be accommodated within the evaluation will be scoped and documented. The Best Foot Forward project in the northern metropolitan area aimed to develop and test a systems approach to falls injury prevention and harm minimisation among older people to build capacity in services and communities to reduce the incidence of falls and falls injuries. Best Foot Forward was funded by the Health Promotion, Department of Health for two years during which time the Project Coordinator engaged with organisations and professionals who work with older people in the development and implementation of community strategic plans.37 Home Medicines Review (HMR) is a service to patients living at home in the community. The goal of Home Medicines Review is to maximize an individual patient's benefit from their medication regimen, and prevent medication-related problems through a team approach, involving the patient's GP and preferred community pharmacy, with the patient as the central focus.38 In South Australia, two organisations involved in supporting this have worked to collaborate with the Healthy Ageing Nutrition Project; The Pharmacy Guild of Australia - SA Branch and The Adelaide Northern Division of General Practice. Additionally there have been many opportunities to discuss. 37 Accessed on-line at 38 Accessed on-line at Healthy Ageing Nutrition Project Report of 137

37 The Organisations Group 1 Advisory Partners > Department of Health - South Australia (HPSA) > Department of Families and Communities - Office for the Ageing > Flinders University of South Australia - Public Health > Flinders University of South Australia - Dietetics > Regency Institute of TAFE - community food services > South Australian Community Health Research Unit > South Australian Dental Service Healthy Ageing Nutrition Project Report of 137

38 Group 2 Case Studies Carers Association of SA Contact Person and Position: Di Schneider, Manager, Carer Support Description of Organisation: The Carers Association is the peak Carers organisation representing all Carers in South Australia. An Association exists in each State with the National body being located in Canberra. The Association is a non-profit incorporated community-based organisation with a membership in the thousands. The Carers Association of South Australia aims to empower Carers to participate in partnership with government and non-government organisations for the provision of better services, to improve the conditions under which Carers work, and to increase recognition of Carers' contribution to the South Australian community and economy. Context in Project Carers Association represents Carers who often live with and advocate for older people who are living in home and community environments. A large portion of the work of accessing and preparing food for, and feeding older people, occurs in this environment. Well informed Carers are able to identify people who are malnourished or at risk of malnourishment and are then able to seek supports to manage this situation. Carers have a role in both intervention, and screening process that would facilitate at-risk people being redirected to seek additional information, or higher level care or support. Healthy Ageing Nutrition Project Report of 137

39 Current Activity in Screening and Intervention There is no current activity occurring within Carers Association that is specific to the aims of the project. However, Carers Association has a Resource Centre that is accessed by members and non-members by telephone. The Resource Centre supplies information to callers on health promotion topics and on referral options for specific issues. Carers Association also funds and operates retreats for carers who are seeking opportunities to learn about specific issues of relevance to their own care situation. In addition to this counselling, either individual or group based is offered to members seeking this service. Furthermore Carers Association state-wide operates five Carers Support Services and one of four state Respite Centres. Capacity for Change The Carers Association is keen to participate in change that will result in better informed carers, with information being delivered directly into carers hands in multiple ways and when it is most likely to be utilised (i.e. Just in Time Information via print, peer networks, web and face-to-face) The structures and supports that exist in Carers Association make it an ideal environment for the uptake of new information through existing structures. Healthy Ageing Nutrition Project Report of 137

40 Centre for Physical Activity in Ageing (CPAA) Contact Person and Position: Bob Barnard, Chief Exercise Physiologist Description of Organisation: The central tenet of the Centre for Physical Activity in Ageing (CPAA) is to contribute to the quality of life of individuals through the provision of specialised physical rehabilitation, health promotion, scientific research and educational programs. The CPAA achieves this by: > Believing that the individual is of paramount concern and focus; > Adhering to the belief that activity / exercise is of primary importance to quality of life; > Being recognised as a unique Centre with highly specialised skills in the field of exercise and ageing and physical rehabilitation; > The provision of specialised programs that provide an opportunity for individuals to participate in regardless of their level of disability with focus on the older client and "work fitness" rehabilitation; > The provision of specialised educational services aimed at meeting the needs of various groups within the community; > Contributing to the scientific knowledge and understanding of the role of activity / exercise amongst the aged; and > Sound management and planning that will result in direct benefits to current and future clients. Context in Project CPAA s mission includes reference to provision of health promotion, scientific research and educational programs. Each of these undertakings can be linked to the objectives of the Healthy Ageing Nutrition Project. There are complementary outcomes to be achieved by CPAA and the Healthy Ageing Nutrition Project. The WHO report of a Joint WHO / FAO Expert Consultation Report on Diet, Nutrition and the Prevention of Chronic Disease, Geneva 2003, linked nutrition and physical activity as two main preventative factors requiring urgent action. Links between CPAA and the objectives of the Healthy Ageing Nutrition Project support this. Healthy Ageing Nutrition Project Report of 137

41 Current Activity in Screening and Intervention There is no current activity in CPAA that directly relates to the objectives of the project. However, CPAA has a screening process that is required for referral. Nutritional screening could be included at that point. Additionally there is a large body of work being carried out to educate both older people and their fitness instructors about factors which affect the health of older people and which relate to the mission of CPAA. The message of the project has a fit with this activity. Forums for this education include printed newsletters and face-to-face training sessions. Capacity for Change CPAA has a willingness to have a complementary approach between their activity and the objectives of the Healthy Ageing Nutrition Project. Healthy Ageing Nutrition Project Report of 137

42 Hampstead Rehabilitation Centre Contact Person and Position: Dr Bob Penhall, Director, Geriatric and Rehabilitation Medicine Service, Catherine Painter, Dietitian Description of Organisation: The mission of Hampstead Rehabilitation Centre is to maximise independence and optimise lifestyle through rehabilitation. Hampstead Rehabilitation Centre is a campus of Royal Adelaide Hospital. It is a 150-bed facility which provides clinical rehabilitation services for people suffering from traumatic brain injury, stroke, other neurological and medical disorders, spinal cord injury, orthopaedic conditions and amputations. Rehabilitation is a process of restoring function through re-learning lost abilities or finding new ways of doing everyday activities to maximise lifestyle. Rehabilitation is very different from being treated in an acute hospital care setting. In all areas trained allied health, medical and nursing staff work with clients, client s families and friends, and others, to design and implement rehabilitation programs using an integrated team approach. The major focus of the inpatient units is to provide highly specialised physical rehabilitation programs for clients with disabilities arising from medical and age related illness, orthopaedic injury and amputation, stroke, neurological illness, spinal cord and brain injury. A range of inpatient and outpatient services support these programs. Context in Project Hampstead Rehabilitation Centre s Medical Rehabilitation Program provides inpatient therapy for people with a variety of medical illnesses, placing special emphasis on neurological disorders, particularly strokes. The program caters for a wide variety of conditions and is one of a range of integrated services from the acute phase, to outpatient participation in hydrotherapy and the Centre for Physical Activity in Ageing programs. Healthy Ageing Nutrition Project Report of 137

43 This centre offers two streams of care: a) Planned Respite and Crisis admissions, to relieve patients or carers with social crises and b) A Recovery Care Rehabilitation environment for patients, with various medical conditions, who may require a longer stay or less intensive therapy to facilitate successful discharge to an independent community setting, thus preventing or delaying institutional care. Some patients in the Medical Rehabilitation Program are likely to be at risk of malnutrition and as such could expect to benefit from a planned screening and intervention program. Current Activity in Screening and Intervention Screening initiatives for nutrition have been trialled at Hampstead Rehabilitation Centre with positive outcome. Nutritional screening is currently not a routine function for patients admitted to Hampstead Rehabilitation Centre; however, a part-time dietitian is available on site and is available to consult upon request. Hampstead Rehabilitation Centre has a multi-disciplinary approach to care and nursing and medical staff, speech pathologists and occupational therapists may also be involved in planning care for those patients where nutrition is an identified concern. Capacity for Change The multi-disciplinary team approach, the commitment of the Geriatric and Rehabilitation Medicine Service director and the facility-based dietitian are positive indicators of Hampstead Rehabilitation Centre s capacity to support an on-going approach to screening and intervention for nutritional risk among older people who are patients of the Centre. Healthy Ageing Nutrition Project Report of 137

44 Interested Dietitians Organisation Name: Dietitians Contact Person and Position: Various, initially including: Lynne Daniels, Professor of Dietetics, Flinders University of South Australia (FUSA) Elizabeth Kellett, Chief Dietitian, Flinders Medical Centre Julie Dundon, Dietitians Association of Australia, South Australia; Private Practicing Dietitian, Michelle Miller, Dietitian, Repatriation General Hospital; Researcher, (FUSA) Catherine Painter, Dietitian, Royal Adelaide Hospital / Hampstead Rehabilitation Centre Description of Organisation: The group labelled Dietitians in this project are not representative of a single organisation; however, do provide a broad representation of the roles of dietitians in South Australia. If seeking to act toward a common goal, this group of representative dietitians has a collective power that as yet has not been actioned in any noted, organised activity. Context in Project The sustainability of this project relies on a number of factors, including organisations reengineering their business to provide recognition and support to the issues surrounding nutrition and older people; government awareness of and commitment to change issues in the field of nutrition and older people; and on a group to champion the issue to ensure it has a life and voice well beyond the life of the project. Prominent dietitians (including those represented in this group for the purpose of the project) are well placed to be that champion group. In order for this to occur the group needs to have some opportunity to consider their willingness and capacity to act as a collective and to identify targets for action, should that be the intent of the group. Healthy Ageing Nutrition Project Report of 137

45 Current Activity in Screening and Intervention Dietitians in this group are currently active in screening clients in the group which is of interest in the project, and in intervening and then monitoring the intervention. Members of this group are also active in the education and training of upcoming professionals; in representing other dietitians and in researching within their fields. The group s members have broad professional interests and the commitment of each brings a complex of knowledge and network to the project that spans across the activities and interests of the other organisations that are case studies in this project. Capacity for Change The single largest opportunity for this group is to facilitate opportunities and support for the group to act collectively in a way that is likely to produce interest, action and change in the broader health care community. There is interest among this group to explore this opportunity. Healthy Ageing Nutrition Project Report of 137

46 Meals on Wheels SA Inc Contact Person and Position: Cam Pearce, CEO Description of Organisation: Meals on Wheels (SA) Incorporated provide meals, personal contact, and security to elderly, infirm, and disabled members of the community through its Branch Volunteers. Meals On Wheels is a not-for-profit, local community, branch based, volunteer organisation working throughout South Australia and made up of people from all parts of the community committed to helping people live independently in their own home. Meals on Wheels provide balanced nutritious meals and personal contact to elderly, infirm and disabled members of the community, with the dedicated support of volunteers. A hot three course meal is delivered each week day Monday to Friday (except public holidays), throughout the year. The meal consists of soup, main course and dessert and accounts for about a third of an elderly person's daily nutrition and energy requirements. Special needs are also catered for. Meals are delivered between 11.15am and 1.30pm each day and are charged to recipients at a very reasonable price representing excellent value for money. The service assists people to remain independently in their own home, preventing premature admission to other types of care and enhancing their quality of life. Service is based on referral from a health professional or other interested party. The service caters for both long and short term needs. Those receiving meals long term are generally the aged and infirm, assessed as permanently requiring meals. Short term recipients are often recuperating from surgery, an accident or prolonged illness. Carers can also access the service. The strength of Meals on Wheels (SA) Inc. comes from the 10,000 volunteers from 100 branches throughout South Australia, who prepare, cook and deliver over 5,100 meals each weekday. Volunteers serve as cooks, kitchen helpers, drivers and deliverers, with most offering their services either once a week or fortnightly. Healthy Ageing Nutrition Project Report of 137

47 About 70 per cent of Meals on Wheels meals are produced through 31 fresh cook kitchens (90 per cent of which are in the broader Adelaide urban area); 20 per cent through Hospital based branches and 10 per cent through our Kent Town Cook Chill production facility which is run by paid staff. Seventy per cent of our recipients are over 80 years of age and about half are on meals for the short term, that is, less than three months and are recovering from illness etc; the other half are long term frail aged. Sixty-five per cent of recipients are women and 35 per cent are men. Meals on Wheels utilises its own kitchens to produce fresh-cook meals. In country towns, hospital kitchens cook meals and Meals on Wheels' volunteers deliver them to people in the town and outlying areas. Meals for some branches are also prepared using cook-chill technology. This involves reducing the temperature of the meal to three degrees Celsius after cooking, then reheating in ovens later for delivery. For recipients in remote areas, frozen meals are provided. Eighty per cent of the organisation's funding comes from meal sales and the remaining 20 per cent comes from Home and Community Care - a joint Federal and State Government program. Meals on Wheels (SA) Inc. is governed by a voluntary Board of 13 people from both the branches and the broader community to ensure all necessary board skills are met. Four committees report to the Board covering different types of branches - fresh cook; cookchill; hospital based; and a finance, audit and governance committee covering governance and related matters. A small group of paid staff based in Adelaide provides administrative, policy and other support to branch volunteers. Healthy Ageing Nutrition Project Report of 137

48 Context in Project Refer to above statement. Meals on Wheels are the largest provider of this type in South Australia and are therefore a key stakeholder in this project which focuses on both building the capacity of the health system to meet a need. Currently Meals on Wheels is meeting some of the anticipated need. Meals on Wheels have a role in client education about eating well and also have on-going client contact which provides an opportunity to monitor client well being. Current activity in screening and intervention There is a screening process in place to determine eligibility for service, and Meals on Wheels core business is quite obviously focussed on intervention. Capacity for Change Meals on Wheels have a number of perceived or actual constraints on their service, including available funds (bound by reasonable cost to client), availability and capacity of volunteer staff to increase workforce number or activity, and external regulatory factors such as compliance with food safety legislation which has an impact on the shape and resources of the business of Meals on Wheels. However, significant change in line with legislative and quality improvement requirements is already being undertaken. A partnership with a group of consultant dietitians exists. Meals on Wheels are willing to participate in moving toward the goals and objectives of the Healthy Ageing Nutrition Project. Healthy Ageing Nutrition Project Report of 137

