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

Hans Drenth; Sandra Boxum-Bergsma; Harriët Jager-Wittenaar; Jan-Jaap Reinders; Manon van den Berg; Job van 't Veer; Michael Tieland; Sophie Spoorenberg; Anjo Geluk-Bleumink; Philip van der Wees

doi:10.1186/s12913-026-14047-7

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

Vertaalde titel van de bijdrage: Co-design van een interprofessioneel zorgpad voor (risico op) ondervoeding en sarcopenie bij thuiswonende ouderen

Hans Drenth, Sandra Boxum-Bergsma, Harriët Jager-Wittenaar, Jan-Jaap Reinders, Manon van den Berg, Job van 't Veer, Michael Tieland, Sophie Spoorenberg, Anjo Geluk-Bleumink, Philip van der Wees

Onderzoeksoutput: Article › Academic › peer review

Samenvatting

Achtergrond
Het integreren van zorg voor (risico op) ondervoeding en sarcopenie in de eerstelijnszorg is uitdagend, omdat de beperkte fysieke nabijheid van zorgprofessionals de samenwerking bemoeilijkt. Beide aandoeningen komen veel voor bij thuiswonende ouderen en gaan gepaard met aanzienlijke achteruitgang in fysiek functioneren, zelfstandigheid en kwaliteit van leven. Zorgprofessionals behandelen ondervoeding en sarcopenie vaak afzonderlijk, wat leidt tot gemiste kansen voor vroege (risico)signalering en gecoördineerde zorg. Een interprofessioneel zorgpad kan een evidence-based en gestructureerd kader bieden om deze integratie te ondersteunen. Daarom was het doel van deze studie om, binnen de Nederlandse eerstelijnscontext, een interprofessioneel zorgpad te co-designen voor het aanpakken van (risico op) ondervoeding en sarcopenie bij thuiswonende ouderen.

Methoden
Er werd een ontwerpgerichte aanpak toegepast, waarbij het Double Diamond-model werd gebruikt om het ontwikkelproces te sturen in de fasen discover, define en develop. Methoden omvatten het ontwikkelen en valideren van persona’s, deskresearch, patient journey mapping, service blueprinting en prototyping. Daarnaast werd een interprofessionele visualisatie geïntroduceerd die elementen van de patient journey map en service blueprint combineert, om zowel frontstage- als backstage-zorgprocessen in de tijd weer te geven. De data werden iteratief geanalyseerd.

Resultaten
Dertien zorgprofessionals namen deel aan het co-designproces, waaronder wijkverpleegkundigen, diëtisten, fysiotherapeuten, doktersassistenten, casemanagers dementie, huisartsen en een specialist ouderengeneeskunde. Het proces bestond uit drie fysieke bijeenkomsten en twee online vervolgsessies. Daarnaast werd één thuiswonende oudere geïnterviewd. Het co-designproces resulteerde in een prototype van een interprofessioneel zorgpad dat een gestructureerde werkwijze biedt voor signalering, screening en behandeling van (risico op) ondervoeding en sarcopenie. Het zorgpad richt zich op interprofessionele, persoonsgerichte en geïntegreerde zorg, met een vast aanspreekpunt, gedeelde behandelplannen, continue interprofessionele communicatie, gezamenlijke besluitvorming, duidelijk gedefinieerde rollen en regelmatige teamevaluatie. Het zorgpad bevat praktische hulpmiddelen zoals signaleringskaarten, sjablonen en formats voor taakverdeling, werkafspraken en teamevaluatie.

Conclusie
Deze studie presenteert een co-ontworpen prototype van een interprofessioneel zorgpad voor (risico op) ondervoeding en sarcopenie bij thuiswonende ouderen. Toekomstig onderzoek zou de haalbaarheid in de dagelijkse eerstelijnszorgpraktijk moeten evalueren.

