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Morrison, Duncan, et al., 2018). As nursing staff have a pivotal role in malnutrition and dysphagia management (Hines, Kynoch, & Munday, 2016), dietitians and SLPs can work together to empower, educate and support nurses in providing mealtime care and monitoring nutrition and dysphagia risk. Clients with severe dysphagia often need for enteral feeding, and SLPs can work with dietitians to improve nutrition care through use of standard feeding protocols (Box 1). Developing collaborative relationships between speech- language pathologists and dietitians The collaborative relationship between SLPs and dietitians is critical in facilitating a more holistic and comprehensive approach to patient-centred care. Indeed, effective collaboration enables clinicians to view dysphagia holistically (Speech Pathology Australia, 2012). It is imperative that SLPs and dietitians acknowledge and respect the expertise of both disciplines and understand relevant scope of practice boundaries, but also know where our ‘common ground’ lies and where we can work in an interdisciplinary manner in the best interests of our clients. Interprofessional education and work shadowing are practical ways to optimise this mutual understanding. Furthermore, collaborative research provides exciting opportunities to advance the evidence base as we investigate novel dysphagia management approaches (e.g., carbonated fluids) that may improve client outcomes. Finally, changing population demographics including the growing ageing population as well as technological advancements will impact on how we deliver our services. SLPs and dietitians are uniquely placed to develop innovative interdisciplinary care models that address these future health care challenges. Acknowledgements The authors would like to thank Dr Merrilyn Banks (Advanced Accredited Practicing Dietitian) and Dr Clare Burns (Advanced Speech Pathologist) for critical review of this manuscript; and dietitians and speech-language pathologists from Royal Brisbane and Women’s Hospital for contributing ideas and examples for inclusion in this manuscript. References Abbey, K. L., Wright, O. R., & Capra, S. (2015). Menu planning in residential aged care - the level of choice and quality of planning of meals available to residents. Nutrients , 7 (9), 7580–7592. Agarwal, E., Ferguson, M., Banks, M., Bauer, J., Capra, S., & Isenring, E. (2012). Nutritional status and dietary intake of acute care patients: Results from the Nutrition Care Day Survey 2010. Clinical Nutrition , 31 (1), 41–47. Banks, M., Hannan-Jones, M., Ross, L., Buckley, A., Ellick, J., & Young, A. (2017). Measuring the quality of hospital food services: Development and reliability of a meal quality audit tool. Nutrition and Dietetics , 74 , 147–157 Beck, A. M., Kjaersgaard, A., Hansen, T., & Poulsen, I. (2017). Systematic review and evidence based recommendations on texture modified foods and thickened liquids for adults (above 17 years) with oropharyngeal dysphagia - An updated clinical guideline. Clinical Nutrition . doi:10.1016/j.clnu.2017.09.002

clients (Collins et al., 2017). Joint sessions ensure that clients and their carers receive consistent messages about their treatment plan and may also contribute to interprofessional education (see Box 1). The partnership between dietitians, SLPs and the client is never more important than when developing a plan for managing dysphagia. There are limitations associated with texture modification of food and fluids (Beck, Kjaersgaard, Hansen, & Poulsen, 2017) and consistent observations that people eat and drink poorly when prescribed these diets (Agarwal et al., 2012; Vivanti et al., 2009; Vucea, Keller, Morrison, Duizer, et al., 2018). Therefore, it is crucial for the multidisciplinary team, client and family to weigh up potential risks and likelihood of complications of dysphagia versus those related to poor intake and malnutrition. There is no “one-size-fits-all” approach here, and care planning will depend on acuity, presentation, prognosis and client preference. Regardless, it is essential that SLPs and dietitians work together to explore a range of strategies to promote safe swallowing (Turkington, Ward, & Farrell, 2017). For example, carbonated drinks, in comparison to thickened fluids, may have possible benefits in increasing client quality of life, but these management approaches still require further translational research (Robbins et al., 2008). Texture modified diets for people at risk of malnutrition should always be implemented alongside nutrition support strategies such as naturally thick nutritious fluids (e.g., thick shakes, oral nutrition supplements), naturally minced and moist or puree foods (e.g., eggs, dairy desserts), food fortification (e.g., extra cream, butter, cheese, protein powders), use of high energy sauces and intake monitoring (e.g., food and fluid charts). Free water protocols may allow clients with dysphagia to consume thin water in between mealtimes where good oral hygiene can be assured (Gillman, Winkler, & Taylor, 2017). Implementation of these free water protocols with specific cohorts (i.e., rehabilitation inpatients) could be approached as a partnership between SLP, dietetics and nursing. Improving systems of care Taking a systematised and interdisciplinary approach to care is also important to consider in health care facilities such as hospitals, geriatric rehabilitation and residential aged care (Bell, et al., 2018). Clients with dysphagia requiring texture modified diets often have fewer menu choices, and meals can be less appealing and nutritionally diluted through addition of liquids during blending (Abbey, Wright, & Capra, 2015). SLPs and dietitians can work together to ensure that food services provide a variety of meals and snacks that are visually appealing (e.g., puree meals moulded to look like the original food items (Germain, Dufresne, & Gray-Donald, 2006), and fortified with extra energy and protein (Zanini et al., 2017). To develop and implement feasible diet plans for clients with dysphagia, SLPs, dietitians and food service staff need to have good working relationships and an understanding of the complexity of institutional food service systems and what is (and isn’t) possible to deliver within this system (see Box 1). Good mealtime practices are important to support clients with malnutrition and dysphagia. Appropriate mealtime positioning supports optimal swallowing as well as increased independence with opening food packages (Bell, Tapsell, Walton, & Yoxall, 2017); similarly, assistance and supervision at mealtimes is key to monitor for signs of aspiration, but equally important to support good intake (Wright, Cotter, & Hickson, 2008), particularly as people with dysphagia often need help with eating (Vucea, Keller,

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JCPSLP Volume 20, Number 3 2018

Journal of Clinical Practice in Speech-Language Pathology