49 Metropolitan Domiciliary Care (MDC), Day Rehabilitation Centre Contact Person and Position: Bob Penhall, General Manager, Medical Services Description of Organisation: The newly amalgamated organisation comprised the previously unincorporated domiciliary care regions that had been affiliated with hospitals (Eastern Domiciliary Care, Northern Domiciliary Care & Rehabilitation Service and Western Domiciliary Care & Rehabilitation Service) with the incorporated Southern Domiciliary Care & Rehabilitation Service. Tregenza Avenue Aged Care Service a separately run business unit which offers high and low care residential care, transition care, community-based accommodation and community centre day activities adds to the spectrum of services being offered by MDC. The MDC Board of Directors commenced meeting in July 2002 and membership of the Board was finalized in October An Acting Chief Executive Officer (CEO) was in place from July to September 2002 and the new CEO commenced in December The Board identified that a focused strategic plan would need to be completed once the new CEO was at the helm. The plan would need to be aligned with outcomes and recommendations of state and national strategic directions and give consideration to existing domiciliary care services plans as well as the findings and recommendations of former reviews. Most importantly it would need to build upon the good work and models of service delivery already in operation within the organisation. Metropolitan Domiciliary Care operates within the broader system of community and primary health care. We work to facilitate access for our clients to other parts of this broader system where needed and made referrals to specialised services for particular client groups. Metropolitan Domiciliary Care (MDC) was incorporated in July 2002 as an entity under the South Australian Health Commission Act (1976). Our Services include: > Information provision > Health promotion / Early intervention (including falls prevention) > Equipment provision Healthy Ageing Nutrition Project Report of 137

50 > Home modification > Home help > Personal care > Rehabilitation (in home & centre based) > Respite care > Assistance for people with memory loss > Aged care assessment > Services responsive to culturally and linguistically diverse populations > Specialised Aboriginal services > Palliative care Our Expertise includes: > Paramedical aid > Occupational therapy > Physiotherapy > Social work > Speech pathology > Podiatry > Dietetics > Medical services Healthy Ageing Nutrition Project Report of 137

51 Context in Project Metropolitan Domiciliary Care has a client base of around 20,000 and is able to determine those clients who are at nutritional risk due to poor mobility, social dependency, physical dysfunction or other cause through the client intake process. Clients are then able to be followed up through the case management procedures to be further screened and followed-up. Referral onto other agencies or inclusion of specific professionals, such as geriatricians and dietitians, in the case management process is common. Metropolitan Domiciliary Care s activities are central to the objectives of the Healthy Ageing Nutrition Project. Current Activity in Screening and Intervention Metropolitan Domiciliary Care currently has a process for intake of clients through the Metropolitan Intake Team (MAT) which conducts a needs analysis of the client over the phone at the time of referral (either self referral or third party referral). The screening at this point determines key issues to be followed up by the case manager. The case manager might be a Social Worker, Occupational Therapist or Physiotherapist. The case manager then uses his or her own professional skills and knowledge to consider and plan appropriate interventions and referral options. Capacity for Change Metropolitan Domiciliary Care is undergoing rapid change in structure at the present time, but has the scope for tools and processes to be introduced to better support professionals in managing cases where clients are likely to be nutritionally at risk. Healthy Ageing Nutrition Project Report of 137

52 Multicultural Aged Care (MAC): PISA Italian Meal Service, Maltese Meal Service and Greek Meal Service Contact Person and Position: Andja Ristivojevic, Services Development Coordinator Description of Organisation: Multicultural Aged Care pursues the vision that all older people from culturally and linguistically diverse backgrounds will lead the lifestyle of their choice. MAC aims to strengthen the ethnic communities capacity to develop and manage the care of their older people and to provide for their happiness and well being; and support and assist service providers to give older people from culturally and linguistically diverse backgrounds the services of their choice. MAC is funded by the Commonwealth Department of Health and Ageing and the South Australian Department of Human Services. MAC partners three organisations in the provision of culturally specific meals services - PISA (Italian Meals Service), Greek Meals Service and ISMA (Maltese Meals Service). Context in Project Along with Meals on Wheels, the three Meal Services which are offered in a partnership arrangement with Multicultural Aged Care, represent the majority share of organised, home delivered, community meal services in the Adelaide Metropolitan Area Additionally, MAC is aware of and supports a number of other organisations who are providing some level of food service support (from meal support through to shopping support services) in the community through various ethnic clubs and organisations. This makes Multicultural Aged Care a key stakeholder in the capacity building component of the Healthy Ageing Nutrition Project. Multicultural Aged Care have a role in client education about eating well and the workforce of the three meal services also have on-going client contact which provides an opportunity to monitor client well being. Healthy Ageing Nutrition Project Report of 137

53 Current Activity in Screening and Intervention The three Meal Services which are offered in a partnership arrangement with Multicultural Aged Care are actively providing intervention services that align with the outcomes of the Healthy Ageing Nutrition Project. There is no known, specific screening activity occurring. Capacity for Change In line with their commitment to continuous quality improvement, Multicultural Aged Care wish to improve the scope and quality of service that are currently being offered through their three partnered meal services. MAC are willing to support the distribution of information to providers through their existing network and are open to exploring initiatives that are generated as a result of the activity of the Healthy Ageing Nutrition Project. Healthy Ageing Nutrition Project Report of 137

54 Resthaven Incorporated Contact Person and Position: Andrew Stoll Executive Manager, Community Services, and Chris Headland Executive Manager, Residential Services Description of Organisation: Resthaven aims to be highly respected through the delivery of responsive, flexible, innovative and effective services. Resthaven strives to serve older people, responding to their needs through the provision of quality services. Resthaven is a Uniting Care agency - an aged care community service of the Uniting Church in Australia (SA Synod). Resthaven provides a range of residential care for approximately 1,000 older people in high (nursing home) and low dependency (hostel) aged care facilities and independent living units. Resthaven is committed to continuous quality improvement in its endeavour to meet the needs of older people. Residential care services are adapting to cater for the increasing frailty of many residents. The average age of residential clients across the organisation is approximately 86 years. Community Services for older people living in the community include therapy services (podiatry, speech, physiotherapy and occupational therapy), several community aged care package programs, planned in-home respite services and a variety of other programs. Resthaven employs over 900 staff and is supported by approximately 430 volunteers and is a charitable Public Benevolent Institution, separately incorporated and financially independent of the Uniting Church. Resthaven generates revenue from Federal Government grants and residents' contributions. Bequests and donations to Resthaven have a significant impact on continuing to help maintain the level of care and services we currently provide to the community. Healthy Ageing Nutrition Project Report of 137

55 Context in Project Resthaven is a provider of both residential care and home and community care, and is a multi-site organisation. This provides an opportunity to look at change in a number of settings and to consider the different issues for residential care clients, to those who are living in the general community. Resthaven has a Clinical Manager who is committed to seeking evidence based, best practice solutions in the residential care setting. Current Activity in Screening and Intervention Resthaven s Clinical Manager has already commenced work on collecting evidence and selecting a tool for use in the residential care setting. She has considered and possibly excluded use of the MNA at this stage however this does not preclude further evidencing and trial of the MNA. Current intervention plans already exist however will be more intensively utilised following the introduction of better defined screening processes. Capacity for Change Resthaven is committed to providing evidence based, best practice solutions in the residential and community care setting. Providing the aims of the project are commensurate with the business plan of the organisation, Resthaven are committed to considering options for change. Healthy Ageing Nutrition Project Report of 137

56 Royal District Nursing Service of South Australia (Inc) Contact Person and Position: Cathy Isam, Senior Projects Officer, Business Development Unit Description of Organisation: RDNS (Royal District Nursing Service) of SA Inc is a nongovernment and not for profit organisation providing a 24 hour, 7 day home and community nursing service to a population of 1.072million across Adelaide. It is principally funded by the joint State-Commonwealth HACC (Home and Community Care) Program. Other sources of funding include contracts with the Department of Veterans' Affairs and other agencies and fundraising and community support provided by the RDNS Foundation. RDNS commenced in South Australia in RDNS employs 314 (FTE) nursing and support staff and provides services to an average of 4,200 clients each month with around 1,100 new admissions per month. In RDNS provided 446,000 nursing visits and 170,000 other client contacts and travelled 3.7million kilometres in a fleet of 195 cars. Nursing services are provided at home or at an RDNS Nursing Centre. Specialist nursing services include wound management, diabetes management, palliative care, continence management, health care for people with disabilities, HIV-AIDS, and dementia and mental health. The RDNS 24 hour Health Contact Centre (Healthcare Access) offers a 24 hour nursing advice and information service to clients who are receiving RDNS services. RDNS also runs Marree Hospital in the remote north of South Australia. RDNS is accredited by the Australian Council on Healthcare Standards and is committed to providing high standards of care. Context in Project RDNS has a large intake of clients into its service at around 1,100 clients per month. A portion of these clients could benefit from assessment with the MNA. If the client wishes to seek assistance, RDNS staff are well placed to provide advice, patient education, referral or support depending on the specific circumstance. Healthy Ageing Nutrition Project Report of 137

57 Current Activity in Screening and Intervention RDNS are currently using a series of client assessment tools, from the first point of contact or referral at the call centre, through to general and specialist nursing assessments. With the exception of diabetes specialist assessments, nutrition, and more specifically malnutrition are not highlighted as specific areas for information to be collected, however information relevant to nutrition and nutritional risk is gathered incidentally. Many of the risk factors highlighted in the MNA are identified at points throughout the RDNS client assessment process, including, dementia and, mobility. The Client Assessment Dependency Instrument has a question relating to independent living and eating and the Trial Client Assessment Tool has an area for general comment relating to nutrition and oral hygiene. Management options in relation to nutritional risk are determined through professional decision making. Capacity for Change RDNS has recently reassessed their Trial Client Assessment Tool and will shortly be proceeding to develop general assessment competencies. There may be an opportunity to view the inclusion of a specific nutrition assessment in the context of this change. RDNS will consider their position in relation to the goals and objectives of the Healthy Ageing Nutrition Project and participate in change which is complementary to the organisation s own business plans and strategies. Healthy Ageing Nutrition Project Report of 137

58 SA Divisions of General Practice (SADI) > Adelaide Northern Division of General Practice > Adelaide North Eastern Division of General Practice Contact Person and Position: Anna Fergusson, Programs Coordinator, Diabetes and Population Health Description of Organisation: SADI is the support and coordination body for the fourteen Divisions of General Practice in South Australia. It is a conduit and focal point for information between Divisions and State and Federal Government. SADI is a non-government organisation managed by GP representatives from the fourteen Divisions and is professionally staffed. SADI is an advocate for Divisions in health policy and planning, program development, implementation and evaluation. Context in Project GPs are a key group in the provision of screening, management and referral of older people and are therefore well placed to utilise the tool recommended by the project for screening and also to take up the messages of the project for use in planning interventions or further referral for patients. Information provided through the Divisions is selectively taken up my members depending upon their own perceptions of their need for information, tools or other supports. Politically, SADI is also well placed to advocate for change if its member GPs through their own divisions support for changed conditions or funding in relation to the provision of services for supporting improved nutrition in older people. Healthy Ageing Nutrition Project Report of 137

59 Current Activity in Screening and Intervention Currently GPs receive funding for providing EPCs or Enhanced Primary Care plans to clients who present themselves for this service and who are aged 75 years or more (or 55 year or more for Aboriginal or Torres Strait Islanders). The EPC includes a set of recommended questions on Nutrition that are more complex, but of unknown effectiveness, compared to the MNA. There is no set referral plan from this as the EPC has an aim of having a comprehensive plan to manage the case. It is anticipated that many GPs are using their own initiatives to screen and refer patients in the age group that is of concern in the Healthy Ageing Nutrition Project, although the information, referral structures and resources available to do this are currently unmapped. Capacity for Change There is capacity for the existing structures of SADI to be used to spread the message and achieve some of the objectives for this project. The uptake of any activity is at the discretion of the individual member GPs of each Division. Healthy Ageing Nutrition Project Report of 137

60 SECTION 2: EXTERNAL EVALUATION REPORT, APRIL INTRODUCTION AND BACKGROUND The South Australian Community Health Research Unit (SACHRU), Flinders University, was contracted in August 2004 to undertake external evaluation for the Healthy Ageing Nutrition project. This external evaluation complements the internal evaluation undertaken by the project team. Purpose of the Evaluation Reflection and evaluation of action was embedded in the action research methodology utilised by the project. The purpose of the external evaluation 39 was to: 1. Triangulate processes and outcomes of the project i.e. to contribute other sources of data/ perspective and/or use other methods to obtain information about project processes and outcomes 2. Assess the strength of the action research process and progress towards project objectives. In line with the HSRIP application, the evaluation focussed on: > Progress towards meeting the Healthy Ageing - Nutrition Project objectives > Strength of the action research (and competencies) approach to workforce development in progressing Healthy Ageing - Nutrition Project objectives > Reach of the project, in terms of workforce participation, coordination and collaboration 39 HSRIP application Healthy Ageing Nutrition Project Report of 137

61 Project Goal and Objectives The goal of the project was to develop workforce capacity through increased awareness and the use of an early intervention strategy to improve the nutritional health of older people in South Australia. Objective 1 To increase awareness and knowledge of the food and nutritional needs of older people among carers and professional groups (known here as the workforce ) Objective 2 To increase knowledge and skills of the workforce in early identification of nutritional risk by the use of simple assessment and screening tools Objective 3 To increase the use of appropriate nutrition early intervention strategies Objective 4 To increase intersectoral collaboration in addressing food and nutrition needs among organisations and groups who support healthy ageing 2. EVALUATION METHODS The SACHRU evaluation plan was designed and developed in consultation with the project manager and project management team. To reflect the action research methodology of the project, the evaluation focused on qualitative case studies of the ten participating organisations and facilitated reflection by the project stakeholders. Data collection and analysis is described below. Healthy Ageing Nutrition Project Report of 137