Vertaalde titel van de bijdrage	Co-design van een interprofessioneel zorgpad voor (risico op) ondervoeding en sarcopenie bij thuiswonende ouderen
Originele taal-2	English
Artikelnummer	245
Pagina's (van-tot)	01-14
Aantal pagina's	14
Tijdschrift	BMC Health Services Research
Volume	26
DOI's	https://doi.org/10.1186/s12913-026-14047-7
Status	Published - 20 jan. 2026

Keywords

Zorgpad
Interprofessionele Samenwerking
Ondervoeding Risico
Sarcopenie
Ontwerpgerichte Aanpak

Research Focus Areas Hanze University of Applied Sciences

Healthy Ageing

Research Focus Areas Research Centre or Centre of Expertise

Kwetsbaarheid en passende zorg

Publinova thema's

Overig
Gezondheid

Toegang tot document

10.1186/s12913-026-14047-7Licentie: CC BY

Citeer dit

Drenth, H., Boxum-Bergsma, S., Jager-Wittenaar, H., Reinders, J.-J., van den Berg, M., van 't Veer, J., Tieland, M., Spoorenberg, S., Geluk-Bleumink, A., & van der Wees, P. (2026). Co-designing an interprofessional care pathway for (risk of) malnutrition and sarcopenia in community-dwelling older adults. BMC Health Services Research, 26, 01-14. Artikel 245. https://doi.org/10.1186/s12913-026-14047-7

@article{3963061715974ff19ddcd499e9076b0d,

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

abstract = "Background 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. Methods 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. Results 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. Conclusion 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.",

keywords = "Zorgpad, Interprofessionele Samenwerking, Ondervoeding Risico, Sarcopenie, Ontwerpgerichte Aanpak, Care Pathway, Interprofessional Collaboration, Malnutrition, Sarcopenia, esign-oriented Approach",

author = "Hans Drenth and Sandra Boxum-Bergsma and Harri{\"e}t Jager-Wittenaar and Jan-Jaap Reinders and \{van den Berg\}, Manon and \{van 't Veer\}, Job and Michael Tieland and Sophie Spoorenberg and Anjo Geluk-Bleumink and \{van der Wees\}, Philip",

year = "2026",

month = jan,

day = "20",

doi = "10.1186/s12913-026-14047-7",

language = "English",

volume = "26",

pages = "01--14",

journal = "BMC Health Services Research",

issn = "1472-6963",

publisher = "Springer Nature-BioMed Central",

}

Drenth, H , Boxum-Bergsma, S , Jager-Wittenaar, H , Reinders, J-J, van den Berg, M, van 't Veer, J, Tieland, M, Spoorenberg, S, Geluk-Bleumink, A & van der Wees, P 2026, 'Co-designing an interprofessional care pathway for (risk of) malnutrition and sarcopenia in community-dwelling older adults', BMC Health Services Research, vol. 26, 245, blz. 01-14. https://doi.org/10.1186/s12913-026-14047-7

TY - JOUR

T1 - Co-designing an interprofessional care pathway for (risk of) malnutrition and sarcopenia in community-dwelling older adults

AU - Drenth, Hans

AU - Boxum-Bergsma, Sandra

AU - Jager-Wittenaar, Harriët

AU - Reinders, Jan-Jaap

AU - van den Berg, Manon

AU - van 't Veer, Job

AU - Tieland, Michael

AU - Spoorenberg, Sophie

AU - Geluk-Bleumink, Anjo

AU - van der Wees, Philip

PY - 2026/1/20

Y1 - 2026/1/20

N2 - Background 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. Methods 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. Results 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. Conclusion 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.

AB - Background 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. Methods 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. Results 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. Conclusion 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.

KW - Zorgpad

KW - Interprofessionele Samenwerking

KW - Ondervoeding Risico

KW - Sarcopenie

KW - Ontwerpgerichte Aanpak

KW - Care Pathway

KW - Interprofessional Collaboration

KW - Malnutrition

KW - Sarcopenia

KW - esign-oriented Approach

U2 - 10.1186/s12913-026-14047-7

DO - 10.1186/s12913-026-14047-7

M3 - Article

SN - 1472-6963

VL - 26

SP - 1

EP - 14

JO - BMC Health Services Research

JF - BMC Health Services Research

M1 - 245

ER -

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

Samenvatting

Keywords

Research Focus Areas Hanze University of Applied Sciences

Research Focus Areas Research Centre or Centre of Expertise

Publinova thema's

Toegang tot document

Vingerafdruk

Citeer dit