Co-designing an interprofessional care pathway for (risk of) malnutrition and sarcopenia in community-dwelling older adults

TL;DR

This paper describes the co-design of a care pathway to better manage malnutrition and sarcopenia in older adults through interprofessional collaboration in primary care.

Contribution

A novel interprofessional care pathway prototype was co-designed to integrate malnutrition and sarcopenia management in community-dwelling older adults.

Findings

The co-design process involved healthcare professionals and resulted in a structured workflow for detecting and managing malnutrition and sarcopenia.

The pathway includes practical tools like detection cards and shared treatment plans to support interprofessional communication and decision-making.

Abstract

Integrating care for (risk of) malnutrition and sarcopenia in primary care is challenging, as limited physical proximity among healthcare professionals hinders collaboration. Both health conditions are common in community-dwelling older adults and are associated with significant declines in physical functioning, independence, and quality of life. Healthcare professionals tend to manage malnutrition and sarcopenia separately, leading to missed opportunities for early (risk) identification and coordinated care. An interprofessional care pathway can provide an evidence-based, structured framework to support such integration. Therefore, we aimed to co-design an interprofessional care pathway for addressing (risk of) malnutrition or sarcopenia in community-dwelling older adults within the Dutch primary care context.

We applied a design-oriented approach using the Double Diamond model to guide the development process across the discover, define, and develop phases. Methods included persona development and validation, desk research, patient journey mapping, service blueprinting, and prototyping. In addition, we introduced an interprofessional visualisation combining elements of the patient journey map and service blueprint to represent both front-stage and back-stage care processes along a timeline. The data were analysed iteratively.

Thirteen healthcare professionals, including district nurses, dietitians, physiotherapists, general practice assistants, dementia case managers, general practitioners, and a geriatric specialist, participated in the co-design process. The process comprised three in-person sessions and two online follow-up meetings. In addition, one community-dwelling older adult was interviewed. The co-design process resulted in a prototype interprofessional care pathway that offers a structured workflow for detecting, screening, and managing (risk of) malnutrition and sarcopenia. The pathway addresses interprofessional, person-centred, and integrated care by a designated point of contact, shared treatment plans, continuous interprofessional communication, shared decision-making, clearly defined roles, and regular team evaluation. The pathway includes practical tools such as detection cards, templates and formats for task allocation, work agreements, and team evaluation.

This study presents a co-designed prototype of an interprofessional care pathway to address (risk of) malnutrition and sarcopenia in community-dwelling older adults. Future research should evaluate its feasibility in daily primary care practice.

The online version contains supplementary material available at 10.1186/s12913-026-14047-7.

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