62 Interviews with the Project Manager Three interviews, of about one hour each, were conducted with the project manager in March, September and November The purpose of these interviews was to document progress, identify what was working well, the challenges and unexpected events, what might need to be changed/done differently in light of the experience so far, and broader lessons. Interviews were audio-taped and partially transcribed into text documents for import to NVIVO for analysis. The analysis documented emerging themes and the findings from each interview were used to guide subsequent interviews in order to explore achievements and challenges more thoroughly. Interviews with Participating Organisations Representatives from the ten participating organisations were interviewed twice, once in April and again in November Interviews were conducted by phone or in person depending on the respondents preference. Most interviews took between minutes. As the dietitians group was a loose federation rather than an organisation, three respondents were interviewed to give a range of viewpoints. This meant that 12 sets of interview data were recorded. The first round of interviews asked respondents to rate the quality of the project management and activities, about their expectations and support needs, and to describe their achievements and changes to date. The second round confirmed any further activities within the organisation, any other changes and asked about the perceived level \of achievement of the project s goal and objectives. Responses were hand written at the time of the interview and typed into a word table for analysis by question. Further analysis of the organisational data against the action plans and project objectives and project documentation was then undertaken with the aim of producing case studies of organisational change. Healthy Ageing Nutrition Project Report of 137

63 Project Advisory Group A focus group was held with the project advisory group (n=6) in November The group was asked about their role and function, project management, benefits and challenges in brining about organisational change using an action research approach, achievements and ideas for future development. The discussion was audio-taped and hand written notes taken by an assistant as back-up. As a number of advisory group members were unable to attend on the day, follow up phone interviews were conducted with another four respondents. Reponses from the focus group and the interviews were collated and analysed by question. Review of Project Documentation The Action Plans for each participating organisation were reviewed at the mid-point and at the completion of the project. Other project documentation reviewed included interim reports to the funder, copies of presentations to interested groups, planning documents and minutes, and records of activity with non-case study organisations who had an interest in the project. Synthesis and Reporting An interim report was prepared and presented to the project management group in July 2005, based on the first round of interviews and one interview with the project manager. During December, further analysis and synthesis of all the data from the different sources was undertaken. Each of the ten case study organisations was invited to provide correction of fact and other comments on their own case study. A draft report was presented in December 2005 and following discussion and feedback from the project manager and evaluation management team this final report was produced. Healthy Ageing Nutrition Project Report of 137

64 Strengths and Limitations of the Evaluation The evaluation methodology was grounded by the action research approach of the project. Evaluation was planned for and designed early in the life of the project and maintained a balance between internal and external evaluation. The evaluator, project management team and project manger undertook a consultative process through the evaluation planning, data collection tool design and reporting. This consultative approach maximises the relevance of the evaluation and leads to opportunities for early findings to inform project development. The data collection was from a variety of sources and used a number of different methods in order to strengthen triangulation of findings from a diverse group of stakeholders. The main limitation of the method is that changes in awareness, knowledge and skills were not directly measured and quantified in a pre and post-project design. This would have been both costly and time-consuming, and inappropriate for the project action research approach and the diversity of organisations involved. However, changes within organisations were assessed and some generalisable lessons can be drawn from these case studies. Healthy Ageing Nutrition Project Report of 137

65 3. FINDINGS 3.1 Case Study Organisations Ten organisations agreed to full participation in the project and their involvement and achievements are described as case studies in this section. Each case study consists of a brief description of the organisation, a summary of activities planned and the journey undertaken as part of the project, achievements, perceived enablers and barriers to change and expectations for the future. Metropolitan Domiciliary Care Metropolitan Domiciliary Care (MDC) provides home-based care and support to frail aged clients in the metropolitan area. There is a workforce of approximately 800 multidisciplinary service providers and 20,000 clients at any one time. Coordinated care programs focus on rehabilitation and may include respite care, personal care, equipment and therapy. Priority is given to clients with complex needs requiring case management. MDC is one of the largest organisations participating in the Healthy Ageing Nutrition Project. It is also the auspice agency, housing the project staff and holding the project funding. Shortly before the start of the project, MDC underwent a major change in structure from separate regional services to an incorporated metropolitan-wide organisation in July A transitional phase continued during the life of the project. Preparing for the Journey As a large organisation and the auspice for the project, MDC had a clear role and commitment to achievement in the project. Two areas were flagged for attention: assessment at intake and assessment in the Day Rehabilitation Centre. This kept the project manageable at a time of major organisational change. Within the new geographical teams, MDC hoped to achieve a process of initial needs assessment using the screening tool, then referral with nutrition as one consideration, and evaluation of nutrition outcomes for its clients. The project had been implemented as a pilot within part of the organisation in the lead up to the re-structure. Healthy Ageing Nutrition Project Report of 137

66 At the start of engagement with the project MDC were using a telephone assessment process for newly referred clients. This intake process aimed to assess needs and key issues to be followed up by the case manager. There was no specific focus on nutritional risk although this may be identified as a result of loss of mobility, social isolation etc. Journey Action Plan MDC identified four main goals of participation in the Healthy Ageing Nutrition Project: > Identify nutritional risk at intake > Raise awareness in case managers of nutritional risk > Raise awareness in Day Rehabilitation Centre staff of nutritional risk, simple screening and intervention activities > Share information across the workforce about nutritional risk, simple screening and intervention activities On the Road The Healthy Ageing Nutrition Project contributed a number of articles for MDC s research newsletter, describing the project and updating readers on progress. A flowchart was developed for use by the Metropolitan Access Team to identify and respond to nutritional risk in new clients and a referral letter to inform other clinicians of the outcome. Information sessions were run by the project to raise awareness amongst case managers on nutritional risk, simple screening and intervention activities. Day Rehabilitation Centre staff also attended information sessions and an information board was set up. Across the wider workforce information was provided through newsletters and the project website. Staff from each team attended the Moving into Action forum. Healthy Ageing Nutrition Project Report of 137

67 Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Identify nutritional risk at intake > Implemented and monitoring established by Metropolitan Access Team Raise awareness in case managers of nutritional risk Raise awareness in Day Rehabilitation Centre staff on nutritional risk, simple screening and intervention activities Share information across workforce about nutritional risk, simple screening and intervention activities > Case managers/ team leaders have a raised awareness > Information session run > Information board established > Geriatrician screening of all new clients > Clients monitored and followed up by nursing staff > Staff from each team attended Moving into Action forum > Promotion of project website > Information provided in newsletters and publications Reflections on the Journey Enablers of change include: > MDC founded the project and acted as auspice and so was committed to the success of the project and the importance of nutrition > CEO and management support for project > Expressed need by MDC to look at nutrition for clients in community settings > Some interest pre-project in nutrition and physical activity as determinants of clients remaining in community > Some preliminary work had occurred so participation in the project re-enforced interest > Project provided facilitation, resources and guidance in the change process. Healthy Ageing Nutrition Project Report of 137

68 Barriers to change include: > Undergoing organisational change and the difficulties of introducing more change at this time > Adoption and implementation of new forms and new intake process across the system is quite hard to achieve, particularly when still going through lots of upheaval re. moving roles across regions. The intake screening process has been implemented and there is increased awareness of nutrition in the workforce, particularly in the Day Rehabilitation Centre. These outcomes will be expanded to the rest of the service. Links with GPs and other nutritional support systems have been strengthened. The structural change undergone by the organisation has had the effect of delaying the evaluation of outcomes but nutrition has remained as an important focus. The changes are expected to be sustainable and the organisation is planning for this by up-skilling staff in nutrition, talking with other organisations about nutrition in the community and developing an increased capacity to address nutrition issues. The new procedures are established and a focus on nutrition as part of primary health care will remain after involvement in the current project ends. Multicultural Aged Care Multicultural Aged Care (MAC) is funded by the Australian Department of Health and Ageing and the SA Department of Health. MAC aims to strengthen ethnic communities capacity to care for their older people and to support service providers to give older people from culturally and linguistically diverse backgrounds the services of their choice. MAC established and auspiced three culturally specific meals services (Greek, Italian and Maltese) and supports other ethnic clubs and organisations. There are approximately four FTE paid staff, plus staff at other services, and several hundred volunteers. The Greek, Italian and Maltese meal services deliver meals directly throughout the metropolitan area. Other services supported by MAC include ethnic clubs and organisations providing meal support, shopping services etc. MAC also plays a role in workforce and client education about food and well-being. Preparing for the Journey Healthy Ageing Nutrition Project Report of 137

69 There was no specific nutritional screening activity occurring within MAC s auspiced services. Within a stated commitment to quality improvement the MAC hoped to improve the scope and quality of services currently offered through the partner meal provider organisations. Journey Action Plan As well as increasing awareness of nutritional risk issues among workers and volunteers, the MAC wanted to develop a menu plan for the Italian meals service. Specific goals were to: > Increase awareness among meal providers of issues relating to nutrition and nutritional risk for older people > Develop an appropriate menu plan for the Italian meals service and develop an information source about menu planning > Increase awareness among volunteer workforce of nutrition and nutritional risk > Establish ongoing link to dietetic and food safety information On the Road The Healthy Ageing Nutrition Project was able to provide support and resources to the MAC throughout the project timeframe. In 2004 a dietetic student placement was facilitated. The student was co-supervised by the Healthy Ageing Nutrition Project manager and provided with day-to-day support by MAC. This placement resulted in a comprehensive report on nutrition issues for older people that also looked at cultural considerations for ethnic communities. A detailed four week menu was developed. A second student placement was planned for 2005 to develop a similar menu plan for the Maltese community. However, the student withdrew so this placement did not go ahead. The project provided funding and administrative support to enable the Eat Well for Older Australians brochures and posters to be translated into Italian, Greek and Maltese. These were distributed free of charge to local communities and the Australian Government now has the templates available for national distribution. The project manager presented information on nutrition and nutritional risk to meal service managers. The translated resource material was launched and promoted at Healthy Ageing Nutrition Project Report of 137

70 information sessions for each of the three meal services. Follow up information from the meal services managers on uptake is planned. Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Increase awareness among meal providers of issues relating to nutrition and nutritional risk for older people Develop an appropriate menu plan for the Italian meals service and develop an information source about menu planning Increase awareness among volunteer workforce of nutrition and nutritional risk Establish ongoing link to dietetic and food safety information Promote nutritional message within meal services > Information session run for meal service managers > Menu completed through student placement > Regular training and resources for managers and volunteers > Screening introduced at assessment and at 6/12 months, but not audited > Through student placement links with FU Nutrition and Dietetics Dept established, service managers will follow up as required > Involved in national home delivery food safety review > Eat Well for Life information and brochures and posters translated into Italian, Greek and Maltese and widely distributed Healthy Ageing Nutrition Project Report of 137

71 Reflections on the Journey Enablers of change include: > Regular information and knowledge provided by the project > Project team was easy to work with > Already using QI process > Enthusiastic support within the organisation > New ideas introduced carefully for CALD volunteers and in own language Barriers to change include: > Isolation of cultural communities > QI approach not familiar to some people > Time needed to participate in project A nutritionally and culturally appropriate Italian menu plan was developed by a dietetic student on placement. Information sessions to increase awareness of nutritional issues have been run for meal service managers and volunteers and a statement about nutritional issues and nutritional risk screening was provided for meals services to translate into their community languages. The assessment policy and priority criteria for clients are currently under review. There is increased awareness and knowledge about nutrition issues e.g. about what to do if client doesn t eat the meal provided. There are also plans to pass nutrition information on to clients and families. Working with the project has helped to bring new knowledge to MAC and to shift the focus to prevention, screening and helping to maintain people in their own homes. MAC hopes to continue to implement the screening process and extend the work to residential facilities as the Australian Government intent is to mainstream ethnic aged care provision. For the future, MAC believes the project needs next stage funding to continue its work and maintain a central point for information. A yearly conference would be an effective way to keep stakeholders up to date. Continuation of the website would also be useful but not as effective as a face to face meeting. Healthy Ageing Nutrition Project Report of 137

72 Royal District Nursing Service of SA Inc (RDNS) The RDNS is a non-government and non-profit organisation providing 24 hour, 7 day home and community nursing services across metropolitan Adelaide. Principal funding is through the HACC program. RDNS employs over 300 nursing and support staff and provides services to approximately 4,200 clients per month. Over 1,000 of these are new admissions each month. RDNS also provides a 24 hour Health Contact Centre offering nursing advice and information to clients. Access to a large number of aged clients and carers in their own homes or in community settings means that RDNS is in an ideal position to identify nutrition issues. Preparing for the Journey There was some initial hesitation on the part of RDNS to become a partner organisation in the Healthy Ageing Nutrition Project, believing that they would be required to trial a nutrition assessment tool. The project manager was keen for RDNS to be involved and her persistent and flexible approach paid off. RDNS were reassessing their client assessment tools at the time and planned to use participation in the project as an opportunity to consider the inclusion of specific nutrition assessment in a generic assessment tool. The basic client assessment tool used by RDNS does not specifically target nutrition and malnutrition although it does identify some risk factors associated with nutrition such as dementia and oral hygiene. Specialist client assessment tools e.g. for Diabetes Management, Wound Management do specifically include nutrition. Journey Action Plan There were two main aims within the organisation s action plan: > Increase client and community awareness of RDNS involvement in the project and nutritional risk issues > Develop a literature review on the nutritional needs of older people living in the community with chronic illness Healthy Ageing Nutrition Project Report of 137

73 On the Road The project provided resources in the form of sample assessment tools and journal articles. Links between RDNS and other partner organisations were facilitated through membership of the advisory group and other meetings. COTA National Seniors and RDNS produced a pamphlet based on the NHMRC Eat Well for Life material describing healthy eating ideas and food safety tips. As part of the response to involvement in HA-N a proposal to fund a link worker for nutrition was developed in partnership with MDC, MOW and ANEGP. A research proposal to examine the nutritional needs of malnourished older people living at home was submitted with Meals on Wheels as a partner organisation. The literature review was undertaken by the RDNS Research Unit and distributed to project partners. It is also available from the RDNS website ( Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Increase client & community awareness of RDNS involvement in project and nutritional risk issues Develop literature review on nutritional needs of older people living in community with chronic illness Development of communication and information strategies for staff > Nutrition information available to clinical leaders > Increased awareness of nutrition issues > Nutrition included on revised basic client assessment tool > Literature review produced and available on website > Identified gap in resources for people with nutrition issues and dementia in community > Looking at link worker to assist linking client with services needed. > Pending redevelopment of Intranet site Healthy Ageing Nutrition Project Report of 137

