Background: Malnutrition often remains undetected in older persons, leading to increased health problems and comorbidity, prolonged hospital stays and readmission. Since malnutrition is a multi-factorial condition, a multidisciplinary and integrated approach is recommended for screening and treatment and this is especially the case in community care, where exchange of health information is often challenging.
Methods: Recently, the Global Leadership Initiative on Malnutrition (GLIM) reached a consensus for a global definition of malnutrition. In our study, the GLIM criteria were applied to data from the interRAI Home Care (interRAI HC) and the interRAI Long Term Care (interRai LTCF) instruments to identify malnutrition and to explore factors significantly associated with the development of malnutrition.
Results: The study analyzed data from 6334 older people receiving home care and 5598 nursing home residents. Most people needed extensive assistance with activities of daily living and had moderate cognitive impairment. The findings revealed that a notable proportion of residents were malnourished, with additional cases developing over one year. Key risk factors associated with malnutrition included dysphagia, advanced age, loss of appetite, bladder incontinence, low fluid intake, depressive symptoms, limited mobility, wandering behavior, falls, and visual impairments. while diabetes and visits to the physician appeared to have a protective effect. These significant factors varied across settings.
Conclusion: These results highlight the utility of a holistic assessment as the interRAI for routine screening, enabling the early identification of at-risk individuals. Understanding malnutrition as a multi-factorial condition emphasizes the need for a holistic and integrated approach to its prevention and management, addressing medical, psychological, and social needs simultaneously. Early identification of risk factors through tools like interRAI assessments and comprehensive care planning is critical in reducing malnutrition's prevalence and consequences.The development of a predictive algorithm to support prevention strategies is ongoing. The worldwide use of the GLIM and the interRAI instruments makes these findings relevant for global clinical practice, policy and research. Adapting the interRAI instruments to the GLIM definition improves accurate detection, prevention and early treatment of malnourishment, avoiding further health deterioration in older people.

BACKGROUND
As a consequence of the Aging society, the elderly people have growing need for long-term care and often for special nursing in addition to the health care system. The focus of Hungarian health care system lacks basically the examination of health care provisions carried out in the social care system. The main objective of this study is to assess the health care needs within the residential social care institutions for elderly people and to follow the implemented capacity transfer from hospitals nursing wards to social care residential homes.

Approach
In 2015 March-May time period - with the support of the State Secretary of Social Affairs of the Ministry of Human Capacities (MHC) about 600 elderly people an empirical survey has been carried out using institutional and individual datasheets focused on care problems and health care activities. Data have been analysed by descriptive and regression statistical methods. Qualitative analysis was carried out making 6 + 4 interviews with directors of residential care homes and public administrators before (2015) and after (2024) the implementation capacity transfer from healthcare to social care.

RESULTS
The results showed that the average age of inhabitants of residential social care institutions became increasingly higher (78 years). Among residents gradually growing rate of dementia (21.2%), need for intensive care (at least 12 hours a day), or continuous (24-hour) monitoring and wide range of special nursing activities (in the sample up to 35%) were observed. Based on this health needs assessment (HNA) our research and administrative group had developed an integrated organizational care model that later MHC approved as a comprehensive regulatory background on newly established skilled nursing facilities (by amendments of social care act, and ministerial order on minimum requirements of residential homes). Our research and developing expert work continued with the detailed analysis and obsevation of the current capacity transfers including 2400 beds in 2023-2024 from nursing wards of hospitals to skilled nursing facilities of residential homes summarising the advantages and futher challenges of these organizational changes.

Implications
The Hungarian integrated skilled nursing program was really based on a HNA, which was followed by a comprehensive regulatory background, which can set an example for the integrated care efforts of other countries. However, further human resource development, improvement of the competence level of APNs, and further integration of social and health resources are needed in order to create a better incentive system. In the continuation of this programme the development and sustain the care pathway management is also needed, connecting home, day care and ambulatory care platforms.