74 Reflections on the Journey Enablers of change include: > Provision of information by the project re nutrition and how to address issues > Ability to find out more information and what others are doing > Flexibility of approach, acceptance of difference in organisational priorities > Screening and assessment tools available but not dictated by project > Opportunity to further interest of the research unit of the organisation Barriers to change include: > Implementation barrier (once at risk clients are identified, where are the solutions and resources?) > Risk of multiple assessments RDNS has found the networking and sharing of ideas useful in terms of seeing the big picture. Linking with others is thought likely to increase the successful achievement of objectives. Funding applications to further nutrition work have been developed with partners. A consumer reference group has been established and assisted with production of the healthy nutrition pamphlet produced with COTA. The literature review Nutrition for People Living in the Community with Chronic Illness concludes that issues of poor nutrition or malnutrition are serous and prevalent problems for older people. Good nutrition is not just about sustenance but is embedded in the socio-cultural context. Little is known about the older person s perspective on food and nutrition and a relationship of trust and shared decision making about nutrition should be encouraged between health providers and their clients. For the future, RDNS notes the need to ensure screening is not duplicated e.g. through links with MDC or others already doing nutritional screening. Nutrition assessment and screening will be adopted and audited. Information on nutrition (assessment, screening and resources) will be added to the redeveloped RDNS Intranet. RDNS believes it is important to have an organisation within South Australia with the capacity and mandate to continue building links and providing an overview of nutrition issues. More research into this complex issue is required. Healthy Ageing Nutrition Project Report of 137

75 Dietitian Group This group was brought together for the purpose of the project and is not representative of a single organisation. Members of the group do provide a broad representation of the role of dietitians in SA: public hospital, private practice, community based services and academics. From the project perspective the main role of the group is to enhance sustainability by acting as a champion for nutrition and older people, particularly once project funding has finished. The group process gives an opportunity for individual dietitians to consider their capacity and willingness to work together to identify and act on needed changes. Many of the dietitians in the group are active in providing education and training for future health professionals, in undertaking research and in membership of professional associations. Preparing for the Journey Dietitians in the group are currently screening the aged clients that are the focus on the Healthy Ageing Nutrition Project and providing interventions and monitoring. The project manager organised a number of meetings to help bring individuals together and sustain commitment to the group. Dietitians from private and public practice were invited to join the project and a core group was formed that was willing and interested in the healthy ageing issue. Journey Action Plan The dietitian group started by establishing itself and discussing issues and priorities: > Form and commit to a special interest group > Define residential care standards > Raise awareness in government of benefits of early intervention in nutritional risk, including writing an issues paper > Influence standards and uptake of education on nutrition requirements Healthy Ageing Nutrition Project Report of 137

76 On the Road Following the first group meeting in July 2004, a draft discussion paper was developed from the key issues raised. Four potential nutritional screening tools were identified although it was noted that not all had been validated or were appropriate for different settings. Special equipment or training may also be needed to use the tools. It was noted that there was little systematic policy or priorities for nutrition in aged care facilities. Chefs/cooks did not require specific training in preparing food for older people. However, the Aged Care Standards Agency was about to undertake a review and this would provide an opportunity for dietitians to have some influence. The Victorian HACC standards were cited as an example of good practice. The different funding arrangements for private and public aged care facilities and for acute or nursing home care act as a barrier to a systematic approach to address nutrition in these settings. During the life of the project there was considerable two-way exchange of information and resources. These included an article in the DAA newsletter in December 2004 which prompted interest from a number of interstate dietitians/nutritionists. A meeting of the group with a representative from the Aged Care Standards and Accreditation Agency was arranged and contact with TAFE to consider specific training was facilitated. One of the dietitian group members presented information to an ANEDGP meeting and the project purchased and distributed copies of a brochure outlining dietitian services and how to access them. Another member of the group obtained and collated information on current practice in aged care nutrition from interstate. In July 2005, a dietetic student presented a paper on the role of the dietitian in the aged care sector in SA to the group. This paper was also presented at the DAA State Conference in South Australia. In April 2006 a two-day seminar for aged care cooks and carers was held with over 50 registrants from across metropolitan and country South Australia. Healthy Ageing Nutrition Project Report of 137

77 Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Form and commit to special interest group > Group formed and functioning > Unclear if group will continue postproject Define residential care standards > Residential aged care nutrition standards assessors have been upskilled in nutrition Raise awareness in government sector of benefits of early intervention in nutritional risk, including writing issues paper Influence standards and uptake of education on nutrition requirements for all stages of aged care training > Collation of papers and material from SA and interstate > Getting ageing & nutrition on government agenda > Response to Senate Inquiry > Planned as next step > Seminar for nursing home cooks and carers run in April 2006 Reflections on the Journey Enablers of change include: > Having a project facilitator willing to act as leader, with time and capacity to work at policy level and across organisations. > Having a project manager to help establish the group > Project manager has good project management experience rather than being a dietitian, means she is able to ask the hard questions > Seeing an unmet need in the sector > Becoming more aware of interstate activities and resources. Healthy Ageing Nutrition Project Report of 137

78 Barriers to change include: > Too few group members, low critical mass in SA > Very few private or community dietitians in SA, especially with an interest in ageing > People in group are all busy, need support and commitment from their employing organisations > Funding in acute care hospital does not support work in community setting > Population health approach in theory, but need public sector dietitians need permission to work in new ways > Recommended screening tool not realistic for community based services, need to offer alternatives > Lack of high level understanding of importance of nutrition and ageing The key achievement for this group was the recognition of the need for nutrition accreditation standards in residential aged care. Also, good links were made with meal provider organisations and carers. There is general agreement that ageing and nutrition is now a higher priority for government and service providers although there is still a way to go in terms of resources. A considerable quantity of material has been identified and collated that will assist in future development. The small number of dietitians in SA with an interest in ageing was noted as a particularly barrier and it is unclear if the special interest group will be viable after the project funding has finished. There was some potential conflict of interest and lack of understanding between dietitians employed in different settings but the group worked to overcome these. The dietitian group stressed the need for a facilitator or leader to keep the collaboration active. There is a gap in SA in resources to address the issue of nutrition and ageing and there needs to be an organisation or a key person within the government sector with responsibility for driving this topic. Healthy Ageing Nutrition Project Report of 137

79 Meals on Wheels (SA) Inc (M OW) Meals on Wheels provides meals and personal contact to elderly, infirm and disabled members of the community. It is a not-for-profit, branch-based volunteer organisation working throughout SA, delivering a balanced nutritious three course meal each week day to over 5,000 people. 10,000 volunteers operate through 100 branches. There is a small group of paid staff providing administrative and policy support to branches. Screening for eligibility for the service already exists and significant change in response to legislative issues of food safety and quality improvement is being undertaken. Preparing for the Journey Prior to participation in the Healthy Ageing Nutrition Project, MOW commissioned a satisfaction survey in 2003 with a sample of meal recipients. High levels of satisfaction with the nutritional value, variety and, to a lesser extent, taste were reported. However, most respondents indicated that they divided the delivered meal over lunch and dinner. Since the meal is intended to provide one third of the daily nutritional intake this finding was of concern to the organisation. Participation in the Healthy Ageing Nutrition Project was therefore timely in assisting with quality improvement and assessment of nutritional status of recipients. Following a meeting between the CEO and the Project Manager, MOW accepted an invitation to participate in the project in June A presentation was made to the Board to ensure members understood and supported the project. The Project Manager promoted and presented on the project at a MOW conference for approximately 70 supervisors and cooks in August 2004 and also collaborated with the dietitian presenter. In September 2004 the MOW newsletter featured the Healthy Ageing Nutrition Project and a press release to coincide with National Meals on Wheels Day also referred to involvement in the project. Towards the end of 2004 a Welfare Development Manger was appointed with responsibility for the assessment team. The creation of this position signified the commitment of MOW to the action plan and meant there was more time and resources available for implementation. Healthy Ageing Nutrition Project Report of 137

80 Journey Action Plan The MOW organisation was very clear that it was looking for sustained change rather than a project approach. Two main areas of focus were established in the action plan: > Increase understanding of nutritional risk and issues by the Board, staff and volunteers > Increase use of nutritional screening tool by welfare officers at intake and follow up On the Road Throughout the project, resources and contacts were provided to assist achievement of the action plan. These included links to community nutritionists, information on Divisions of General Practice resources and events, and contact information for relevant government departments and workforce training opportunities. Two dietetic student placements were facilitated and MOW was able to provide accommodation and day-to-day supervision. The student placement in early 2005 resulted in a comprehensive report on how the NRSMT was being used by welfare officers and the implications of this and of a survey of a small sample of new recipients. The student was jointly supervised by the Welfare Development Manager and the Project Manager. The aim of this placement was to establish a data collection and management system for nutritional screening and follow up of new recipients. The student study confirmed that about 70 per cent of recipients divided the delivered meal over lunch and dinner without apparent supplementation. Given that the majority of recipients are frail aged, have a chronic disease or disability, or were recently discharged from hospital a high risk factor rate for nutrition is likely. In fact 80 per cent of respondents surveyed had one or more of the risk indicators in the NRSMT. The report also suggested that welfare officers were not consistent or systematic in their application of the NRSMT when assessing new clients. A data collection and management system would serve to improve this aspect of the organisation s function. A second student placement in July/August 2005 extended the previous survey and included people who had withdrawn from receiving the MOW meal service. The study also tested the appropriateness of ANSI, another screening tool. MOW agreed to be a partner in a proposal for HACC funding although this was ultimately unsuccessful. Healthy Ageing Nutrition Project Report of 137

81 Links to other organisations were established thorough participation in the project Forum, the Aboriginal Forum and the project reference group. In November 2005, the Healthy Ageing Nutrition Project was invited to contribute to a new magazine to be produced jointly by MOW and RDNS focussing on positive health. An article was accepted and other nutrition topics will be included in future editions. Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Increase understanding of nutritional risk and issues by Board, staff and volunteers Increase use of screening tool by welfare officers at intake and follow up > Sharing materials > Continuing education > Information pack to staff and volunteers > Increased awareness in volunteers > Integration of nutrition screening tool by student. > Nutrition risk assessment tool used for new and reviewed clients and integrated into the IT system > Referral system established and increased referrals to service providers e.g. GPs Healthy Ageing Nutrition Project Report of 137

82 Reflections on the Journey Enablers of change include: > Support of the Board, flowing through to awareness building > Nutrition is a core value, clear link between nutrition and frail aged > Nutrition drive already underway so project was timely > Organisation willing to provide in-kind support and take on extra work > Focussed on staff rather than volunteers at this stage > New position of client services manager with development focus Barriers to change include: > Resistance to change and pace of change > Motivation to change (no major issues or obvious need driving change) > Large volunteer workforce means pace of change is slow People making up the large volunteer base are aware of the project but are not directly involved at this stage. The need for a very carefully planned approach to change management with long term volunteers is stressed by the organisation. Paid staff (e.g. welfare development managers) are more directly involved in the project. Activities and achievements include three student placements, the production of the 2 nd edition of a booklet on healthy eating for people with diabetes and links with Flinders University Nutrition and Dietetics Department. Opportunities for collaborations and to meet with others were valued. Medication, exercise and nutrition are all important components of maintaining the older person in their own home. Meals on Wheels considers it important to sustain the change at organisational level rather than as a short term program based approach. There is a need for a central resource person to keep issues and actions on the agenda. The organisation has adopted a new slogan, Driven by Nutrition, and this theme will be further developed in Healthy Ageing Nutrition Project Report of 137

83 Centre for Physical Activity in Ageing (CPAA) The CPAA aims to contribute to the quality of life of individuals through the provision of specialised physical rehabilitation, health promotion, research and education. CPAA works from the principle that activity and exercise are of primary importance in maintaining quality of life and the Centre has specialled skills in exercise and ageing and in physical rehabilitation. Specialised programs for individuals ensure that people can participate regardless of age or disability. The CPAA also runs education sessions for community groups and contributes to knowledge and understanding of the links between activity and ageing. The Centre has a large number of clients with approximately 10 new clients refereed per week. Preparing for the Journey Nutrition and physical activity have been identified by WHO as the two major factors in preventing chronic disease and participation in HA-N supports this link. There was no activity related to nutrition screening before participation in the project but the screening process on referral of new clients was thought to be adaptable to include nutritional risk status. Nutrition could also become part of the education provided through newsletters or in face-to-face training with older people and their exercise instructors. The CPAA identified clear steps and a time line for their journey. This started with assessing baseline knowledge in staff and clients about the relationship between nutrition and physical activity, nutrition guidelines and nutritional screening. Plans to promote the links between nutrition and physical activity and to provide education for staff and clients were established. The nutritional risk screening process (for approximately 10 new clients per week), follow-up procedures and staff training were planned. The action plan was confirmed in November 2004 and the participation of CPAA was announced in a newsletter to staff, clients and families. An additional staff member was recruited to work with the project. There was some early discussion about community gardens and the potential for linking gardening activity with healthy foods but this was not developed further. Healthy Ageing Nutrition Project Report of 137

84 Journey Action Plan The action plan was formally agree in November The main actions planned were: > Promote the link between nutrition and physical activity messages in educational material > Promote nutritional screening and awareness of nutritional risk to the workforce > Promote nutritional screening and awareness of nutritional risk to clients > Establish screening and referral processes > Update the nutrition component of fitness leader training to include awareness and response to poor nutrition On the Road Following the client and staff surveys to assess baseline knowledge, two education sessions were held for staff on 11 th and 12 th November This was to inform staff about the involvement of CPAA in the Healthy Ageing Nutrition Project and provide initial training in nutrition and the links to physical activity. The results of the surveys were also disseminated. The link between nutrition and physical activity was promoted in CPAA materials and at presentations, forums and so on. Work was undertaken with the Project Manager to develop a screening tool, follow up flow chart and resource kit. Access to the ANSI tool was facilitated by the project and this was adopted for new clients. A follow up process was developed based on the work done by a student placement at the Carers Association. This sharing of resources was facilitated by HA-N with CPAA then adapting the tool for their own clients. Other resources and contacts were also brokered by the project. The Project Manager worked with CPAA to design a follow up letter to the general practitioner when a client at nutritional risk was identified. The Project Manager worked with CPAA to assemble resource kits for clients. These contain nutrition advice, recipes and shopping ideas, meal delivery services, and information on medications. Healthy Ageing Nutrition Project Report of 137

85 An information workshop for clients was held in March 2005 and attended by approximately 65 people. The Project Manager provided promotional resources on the Healthy Ageing Nutrition Project and arranged a dietitian speaker. The project also provided access to the ANSI screening tool and attendees worked through this to determine their nutritional status. The third session was about nutrition and physical activity. In June 2005 CPAA agreed to be partners in a proposal for HACC funding to provide a link worker. Unfortunately this proposal was not successful. A training session for CPAA staff on nutritional risk and the screening process was held in July 2005 prior to screening getting underway. There was some delay while ethics approval was sought. Further resource materials were needed and acquired during this period. The nutrition component of fitness leader training has been updated to include awareness of, and response to, poor nutrition. It became apparent from the screening process that, for CPAA clients, obesity or overweight is more often an issue than underweight or malnourishment. It was decided to undertake research on the reliability of knee height measurement rather then total body height as more appropriate for many CPAA clients. Accurately measuring total body height can be difficult in older people or those with a disability. This work is due to be completed in Healthy Ageing Nutrition Project Report of 137

86 Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Link nutrition and physical activity messages in educational material Promote nutritional screening and awareness of risk in workforce Promote nutritional screening and awareness of risk to clients Establish screening and referral processes Update nutrition component of fitness leader training to include awareness and response to poor nutrition Research reliability of knee height measurement for CPAA clients > Raised awareness > Information delivered > Added nutrition topic to program > Developed link to Active Ageing Australia > Skill and professional competency building within organisation > Increased knowledge and training for staff > Forum held for 65 people and another planned > Planning to change assessment and screening process > Assessment and screening process in place and will be reviewed > Links established with communitybased nutritional counselling services > Updated to include awareness of, and response to, poor nutrition. > Ground to knee measure trialled as more appropriate for older population Healthy Ageing Nutrition Project Report of 137

87 Reflections on the Journey Factors that assisted the journey: > The opportunity presented, had been previously talked about and already had some nutrition programs so project provided timely stimulus > Flexibility to add nutrition to activities > Support by CEO > Project s recognition of different needs and client groups > Support from staff and internal project worker > High level of interest from client group Barriers on the journey: > Time needed within the organisation and large numbers of clients > Internal structure > Other changes happening concurrently > Some staff slow to take action For CPAA clients, obesity or overweight is more often an issue than underweight or malnourishment. This is an area for more development. Links have been made with other organisations, for example, a local service provider for nutrition counselling and a falls prevention program. Knowledge about nutritional risk has been increased and a screening tool is available, although CPAA is not yet in position to audit its use. The need to provide follow up training and support was noted. A CPAA project worker will continue in this area, funded from the global budget. CPAA suggests a link worker position would be useful for accessing resources, and following up on ideas and issues. As a result of participation in the project, CPAA now has in place procedures to screen new clients for nutritional status, follow-up pathways if required and a client nutrition resource kit. Links to community-based nutritional counselling services are being further developed. Healthy Ageing Nutrition Project Report of 137

88 Carers SA Inc. Carers SA is the peak organisation in South Australia, representing all Carers in the State. Carers SA was established in 1989 by grass-roots Carers and is now a non-profit community-based organisation with several thousand members. Carers SA aims to empower Carers to participate in partnership with Government and non-government organisations for the provision of better services and to improve conditions and recognition for the work of Carers. Carers SA has a Resource Centre that supplies information and referrals to callers. It operates retreats to provide Carers with a break from their caring role. It provides other services such as counselling, Carer support, advocacy, training and community education. A Carer is someone who provides care and support for their parent, partner, child or friend who has a disability, is frail aged, or who has a chronic mental or physical illness. There are about 235,000 Carers in South Australia providing 70 per cent of all community care. Family Carers are therefore a major part of the aged care workforce in the community. Preparing for the Journey Carers SA represents Carers who often live with and advocate for older people who are living in home and community environments. A large portion of the work of accessing and preparing food for and feeding older people occurs in this environment. Well informed Carers are able to identify people who are malnourished or at risk of malnourishment and are then able to seek supports to manage this situation. Carers have a role in both intervention and screening processes that would facilitate at-risk people being redirected to seek additional information, or higher level care or support. In addition, many Carers neglect their own needs and are at risk nutritionally. Nutrition had not previously been a focus but Carers SA was keen to participate in the project, seeing it as an opportunity to lead to better informed Carers. Carers SA has several thousand members including individual Carers, carer organisations and carer support groups. The Carer Resource Centre is the first point of contact for all Carers, service providers and the general public. Carers can be linked individually to share experiences and provide mutual support or through carer retreats and Carer support services. Healthy Ageing Nutrition Project Report of 137

89 Carers SA also runs a respite centre in the southern region of SA. As well as the central state office there are six regional locations. These structures, networks and support systems already in place provided an ideal environment for the dissemination and uptake of new information on the topic of food and nutrition. Journey Action Plan In July 2004 the Project Manager and the Carer Support Manager of Carers SA met to establish the action plan. Three main actions were planned: 1. The establishment of a nutrition interest group among members 2. Strategies to ensure that the Carers voice is heard by other health organisations 3. The establishment of resources for Carers on identifying and management nutritional risk. In August the baseline data and action plan were formally accepted by the Executive Director and another meeting took place with the manager and one member of a small group of interested Carers to plan for the upcoming advisory group meeting and the Healthy Ageing Nutrition Forum. These were seen as a way for Carers to be involved and their voices to be heard. Information about the project continued to be disseminated and an additional Indigenous Carer expressed interest in attending the Forum. On the Road During the establishment phase there was already a valuable exchange of information between the project and the organisation. The project manager provided information about a manual on aged care services and this was followed up as a useful resource for Carers. Carers SA was able to provide information and a contact for two relevant projects in the northern Adelaide region; one on Carers and one on falls prevention. Nutrition screening tools were made available via the project worker. Contact with a food safety person was initiated. Copies of the Meals on Wheels Healthy Eating booklet were provided and contact between Carers SA and Meals on Wheels facilitated. This included the opportunity for Carers to provide feedback before the next print run of the booklet. Healthy Ageing Nutrition Project Report of 137

90 Action 1: The establishment of a nutrition interest group among members Six Carers with an interest in food and nutrition formed the Carer reference group. Members of this group were actively involved in presenting at the Healthy Ageing Nutrition Forum, organising and presenting at the Think Nutrition forum, and helping to produce the Information Pack. Reports on the progress of the project were made to regional Carer advisory groups and in the SA Carer newsletter. Action 2: Strategies to ensure that the Carers voice is heard by other health organisations One Carer and the manager represented the organisation on the Project Reference Group. This provided valuable links to other organisations and brought Carers SA into the loop that is often taken for granted by government agencies. In October 2004 five Carers attended the Healthy Ageing Nutrition Forum to speak from the Carer perspective. Carer stories revealed a number of issues: > Little information available to Carers on food and nutrition > High cost of special diets > Inconvenience and extra work in preparing two different meals > Importance of massage and exercise in maintaining mobility > Need for practical food ideas for specific medical conditions > Eating alone and missing the social experience of sharing a meal > Need to make food interesting to stimulate the appetite > Need to eat well for better health to fulfil the caring role Action 3: The establishment of resources for Carers on identifying and management nutritional risk In December 2004 planning for a student placement started. Carers SA made workspace available and the 4 th year dietetic student from Flinders University was jointly supervised by the Project Manager and the Carer Support Manager. The student worked on putting together the information pack for Carers, helping to plan the Think Nutrition forum program and developing website information. The September newsletter featured nutrition and promoted the forum and the information pack. On 20 th September 2005, a three-hour Think Nutrition forum was held for Carers. The Information Pack was launched at this forum along with Carer stories and presentations on screening and nutrition, medications, physical activity and food services. Written feedback from 24 respondents rated all the sessions highly. Healthy Ageing Nutrition Project Report of 137

91 The Think Nutrition brochure, information pack and forum were all designed to provide and promote information to Carers about food and nutrition. In developing the pack a large number of resource materials was considered; all had some value but nothing was identified that could be used alone. Much of the material was illness based rather than looking at positive health. It was agreed to put together a pack of information from resources that were free, based on good nutrition, comprehensive and focused on the Carer and their loved one. The pack includes: > Simple nutritional risk screening tool > Food safety in the home > Tips for eating well and good food preparation > Special diets for specific conditions > Physical activity > Getting help with nutrition and physical activity > Food services > Websites and resources > Managing medication > Preventing falls > Aids and equipment > Looking after yourself Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Establishment of an interest group among members Ensure the Carers voice is heard by other health organisations > Interest group established and meets regularly > Members attended Healthy Ageing Nutrition Forum > Broader membership kept informed through newsletters > Carers represented on project advisory group > Carers presented at Healthy Ageing Nutrition Forum > Carer stories on project website were planned but did not go ahead Healthy Ageing Nutrition Project Report of 137

92 The actions planned were: Achievements at October 2005: Establishment of resources for Carers on identifying and management nutritional risk > Information for Carers drafted > Forum planned > Student placement assisted with information resource > Resource pack piloted and about to be finalised, includes simple assessment tool > Metro forum run > Planned a country forum is planned and may be repeated in metro Reflections on the Journey Factors that assisted the journey: > Acceptance of a workforce definition that included Carers > Group of Carers, Board and ED all supportive > Framework of huge network of Carers already in place, so a new topic but an established system for communication > Becoming part of a network of services that was previously not open to Carers > Capacity to take on a student and the work associated with the project > Health and wellbeing of Carers, rather than illness, is a major issue Barriers on the journey: > Lack of expertise and resources within the organisation, needed to link in to these > Process has been one of development rather than change Carers SA has benefited by expanding its networks and increasing understanding of the complexities of the health system and the links between nutrition, medication and falls. The organisation relies on the project for relevant information and resources and the website contributes to this role. If the project does not continue in some form there is risk that Carers will fall out of the loop. As a result of the Healthy Ageing Nutrition Project, several thousand Carers now have access to information and resources on looking after their own nutritional health as well as that of their loved one. Healthy Ageing Nutrition Project Report of 137

93 SA Divisions of General Practice (SADI), North East and Northern Divisions of General Practice SADI is the support and coordination body for the 14 Divisions of General Practice in South Australia. SADI is a non-government organisation and acts as an advocacy body for Divisions in health policy and planning, program development, implementation and evaluation. SADI provides an information exchange point between the Divisions and the State and Federal Governments. GPs are a key group in the provision of health and medical services to older people, including screening, management and referral of nutrition problems. The project has mostly worked with the North East Division of General Practice and to a lesser extent with the Northern Division of General Practice. Preparing for the Journey Currently GPs receive funding for providing Enhanced Primary Care to clients aged 75 years or older (55 year for ATSI patients). The care plan includes a set of questions on nutrition, however this is more complex and of unknown effectiveness compared to the MNA screening tool. Little is known about the resources and referral patterns for GP clients who are older and have nutritional risk and it is likely that GPs would be interested in information about screening and referral options. Some Divisions, GPs and practices already have an interest in nutrition and older people. However, due to the structure of general practice, individual GPs retain discretion to take on any particular activity in their practice. Journey Action Plan The major aims for SADI and the Divisions were about increasing awareness of nutritional issues and to develop a flowchart for GPs to use with older patients: > Raise awareness of the project across Divisions > Raise awareness of project and key issues across NE Division practices > Develop a flowchart/ map with options for screening and management of nutritional risk in older patients > Education sessions for GPs, practice nurses and others involved in aged care > Collaborate with Home Medication Review project (ANEDGP) to add nutrition questions and raise awareness of the link between nutrition and medications Healthy Ageing Nutrition Project Report of 137

94 On the Road The project manager worked closely with the aged care coordinator at ANEDGP as well as other contacts within SADI and the Divisions. The project was promoted in ANEDGP newsletters and practice fax sheets covering 65 practices and over 250 GPs and aged care providers. A SADI newsletter contained information about the Moving into Action Forum. Two education sessions were funded and organised by the project. A GP forum in March 2004 provided information to GPs about the Healthy Ageing Nutrition Project, nutrition and ageing issues, nutritional risk assessment tools and the role of Meals on Wheels in providing part of the daily nutritional requirement. In October 2005, a session for 11 practice nurses was run and received very positive feedback. Divisions also contributed to the Aboriginal Health Workers forum run in August There was an exchange of information about screening tools for residential facilities and other Divisions expressed interest in being kept informed of the project. The major output from the project was the production of a flow chart for nutritional risk assessment and referral pathways. The flow chart was prepared jointly with the ANEDGP and the Healthy Ageing Nutrition Project with additional consultation with GPs and other stakeholders. The flow chart was updated to reflect changes in Medicare item numbers and was presented in the Aged Care Update Newsletter in January The newsletter is circulated to 500 GPs and 75 aged care facilities, plus community groups. Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: SADI Raise awareness of the project across Divisions > Updated website > NE is a leading Division in aged care > Interstate interest > Moving into Action Forum publicised in newsletter and representatives attended Healthy Ageing Nutrition Project Report of 137

95 The actions planned were: Achievements at October 2005: NE Division Raise awareness of project and key issues across NE Division practices Develop a process map with options for screening and management of nutritional risk in older patients Education sessions for GPs, practice nurses and others involved in aged care > Newsletter and fax-out released > Flow Chart available on website > Link to Healthy Ageing website > Increased knowledge for GPs, practice nurses and other stakeholders > Flowchart developed about screening and intervention options > Flowchart education was well received and internal evaluation positive. > Linking GPs to resources for at risk people > Falls prevention includes nutritional assessment > Education sessions delivered for GPs and for practice nurses. > Information provided to others that are interested and a part of the aged care team through ANEDGP s established network of contacts. > Increased knowledge for GPs and other stakeholders. > Actions brought stakeholders together > Increased awareness of links between nutrition, falls and wound management > Work with Best Foot Forward project and TTG LGA to produce spotters card for health workers Healthy Ageing Nutrition Project Report of 137