Background:
Integrated Care Systems (ICSs) in England bring together health, social and community care, and public health. Initiatives such as Enhanced Health in Care Homes and National Health Service (NHS) policies emphasise the need for integration to support an ageing population. Care home and health services staff need to work together to support physically deteriorating residents. Recently, innovative approaches such as “hospital-at-home” (HAH) are being introduced to reduce hospitalisation for older adults.
Approach:
This mixed methods study used an online survey and semi-structured interviews with care home staff to explore their use and experiences of health services, care pathways and strategies to support their residents. The survey and interview guide were developed with input from five care home staff. Survey participants were recruited via email, post and a network of research ready care homes, and interview participants, via the survey. The survey data were analysed descriptively and the interview data, thematically.
Results:
To date, 48 care home staff participated in the survey and 19 in an interview (data collection will finish in December 2024). The preliminary analysis identified two main findings:
1. Lack of consistent care pathways for physically deteriorating residents

Care home staff used different types of health services (e.g. general practitioners (GPs), 999 emergency calls, or community-based services including HAH) to support residents. Decisions about which service to contact were based on staff experience or easy accessibility. Formal integrated care pathways were lacking and care homes frequently developed their own pathways to support their residents. This meant that unwell care home residents experienced inconsistent care pathways.

2. Challenges and opportunities for integrated care

Most participants identified challenges that affected integration and collaborative working such as negative attitudes and poor communication; a lack of prioritisation when requesting help from urgent and emergency services; and limited understanding of the practice and policy challenges faced by care homes. The challenges were often perceived as unwillingness of healthcare staff to help their residents; leading to tensions between care homes and health services.

Nevertheless, some participants gave examples of successful joint working. Primary Care was the most frequently used service and some care home staff described good relationships with their care home GP. They valued regular GP visits, which they felt reduced the need for additional health and social care services. If HAH services were used, care home staff felt there was good collaboration and knowledge-sharing opportunities. Most survey respondents (66%) stated they would prefer HAH to hospitalisation for their care home residents.
Implications:
Supporting physically unwell residents’ health requires integration of social and health services. The challenges experienced by staff and the lack of consistent formal pathways indicate that effective integration of services for physically unwell residents is yet to be realised. In our study, positive examples of joined-up working between care home staff and NHS services were scarce despite ICSs and policies in England specifically advocating integration. This study highlights the need for improved collaboration and clearer pathways, as well as learning for improving integration and residents’ healthcare.

BACKGROUND

Spain, as a social and democratic state, is committed to ensuring equality of opportunities for all its citizens, which includes fundamental rights in the healthcare and social spheres. The General Health Law of 1986 established a National Health System (NHS) that provides universal healthcare, while the System for Autonomy and Care for Dependency promotes access to social benefits for dependent populations.

In the Balearic Islands, this framework is complemented by regional legislation aimed to ensure the quality of life and autonomy for individuals through diverse socio-health services. However, the lack of coordination among these services is particularly evident in the case of the institutionalized population, due to both the disruption of continuity by their primary care professionals—who are central to our NHS—and the multiplicity of actors involved, including private companies, nursing homes professionals, and representatives from health and social services’ public administrations.

APPROACH

The creation of the integrated care promotion team for nursing homes (EPAIB-RES) in 2023 materialized as a response to these challenges. This multidisciplinary team in Mallorca comprises five nurses, two physicians, and one pharmacist, with the goal of improving healthcare for 3,580 patients living in 41 nursing homes, focusing particularly on those with complex and advanced chronic conditions. The EPAIB-RES aims to foster effective communication between different levels of care, including primary care, hospitals, and health services, thereby facilitating a comprehensive and patient-centred care model.

RESULTS

Since its inception, the EPAIB-RES has implemented numerous interventions at both the residential and individual levels. A total of 272 systemic interventions have been conducted, which include the team presentations to the 41 nursing homes in Mallorca and their corresponding 24 Primary Care facilities, management of outbreaks in collaboration with Public Health, mediation between the nursing homes and various healthcare resources, among others. These actions have established a network of communication and support between healthcare professionals and nursing homes, establishing the EPAIB-RES as a link between them.

At the individual level, the team has conducted 9,006 interventions, 1,846 of which are comprehensive geriatric assessments. These assessments include the identification of chronic patients with complex needs and those with palliative needs, the identification of geriatric syndromes, review of polypharmacy, and close follow-up of complex cases. So far, approximately 25% of users living in nursing homes have been thoroughly assessed, demonstrating the team's ability to respond to the needs of this population.

IMPLICACTIONS

Demographic trends predict a significant increase in the fragile and vulnerable population with greater healthcare and social needs in the coming years. The fragmentation of healthcare and social services generates inefficiencies and adversely affects users, making it imperative to advance the creation of a common socio-healthcare space.

Coordinated projects, such as the development of an interoperable medical record system, case management initiatives, the establishment of consensual protocols, and the existence of teams like EPAIB-RES, serve as successful examples that can provide a solid ground for a future healthcare patient-centred model.