96 The actions planned were: Achievements at October 2005: Northern Division Collaborate with Home Medication Review project to add nutrition questions and raise awareness of link between nutrition and medications > Questions relating to rapid screen / nutritional risk added to blue selfcheck tool and assisted with distribution and uptake of this among project s partner organisations. Updated HMR tool distributed through HMR project and Healthy Ageing Nutrition project. Reflections on the Journey Enablers of change include: > Backup and ongoing contact from project > Awareness and seeing value in working and linking with other providers > Project very relevant to work of Division > Health promotion material useful i.e. display led to interest from practice nurses > Practice nurses and managers help to get message into practices a team approach Barriers to change include: > GPs are diverse stakeholders, some may have barriers to implementing, some will have more interest than others > Assumptions that older people don t have high food and nutritional requirements A large number of GPs and practice nurses have received education in nutritional issues in older people and potential screening tools and referral pathways. The flowchart was developed in a highly consultative way and has been distributed widely to practices, aged care facilities and community groups. Since most older people visit a GP regularly this should lead to increased screening and identification of nutritional risk. Awareness of the links between medications and nutrition has also been increased. Healthy Ageing Nutrition Project Report of 137

97 The project has acted as a reminder that nutrition is an important aspect of chronic disease management. Through the project SADI and the Divisions have strengthened links and seen the value of working in collaboration with other aged care providers. The multidisciplinary focus has increased. A link worker and an ongoing driver are needed as first point of contact and to maintain a flow of up-to-date information and resources. Hampstead Rehabilitation Centre Hampstead Rehabilitation Centre aims to maximise independence and optimise lifestyle through rehabilitation following traumatic brain injury, stroke and other neurological or medical disorders or injuries. The Centre provides inpatient therapy with 150 beds. Clients may also be admitted under a recovery care program or for planned or crisis respite care. Preparing for the Journey Some nutritional screening initiatives had been trialled at Hampstead and a dietitian is available part-time, although screening is not currently routine. Early on a number of meetings were initiated by HA-N to explain the project and gain support from nursing and medical staff. A potential outcome of involvement in the project was to provide a case for increased dietetic services in the centre. It was agreed to focus on one department (three wards) as a trial. Journey Action Plan There were two main aims arising from the organisation s action plan: > Improve management of nutritional risk by systematic screening, assessment and care planning at admission, using a multi-disciplinary approach > Provide information packages to ward staff for the purpose of patient education On the Road With the support of the project manager a set of guidelines for assessment of nutritional status was developed. This involved rapid screen at intake by medical staff followed by further initial assessment using the MNA tool for those identified as at risk by nursing staff. Patients then identified as at risk or already with malnutrition were to be referred to the multi-disciplinary team. Those already with malnutrition were to be immediately Healthy Ageing Nutrition Project Report of 137

98 referred to the dietitian. All would be provided with health information. Nutrition was to be included as an item on weekly case conferences. The implementation of the guidelines was set up as a clinical trial and documentation collected on number and characteristics of patients, interventions and outcomes. The aim was to lead to a formal protocol for assessment and intervention for nutritional risk. Following consultation with clinical staff the guidelines were developed into a flowchart and a data management system was set in place with ward clerks. The project worked with Hampstead to provide nurse training in the use of the screening tools and data collection, and relevant journal articles. The project facilitated the setting up of two information boards on the ward and supplied brochures and other resources, or contact information to obtain these. Other assistance provided by the project was falls prevention and Home Medicine Review information. Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Improve management of nutritional risk by systematic screening, assessment and care planning at admission, using a multidisciplinary approach Provide information packages to ward staff for the purpose of patient education > Good awareness of nutrition as a clinical issue by medical, nursing and allied health staff > Rapid screen at intake then MNA if at risk and referral or education as appropriate > Protocol is accepted and adopted department wide > System setup to provide admissions data > Paper on outcomes planned > Nutrition information is available on wards Healthy Ageing Nutrition Project Report of 137

99 Reflections on the Journey Enablers of change include: > Support by managers > Dietitian interest and support > Some preliminary work on nutrition > Developed protocol for doctors and nurses, not seen as just nursing problem > Project acted as facilitator, involvement seen as positive > Staff were supportive and ready to take on tasks Barriers to change include: > Resident medical staff change frequently giving continuity issues > Hard to implement new system into ward practice, asking people to add new task, record and do quality check > Needs to be seen as consideration of multi-disciplinary team > No specific person to provided daily oversight in organisation, some difficulty in maintaining data collection > Volume of workload > Absence of secretariat support for research Involvement in the Healthy Ageing Nutrition Project has facilitated the development of a nutritional risk protocol, associated systems and an increase in nutrition awareness at individual and organisational level. There has been a large increase in demand for dietetic services following the implementation of the protocol, indicating that nutrition is indeed a significant issue for Hampstead patients. The research focus meant that data collection and evaluation was an integral part of the implementation. However, the organisation notes that it does not have control over medical staff turnover and it can be hard to keep track of data. This means it is not possible to confirm that new practices are implemented systematically. The new system of the agreed protocol will assist in this process. Also in the coming year, two trainee positions will have the responsibility for auditing the use of nutrition assessment, and an increase in dietitian time is being advocated. Nursing and allied health staff have taken on this issue enthusiastically and this will sustain the system changes. Healthy Ageing Nutrition Project Report of 137

100 Resthaven Inc. Resthaven is a Uniting Care agency providing a range of residential care and community services such as therapy and respite. Resthaven strives to serve older people, responding to their needs thorough the provision of quality services. Residential care is provided for some 1,000 older people in high and low dependency facilities and independent living units. Many of these of these are frail with an average age of 86 years. Community services include therapy, aged care package programs and in-home respite. There are over 900 paid staff and approximately 430 volunteers across a range of sites and settings. Preparing for the Journey Prior to involvement in the Healthy Ageing Nutrition Project, Resthaven had identified that their current Nutrition and Hydration Assessment form did not adequately assess nutritional status and did not use a validated tool. Early in 2004 planning to trial the Malnutrition Universal Screening Tool (MUST) started. At the same time, the possibility of trialling the MNA with support from the Healthy Ageing Nutrition Project was flagged. Both tools were trialled in a number of sites for two months. Journey Action Plan Resthaven chose to use their own quality improvement format rather than the project action plan. Resthaven s goal was: > Development of a validated nutritional screening tool for use in residential facilities On the Road The project was able to provide access to the MNA tool so that its use could be trialled alongside the MUST. Initial trial feedback from staff was the both tools required time to be spent on understanding how to implement them. The MNA was reported as more complex and longer to administer; for the MUST height and weight measurements could be difficult. Overall the MUST was considered better suited to hostel/nursing home settings. An additional nutrition assessment tool, used by the Victorian HACC program was suggested by the project manager and this was also obtained for review. Healthy Ageing Nutrition Project Report of 137

101 Eventually the screening tool and BMI index from the Best Practice Food and Nutrition Manual for Aged Care Facilities was revised and adapted in consultation with care coordinators. Nutrition and hydration assessment were combined into one form and its use and effectiveness will be audited in the future. Resthaven also engaged the services of a private dietitian practice to review their current policy and make recommendations. This resulted in an updated Resthaven policy on nutrition and hydration, including for palliative care. Throughout the implementation of the plan the Healthy Ageing Nutrition Project provided information sessions and resources. Resthaven staff attended advisory group meetings and the Forum, and an article on the project was written for the organisation s newsletter. Arriving: Summary of Achievements The actions planned were: Achievements at October 2005: Development of a validated nutritional screening tool for use in residential facilities > Two tools trialled over 2004 > Updated policy and best practice advice > Educational sessions and materials provided increased awareness of food and nutrition. assessment tool implemented > MNE tool adopted and auditing of use underway > Plan to expand to community clients Healthy Ageing Nutrition Project Report of 137

102 Reflections on the Journey Enablers of change include: > Having a change agent in organisation to source best practice, pass on to clinical staff and get feedback, policy development Barriers to change include: > Change can be frightening > Time factors > Can t see value in taking on additional task Resthaven has trialled two risk assessment tools and implementation of the MNE tool is now occurring. Feedback from Care Coordinators has revealed a number of benefits: better care planning, early identification and intervention for at risk residents, pro-active prevention of weight loss. Issues that have arisen include disparity between Australian Standards BMI range and MNE range, the need for menu modifications/supplements, and the need for obesity risk assessment to be added to the screening process. The changes made will be sustained and Resthaven is looking to extend the use of the screening tool to clients in the community and independent living units. The current Nutrition and Hydration Policy is due for audit in January and the findings from this audit will be relevant in assessing outcomes from the Healthy Ageing Nutrition project. 3.2 Themes from Interviews with Project Manager Three interviews were conducted with the project manager in March, September and December Data were collated and are presented below with the evaluator s interpretation of the project manager s reflections. Project Implementation and Management The project advisory group is made up from participating organisations and its membership demonstrates the commitment of these organisations and provides a feeling of ownership to the project. The group set-up reflects the action research approach and procedures are flexible and relevant to stakeholders. The main role is to reflect on the change process within the participating organisations. The size and diversity of the group means there is a need for comprehensive executive support from the project. There is also a need for careful facilitation and documentation of agreements as there may be some Healthy Ageing Nutrition Project Report of 137

103 sensitivity in organisations discussing their change goals and actions in a public arena. The advisory group developed capacity and cohesion over time and is now in a good position to contribute to further activity if the project is able to continue. In terms of project management, infrastructure support took some time to establish as what was needed and who would provide it was not clearly spelt out in the original grant application. Apart from this, the management structure has worked well in the role of day-to-day project management, strategic networking and enhancing sustainability. The diversity of perspectives in the management team has contributed to the dynamic action research approach but may complicate the evaluation by different expectations and focussing on different outcomes. Getting Commitment from Participating Organisations Two pre-existing factors have contributed to the project getting started: > The different perspectives and expertise of the three management group members has enhanced credibility among the various stakeholder groups > Pre-work in the area resulted in a groundswell of organisations ready to start action, including letters of support from 20 organisations. However, these factors also led to high expectations and a need to re-establish commitment to the project following its development from the original idea. Other factors linked to successful start up of the project were the skills and approach of the project manager. While some organisations were keen to be involved, others needed help to get to this point, i.e. informal discussions, understanding of the internal processes and culture, persevering with offers of information and support. Finding the right person to act as contact and driver of change within the organisation is important. Ideally, the person should be a high level decision-maker. Decision-makers may not have clinical knowledge but they are often in a position to lead clinical change. Healthy Ageing Nutrition Project Report of 137

104 The approach taken was to follow up all expressions of interest plus snowballing, which resulted in over 20 organisations being involved in some way. Of these, ten committed to the change process by developing action planners, while the rest were kept informed about the project but without direct involvement. 40 Reasons for not remaining directly involved were varied: two organisations dropped out when they realised no additional funding would be available to them, a few did not see the project as part of their core business and a small number of non-government organisations were found to have inadequate data collection to be able to participate fully. So participating organisations have mostly self-selected by starting action, with much encouragement and some targeting by the project manager. While ATSI communities had not been a focus of the project funding application, considerable time and effort was put into trying to establish relationships with ATSI agencies and groups with an interest in healthy ageing. Part-way through the project the Aboriginal Health Council was invited to join the advisory group and then provided contact details and support to the project manager in engaging ATSI workers. This proved challenging and complex, requiring tolerance from both parties and overcoming barriers related to historical precedents. Starting Change Organisations had a variety of responses to the invitation to develop action plans. Some already had ideas and wanted to jump to action without any reflection. Others found it hard to see opportunities for change and to move beyond the immediate problems they faced. One of the roles of the website was to help with ideas for action and how to work with others. Generally, change seems to be easier in smaller organisations that have more control over their own function and less bureaucracy. Two case studies illustrate the extremes of this. In one large, bureaucratic organisation, planning is locked down and one person within the organisation is unable to drive change, however committed they are. In a small organisation with little structure or planning experience, one person can implement change but it is more opportunistic than considered and seems unlikely to be sustainable: 40 Activity relating to these organisations is described in section x Healthy Ageing Nutrition Project Report of 137

105 They are the two extreme examples but in every organisation, I think it is the combination of the change ready environment and somebody who is willing to take it on and move it forward. How organisations developed and used the action planner also varied. To some extent this was determined by the culture and experience of the organisation, i.e. whether they were familiar with planning and quality improvement processes. A small number of organisations with a clear business and management framework in place decided to use their own quality improvement processes or build the action plan around their framework. Most organisations preferred to let the project manager complete the action planner following discussion and consultation about what changes would be significant and realistic. For the first few months, the action planner was a fluid document in development. Once consensus was reached, the planning tool became the formal documentation of the changes that the organisation had agreed to put in place. Baseline data were obtained for each organisation. This provided useful information for the project in helping to negotiate realistic changes and a comparison with later data to help demonstrate incremental change. This will be particularly important for those organisations that are unsure about their capacity to make changes. Organisations have different reasons for making change and this is complex. Some were driven by wanting to develop best practice, others by seeing a need for change. Change is value-laden and the value set is dependent on each organisation s core business and culture. Organisations with large numbers of volunteers may be slower to embrace change. Change in these organisations is planned by management and introduced very carefully so as not to frighten off volunteers. Keeping the Project on the Agenda All the organisations remained actively involved with the project and met their achievements within expectations. According to the project manager, this continued commitment was facilitated by a willingness to negotiate by both parties, and by maintaining relationships with people in the organisation in a position to make changes and by the action research process. For some organisations the action research Healthy Ageing Nutrition Project Report of 137

106 complemented established quality improvement practices and encouraged organisations to see how they fitted into the bigger picture and to develop benchmarks for addressing nutrition issues. Organisations were helped to make their action plans concrete and manageable. This led to early small successes and led to larger changes. Another enabler of change was described as the supportive environment created by the project. For example, effective communication strategies, consistent marketing and an identifiable initiative all encouraged organisations and other stakeholders to want to be engaged. As with the starting change described above, large organisations proved more challenging in terms of action for change as their planning processes often took longer to shift. However, new structures or procedures were more likely to be sustained as part of the strategic planning in the organisations. Smaller organisations tended to be reactive and more easily adopted change when they could see how it would benefit their clients. In these organisations change seems less likely to be sustained unless it can be incorporated at a structural level. Changes of staff were seen as the main barrier to keeping organisations focussed on the project. Action Research Approach Action research is flexible, adaptable and able to accommodate different agendas. Taking a broad and flexible approach has enabled organisations to have a choice in how they respond to the project and the changes that they have planned. Action research has encouraged people to feel part of the project and valued for their contribution. This ownership and autonomy means that the actions are more likely to be sustained. People within organisations know best what they need and want to promote action for change and most organisations have taken the lead in deciding what changes to make. The project has acted as a guide and support in planning action for change. Some organisations see their action plan as quality improvement process, with a similar plan, do, check, act approach. Action research is seen as a more academic term for this. Healthy Ageing Nutrition Project Report of 137

107 Website The website averaged 65 hits per day during the active phase of the project and this rose to 300 when new information was posted. The content has broadened since the inception with the inclusion of information about physical activity and falls prevention. It is hoped that the website will be an effective means of providing information and links. Links The project has forged links with a number of related projects and issues including physical activity, falls prevention, and medication. The concept of healthy ageing has been broadened by joint presentations to services and groups and the project has demonstrated the close and over-lapping links between these issues. Examples include assessment of nutritional risk as part of the falls prevention chart used in some hospitals and aged care settings, in the home medication review and in the home activity monitoring program. Support In the early and mid-stages of the project, there was a high demand for support and most organisations were in frequent contact with the project manager. Some identified what they needed in support and the impact on the organisation. Others were less clear. The project manager worked pro-actively and re-actively with organisations depending on where they were in the change process. Some organisations needed considerable guidance and input of ideas and this created a tension in the action research approach. The project manager reflected on whether these organisations were being pushed too far and too soon. Evidence from the organisations points to a good relationship with the project manager and an effective balance between motivation and direction. It is difficult to predict how organisations will respond but on the whole there has been a good response to the challenges presented and some organisations have also developed in unexpected ways. Some other organisations were much more experienced in strategic planning and quality improvement and with these the support offered was more reactive in response to requests. The forum, advisory group and many other opportunities to share information meant that the organisational development was able to occur collectively as well as the project working with individual organisations. Action plans were individual but shared common objectives. Healthy Ageing Nutrition Project Report of 137

108 Key Achievements These can be summarised as: > Increased information, resources and awareness about nutritional risk > Increased screening > Training in nutritional risk and screening > Links forged across organisations and issues > RDNS literature review 41 > Aged care accreditation standards > Six student placements > Funding applications > Conferences papers and presentations > Translation of nutrition guidelines into Italian, Greek and Maltese > Beginning involvement of ATSI workers Sustainability and future directions Commitment at organisational level is needed to create and sustain change. The management team and the participating organisations support an ongoing project, with a person who is able to keep action happening, keep resources flowing and develop new issues as they are identified. There has been a growing awareness by the project and organisations about links between nutrition, falls, medication and physical activity. So the focus has broadened to recognise healthy ageing in a holistic sense with nutrition as one important part of an individual s risk factors. Other issues which have arisen during the course of the project include food security, management of obesity and overweight, broader social planning, and how best to involve ATSI communities. 41 Telford K. & Kralik D. (2005) Nutrition for People Living in the Community with Chronic Illness: Literature Review April/May 2005, RDNS Research Unit, RDNS, Adelaide. Healthy Ageing Nutrition Project Report of 137

109 3.3 Organisational interviews Contacts from ten organisations were interviewed in April and in November 2005, either by telephone or face-to-face. Three individuals from the dietitians group 42 were interviewed so the total number of respondents is twelve. Distribution of clients State-wide 4 Metropolitan 4 Local 1 Not applicable 1 Number of clients < ,000 1 >1,000 5 Not applicable 1 Number of workers (paid and volunteer) < >100 6 Not applicable 1 Three organisations (all >100) have a high proportion of volunteers in the workforce. Service type Meal delivery to home 2 Care in home 2 Inpatient/residential care 2 Information / education / workforce development 2 Physical activity programs in community 1 Dietetic services 1 42 For the purpose of the project a Dietitians group was brought together and is treated as one organisation in the quantitative data. Three dietitians were interviewed from this group: one in private practice, one employed in a hospital setting and one employed in a community health setting. Healthy Ageing Nutrition Project Report of 137

110 Structural and Personnel Change in Organisations between Interview Rounds Only one interview respondent from the first round was no longer employed at the organisation for the second round and another organisation reported several changes in Executive Director. However, in both cases the commitment to the project was maintained. An organisation that had been undergoing structural change at the start of the project was still in transition but this was reported to have delayed rather than blocked any achievements. Working with the Healthy Ageing Nutrition Project In the first round interviews, respondents were asked In general, how has it been, working with the Healthy Ageing Nutrition project? Eleven respondents made very positive comments about the project and the project staff. The project manager s role was described as providing responsive support, research and resources, and leadership. Five organisations had already started work or expressed interest in the topic of nutrition and ageing and stated that the project had helped to develop this further. Other positive comments were that involvement in the project had been beneficial for the organisation, had resulted in increased awareness of the issues, increased skills and filled a gap. Two respondents commented positively about their dietetic student placements. For one organisation the project started at a time of major internal change which made it more difficult to be involved. However, the importance of nutrition was recognised and led to active participation. Organisations were next asked what they hoped to get out of their involvement with the project and whether their expectations had been met so far. Organisations listed several expectations from their involvement. Six organisations mentioned goals focussed on information sharing, education, training and workforce development. Six wanted an increase in awareness and knowledge about the importance of nutrition as a component of healthy ageing. Four organisations wanted to increase links and networks, three to establish new screening and assessment procedures and two were concerned with quality improvement or learning about good practice. Four respondents considered their expectations had been fully met and six were partly met or underway with what they hoped to achieve. Healthy Ageing Nutrition Project Report of 137

111 In round two, organisations were asked about the benefits and highlights of working with the project. Six respondents each mentioned increased awareness of nutrition issues and the development of networks/partnerships as benefits. Four respondents noted the flexibility and acceptance of different organisational cultures by the project. Three respondents believed that the breadth of focus achieved (e.g. linking nutrition with falls prevention, medication) was a highlight. Two people each mentioned the good support from the project manager and an increase in knowledge/skills within the organisation. Several respondents also highlighted the benefits obtained from the student placements; these were considered a good resource and students had the potential to take an increased awareness and interest in healthy ageing and nutrition back to their tertiary centres and fellow students. Difficulties were described by nine respondents, three believed the diversity of stakeholders was a challenge and two that there was some potential conflict of interest. Two respondents stated that the small number of dietitians in South Australia with an interest in ageing was a problem. Also in round two, organisations were asked to rate and comment on the quality and effectiveness of project support and communication strategies. All respondents rated the support from the project as high. It was stated that the project manager offered regular input and follow up without being intrusive. Communication was rated as high by 11 respondents and medium by one. Phone calls, s, presentations, attendance at events, resource provision were all mentioned as useful and timely. One respondent noted that while there weren t many advisory group meetings there were enough given the limited capacity of the participating organisations to send representatives. Enablers and Barriers to Beginning Action The enabling factors and barriers to beginning action (from round 1 interviews) have been divided into project factors and organisational factors. Facilitation and support from the project and support from the organisation s Board/management were the most frequently mentioned enablers Healthy Ageing Nutrition Project Report of 137

112 Enabling Project Factors Facilitation/support/leadership 6 Providing information & resources 3 Acceptance of our goals & values 1 Enabling Organisational Factors Support from Board/management 4 Previous work/interest in topic 2 Change agent/ QI process in organisation 2 Relevant and adds value to our work 2 Flexibility to take on new role 1 The most frequently mentioned barrier (n=8) was lack of time and resources within organisations and that participation in the project added to the workload. Six respondents expressed resistance to change as a barrier and four described factors within the organisation that made change more difficult to achieve: lack of a change champion, frequent changes in staff, lack of quality improvement culture and no clear motivation for change. Other barriers were the small number of dietitians in South Australia with an interest in aged care and trying to implement change when there are concurrent organisational changes occurring. Finally, one respondent faced a lack of support as the employing organisation did not see work in the community as part of its role, and one respondent expressed concern about the capacity of the health system to intervene once at risk clients had been identified. Only one barrier related to the project was mentioned: one respondent stated that the proposed screening tool was not realistic for community-based services and alternatives were needed. Communication Strategies and Activities In both rounds of interviews respondents were asked about the project web-site. All respondents had visited the project website although most (n=10) only occasionally. Three had also referred others to the website. Most respondents stated that the website provided good up-to-date resources and materials and this was the main use they made of it. No-one had specifically used the website to advance their action plan, preferring Healthy Ageing Nutrition Project Report of 137

113 personal contact with project staff for this purpose. One respondent referred to the need to maintain the website in future. Eight respondents had distributed information about the project to their workforces, covering approximately 9,600 individuals plus DAA readership (~ 200 in SA). The other four respondents had disseminated information in different ways such as at staff meetings and presentations. One organisation had added information about the project to its own website. All organisations were represented at the Forum and most had sent several people. The main benefits described were hearing about the roles of the diverse services and groups (n=6), opportunities to make new links (n=5) and strengthen existing networks (n= 4), and sharing resources (n=2). Two respondents mentioned the value of being able to present from their perspective to professional groups. Action Planner and Achievements Data from the first round of interviews revealed that most (n=7) organisations had not changed their action plans. Three had: one adding hydration rating to the screening process; one investigating different screening tools more appropriate to the client group; and one stating that the plan had evolved from identification of at risk clients to identifying resources for follow up interventions. Details of individual organisational achievements are documented in the case study section. In summary: > Eight organisations said that awareness of ageing and nutrition had increased > Seven had implemented a nutritional risk screening procedure > Seven had produced or shared information and resources materials > One had implemented a referral/intervention strategy The three dietitian respondents all highlighted the dialogue with the residential aged care accreditation agency as an important achievement. Seven respondents reported new or strengthened links with, for example, meal providers, community heath services, GPs, aged care accreditation body. Four had not made any changes because they already had appropriate networks. Healthy Ageing Nutrition Project Report of 137

114 Will the achievements make a difference at an organisational level? Five organisations reported that there was change at organisational level. Changes included policy change, increased skills and capacity in nutrition, strengthened links and a multi-disciplinary approach. Four organisations responded Yes, but. Reservations centred on the need for ongoing support e.g. up to date information, maintenance of the website, lead organisation or individual to drive the agenda. For one respondent this question was not relevant as the target for change was carers rather than the organisation itself. Any other comments about the organisation s involvement in the project? In both rounds of interviews respondents were offered the opportunity to add any other comments about their organisation s involvement in the project. All the comments were positive. In the first round, respondents re-iterated achievements, and the increase in knowledge and capacity. The link established between medication, exercise and nutrition was noted as useful. In terms of processes, comments included that the project was timely, allowed ownership by the organisation, gave an opportunity to look at the bigger picture outside the organisation, and was respectful of different stakeholders. Second round responses again praised the work of the project manager and the way the project was run, and confirmed achievements. Comments referring to the need for follow up and sustainability are presented in the sustainability and future section below. Healthy Ageing Nutrition Project Report of 137

115 Contribution to Achievement of Project Objectives and Goal Respondents were asked to rate the achievements of the project s objectives in their organisation as high, medium or low. Objective High Medium Low Comment To increase awareness and knowledge of the food and nutritional needs of older people among carers and professional groups To increase knowledge and skills of the workforce in early identification of nutritional risk by the use of simple assessment and screening tools Low scores small number or still working on this Low score no audit to check this but working on To increase the use of appropriate nutrition early intervention strategies Most responses still working on this or no evidence yet To increase intersectoral collaboration in addressing food and nutrition needs among organizations and groups who support healthy ageing Variable responses, some have made lots of links, others already had in place. Links may be individual rather than organisational Healthy Ageing Nutrition Project Report of 137

116 Respondents were next asked to rate the achievement of the project goal in the broader environment. Goal High Medium Low Don t know To develop workforce capacity through increased awareness and the use of an early intervention strategy to improve the nutritional health of older people in South Australia Three of the responses referred to lack of evidence at this stage and the need for more research into the best interventions and how to assess outcomes. Two others mentioned that their organisations are considered by others to be good practice leaders. The inclusion of carers in the definition of workforce has resulted in a large number of people who now have more awareness and information about nutrition. Sustainability of Achievements and Changes All but one respondent believed that at least some of the achievements would be sustained. For example, nutritional screening at admission, information and resources, the new aged care standards and collaborative links were stated as sure to continue. Some respondents qualified their response by noting that a funded person would be needed to maintain links, distribute up-to-date information and generally keep ageing and nutrition on the agenda as an important issue. In terms of changes in the sector more broadly some positive moves were noted. The DAA now has ageing and nutrition on its agenda and a small group of South Australian dietitians is committed to continuing their contribution. Links with organisations and networks working in the area of falls prevention in the northern metropolitan area may extend to other areas. Healthy Ageing Nutrition Project Report of 137

117 One respondent suggested that the collaborative action research approach was a model that could be used to address other topics and another suggested that their organisation might develop a primary health care initiative based on early intervention and linking nutrition with falls. One respondent suggested a final forum to consolidate the achievements and plan next actions. Another talked about the need for nutrition to be a higher priority, with adequate funding for resources, services and supports in the community. One respondent voiced hope that the Department of Health and the Health Promotion Branch would continue and strengthen their commitment in this area Project Advisory Group Six members of the group attended at a session in November designed to gain feedback for the evaluation. A further four people who had not been able to attend on the day were followed-up by telephone. The data have been combined for the purpose of analysis. Role of the Advisory Group Most members of the group described the role as bringing together organisations to discuss ageing and nutrition and to share information. Other responses were to provide input and advice to the project (one person noting this occurred at the start and another that this did not occur), to promote the project to the community, and to support and provide ideas for the project manager. Diversity of Group About half the members stated that it was good to hear a range of perspectives and that the meetings led to the formation of links and collaborations between organisations that had not previously worked together. Two respondents believed there was insufficient diversity: for example CALD organisations did not attend, ATSI representation came on late and it would have been more useful to engage people at the worker level. One person responded that the group was involved in receiving updates and reports rather than the sharing of different perspectives. Healthy Ageing Nutrition Project Report of 137

118 Influence on the Project Only one respondent stated that the group was a forum for raising and solving issues. Most respondents did not believe the group had much or any influence on how the project was implemented, stating that the group was more about sharing information. One person pointed out that day to day management of the project by the group would not have been realistic. Four respondents stated that members had influence in how the project was run in their own organisations but not more broadly. Quality and Effectiveness of Project Management All respondents stated that there had been good communication between members and the project. The project manager was easily accessible, gave prompt feedback and follow up, provided clear, well-researched information and developed useful resources. In one respondent s words: Close to the ideal management model. Action Research Approach Almost all respondents were positive about the action research approach of the project. The strengths were seen to be that each organisation was respected as having different needs and different ways to implement the project. An additional benefit noted was that workers at the coal face had been up-skilled. One person thought there had been sufficient reflection and wanted more implementation. The drawbacks of action research were stated as the potential for organisations to drift off target or slow down in their action plans and the difficulty of engaging people who don t accept the need for change. Enablers and Barriers to Change within the Project Most respondents stated that bringing organisations and people together was the most important enabling factor of the project. For example, the forum had demonstrated there was a critical mass of interest in the topic and set up the other achievements. Another comment was that the organisations were already keen to tackle nutrition and this helped their participation. The wide definition of workforce to include carers was also noted as an enabler. Barriers were mostly related to reluctance to change or change fatigue in some people and organisations or to the extra workload entailed in participation. Several people pointed out that organisations were not funded to participate and staff time and other Healthy Ageing Nutrition Project Report of 137

119 resources had to come from their own budgets. An individual response was that the project had been mainly active in the northern metropolitan region. Enablers and Barriers in the Broader Environment The national and interstate connections were believed to be enablers of change by two respondents. Four respondents talked about the changes in the State health system but it was unclear at this stage whether these reforms would be positive or negative in terms of the aims of the project. Lack of further funding opportunities was seen as a barrier by three people and the ageing population would add to the problems. Two people noted that ongoing promotion would be needed to consolidate and maintain changes in practice. One respondent believed that the tribal behaviour of some health professionals was a barrier to change. Achievement of Objectives In general, fewer respondents felt able to comment on the achievement of project objectives. Objective 1: To increase awareness and knowledge of the food and nutritional needs of older people among carers and professional groups (known here as the workforce ) Respondents thought this had been achieved for the organisations directly involved but not more broadly. Objective 2: To increase knowledge and skills of the workforce in early identification of nutritional risk by the use of simple assessment and screening tools Five respondents reported on organisations that have taken up screening and changed their practice. Objective 3: To increase the use of appropriate nutrition early intervention strategies Resources about services for early intervention have been developed but in general this objective is still to be achieved. Healthy Ageing Nutrition Project Report of 137

120 Objective 4: To increase intersectoral collaboration in addressing food and nutrition needs among organizations and groups who support healthy ageing Two respondents thought this had been achieved by bringing together people and organisations. From the perspective of one organisation this objective had not been achieved. What would you like to see happen next? Five respondents wanted the project to continue in order to sustain the achievements including one person who suggested an organisation might take on the driving role and another who wanted a seminar day to conclude this stage of the project. Three people wanted to broaden the scope of the project to include, for example, more CALD and ATSI workers, and nursing homes. Two people suggested more training in nutrition and ageing for dietitians and dietetics students, and two suggested training for cooks and aged care workers, with accreditation as an incentive. Another two respondents suggested more use of video and television to demonstrate cooking for older people. One person wanted more funding for interventions. What is likely to happen? If no further funding is found, three people thought that the activity would continue in the participating organisations but with no developments. Another believed the project would fold, which would be a great shame after what has been achieved. Two respondents talked about the potential to lose the learning and interest as people moved on or left short term positions. How can the achievements be sustained? Continued promotion of the project and its achievements were highlighted by four respondents. The need for high level champions, resources and policy drivers were also mentioned. One respondent re-iterated the importance and benefit of targeting workers rather than community members or clients directly. Healthy Ageing Nutrition Project Report of 137

121 3.5 Other Activities This summary is based on activity data recorded by the project manager. Contact with other organisations The project had contact with 31 other agencies, groups and organisations in addition to the ten participating organisations. Type of organisation Number Community groups/networks 9 Non-government organisations 6 Aged care providers 4 Health service providers 4 Local governments 3 State and Federal government 3 University departments 2 Activity included meetings and follow up with all organisations, 16 displays or resource provision and eight presentations. Outcomes from these activities included: > Distribution of Eat Well for Life materials > BMI chart introduced to aged care facility > Six final year dietetics student placements > Design and production of fact sheets for distribution by Senior Information Service > Healthy Ageing Record (client held) on Falls, Nutrition and Medication established and trialled in general practices > Contribution to COTA fact sheet Food, Glorious Food > Eat Well for Life translated into Italian, Greek and Maltese and made available nationally > Dietary Guidelines for Older Australians translated into Italian, Greek and Maltese and made available nationally > Contribution to flowchart now being used in general practitioner training by Home Activity Monitoring Program Healthy Ageing Nutrition Project Report of 137

122 Community Affairs Senate Committee A submission was made to Community Affairs Senate Committee in response to a public request for information on specific aspects of aged care. Verbal evidence was given by Leah Trotta and Bob Penhall at the Public Senate Hearing in February The resultant Hansard record is now available at and final Senate report at ATSI worker forum An educational forum was held in August 2005 for with the goals of increasing ATSI workers knowledge about holistic health issues, building rapport with presenting organisations, and providing links and information about mainstream services. The forum was arranged with assistance of the Aboriginal Health Council. Thirteen people attended from ten different agencies. Although only a small number of feedback sheets were completed, those that were indicated satisfaction with the session and increased knowledge. Web links The Healthy Ageing Nutrition Project website is linked to a number of other sites, e.g. The Human Race Metropolitan Domiciliary Care DH, SA Central, CWDiv GP, RDNS Conferences A paper was presented by Dr Robert Penhall at the SA Healthy Ageing Research Cluster forum in October 2005 entitled Healthy Ageing Nutrition Project: an example of a collaborative, action-research based approach to multi-disciplinary research in ageing. The SA Gerontology Conference themed Resilience in Ageing: Enabling and creating resilient individuals, systems, infrastructure and services was held on 26th July Leah Trotta presented a paper titled Healthy Ageing Nutrition Project: an example of building workforce capacity through a collaborative, action-research based approach. Healthy Ageing Nutrition Project Report of 137

123 The 18th Congress of the International Association of Gerontology took place in Rio de Janeiro, Brazil from June 26 to 30th, 2005 with over 4,000 participants. Dr Robert Penhall presented a paper titled Addressing nutritional risk for older people through collaboration, simple screening and early intervention Funding applications July 2005: A collaboration of Metropolitan Domiciliary Care, Royal District Nursing Service, Meals on Wheels, Adelaide North East Division of General Practice and Adelaide Northern Division of General Practice proposed to establish a Nutrition Link Worker to operate between agencies to support clients in seeking an ideal mix of services to meet their nutritional needs. Discussions commenced with the Office for Ageing, Department of Families and Communities regarding Home and Community Care Funding for this initiative, however it was not supported. September 2005: Metropolitan Domiciliary Care, Aboriginal Health Council of SA Inc and Flinders University of SA collaborated and submitted an Expression of Interest for a fiveyear research plan centred on Food, Nutrition and Older People in South Australia to the National Health and Medical Research Council s Ageing Well Ageing Productively Funding Round. To date, no response or further invitation to develop the proposal has been received Healthy Ageing Nutrition Project Report of 137

124 4. DISCUSSION Achievement of Objectives Objective 1: To increase awareness and knowledge of the food and nutritional needs of older people among carers and professional groups (known here as the workforce ) The evaluation did not measure increases in awareness and knowledge directly. However, all ten organisations reported increased awareness and knowledge within their workforce as a result of the project. Nutrition and ageing is now on the agenda for aged care providers, meals services and carers, and, to some extent for governments. Strategies used by organisations to increase awareness and knowledge include information and training sessions for workers, volunteers and carers; development of nutritionally and culturally appropriate menu plans; information-sharing forums; newsletters, websites and publications. The project Forum, website, student placements and other activities have also contributed to increased awareness and knowledge. The impact on organisations outside the project is less clear. Work is underway to add nutrition issues to the accreditation standards for residential aged care. Websites and other resources such as the translated food and nutrition guides will have a broader audience, as will conference papers, reports and other dissemination strategies. Seven organisations have shared information or resources with others; this is also likely to lead to increased awareness. While awareness and knowledge is likely to be sustained within the current workforce, without a driver it is unlikely that information and resources will be kept up-to-date and accessible to a wide range of organisations. Objective 2: To increase knowledge and skills of the workforce in early identification of nutritional risk by the use of simple assessment and screening tools Seven of the case study organisations have changed their nutritional assessment practices and introduced screening tools. This has been accompanied by policy development in the organisation and training for workers. Three of these have processes underway to audit use of screening and at least one more is planning for this. Healthy Ageing Nutrition Project Report of 137

125 Of the other three organisations, two do not provide direct services: one has made available a screening tool for carers and the other has distributed a flow chart for general practitioners. This objective was not directly relevant for the members of the dietitians group since they are already practising in this field. For organisations outside the project there is some potential for increasing nutritional assessment and use of screening tools. Services that have a culture of benchmarking their activities may pick up on new practices they see in similar organisations to their own. The networking and links that already existed, or that have been strengthened by involvement in the project, may form a conduit for transfer of new skills and practices in screening. Organisations that have taken on the use of screening tools are likely to continue as long as some benefit is seen to outweigh costs. Evaluation that can identify costs and benefits is therefore needed. Wide dissemination of the findings from this project and future evaluations of outcomes from changed practice will increase the likelihood that current organisations will sustain the changes and that others will take up nutritional screening. Objective 3: To increase the use of appropriate nutrition early intervention strategies This objective is most likely to occur as a follow up to Objectives 1 and 2 and therefore it is no surprise that it is the least well achieved according to the evaluation evidence reported here. For most organisations, it is a matter of timing; screening is just becoming embedded and the increased need for early intervention strategies will become apparent once nutritional assessment is a standard part of practice. Two organisations have already set referral mechanisms or dietary changes in place. There is some concern about the capacity of dietetic and other professional services to respond to the anticipated increased demand brought about by regular screening. As yet no organisation has been able to evaluate the outcomes of screening and early intervention strategies; this will be an important next step. Healthy Ageing Nutrition Project Report of 137

126 Objective 4: To increase intersectoral collaboration in addressing food and nutrition needs among organizations and groups who support healthy ageing Seven organisations reported new or strengthened links with other organisations as a result of the project. This sometimes meant working with services and groups that were not part of an organisation s traditional network. For some smaller or isolated organisations, the project had the effect of bringing them into the loop. This is illustrated by the exchange of information, resources, speakers and ideas through the website, at the Forum and at other events. The connection made between nutrition, falls prevention and medication has been of particular value for many practitioners. The ATSI forum also brought together a number of health issues in a holistic way and introduced ATSI workers to mainstream services that they could access for clients. This objective appears to be the one most at risk if there is no continuation of the project. It is probable that many of the links made are by individuals rather than by formal organisational links. Individual links are likely to be lost when people move on to a different position. Action Research Approach The strengths of this approach can be summed up as: > sense of ownership and inclusiveness by advisory group and participating organisations > flexibility to respond to different organisational needs > engagement of organisational and other stakeholders > opportunity to reflect in a supportive and trusted environment > organisations have been able to adapt the planning tool to their own situation > ability of project to make adjustments in response to reflecting on actions The challenges of action research include: > need to re-establish support when developmental changes occur > need for balance between leading and supporting organisations in action for change > potential for organisations to go off track or slow down on actions Healthy Ageing Nutrition Project Report of 137

127 These opportunities and challenges of action research seem to have been well-balanced in the project and most respondents were very positive about this approach for workforce development. Particularly in these times of seemingly constant change, managers, workers and volunteers all valued the way the project was able to accommodate different needs and allow organisations to respond in their own way to the achievement of common objectives. At the same time, the project resulted in concrete change in the competency of the workforce to assess and respond to nutritional risk in older people. There was some disagreement about the role of the reference group. The original funding application talks about an advisory group but the Terms of Reference refer to a reference group. Project documentation uses both terms interchangeably. Members of the reference group believed their main role was in bringing organisations together at the same table and exchanging information. It seems the potential for providing advice was limited by the large size of the group and the infrequent meetings. This made it difficult for members to provide advice in any meaningful way. However, the reference group did contribute to early planning and to ideas for sustainability and most members were satisfied with their input to the project. Project Reach Information about the project has been distributed in newsletters and articles to the organisations workforces, covering approximately 9,600 individuals plus national DAA readership (~ 200 in South Australia). Other organisations have disseminated information in different ways such as at staff meetings and presentations. In addition to the active case study organisations, 31 other groups and organisations have been involved with the project. These include community groups/networks, nongovernment organisations, aged care providers, health services, university departments, and Australian, State and local governments. Activities included meetings and follow up, resource provision and presentations. The project also made a submission to the Community Affairs Senate Committee on aged care. Healthy Ageing Nutrition Project Report of 137

128 The website is averaging 65 hits per day although this rises to 300 when new information is posted. The content has broadened since the inception with the inclusion of information about physical activity and falls prevention. All case study organisations had visited the website and most respondents stated that it provided good up-to-date resources and materials. Achieving Change A number of enablers and challenges to achieving organisational change can be identified from the multiple data sources to this evaluation. These are illustrated in Figure 1 and Figure 2 below. Enabling factors include the facilitation and resources provided by the project and the support and commitment by Boards, management, staff and clients to change. The main challenge is the time and resources required from the organisation, particularly when there are competing priorities and resistance to (yet more) change. Figure 1: Organisational Change Enablers Healthy Ageing Nutrition Project Report of 137

129 Figure 2: Organisational Change Challenges Sustaining Change In the absence of ongoing project funding it seems likely that some changes will be sustainable, particularly in larger organisations that have embedded nutritional screening into their intake assessment policy. A change champion in the organisation is important in getting change onto the agenda but if change has been driven by one individual there is a risk that this will be lost if the person moves to another organisation. On the other hand, individuals moving to new positions take their knowledge and skills with them so this could be a way to increase the project reach. Ongoing funding would be useful in maintaining the momentum with participating organisations. Few have the resources to update the information and resources which have been an important part of the project and, as described above, when individual workers move positions their networks may be lost to the organisation. Further development of the nutrition and ageing agenda needs a commitment from policy makers and funders to support an individual or an organisation to act as a driver in brining about and sustaining change. Healthy Ageing Nutrition Project Report of 137