Perspectives of individuals receiving occupational therapy services through the National Disability Insurance Scheme: Implications for occupational therapy educators.

INTRODUCTION: With the introduction of the National Disability Insurance Scheme (NDIS) in Australia, occupational therapy graduates need to be adequately prepared to support service users in this new policy context. There is, however, limited research informed by service users themselves to inform contemporary occupational therapy curriculum redesign. The aims of this study were: (a) to explore the experience of occupational therapy service provision from the perspective of service users with lived experience of disability; (b) to gain an understanding of the perceptions of people with lived experience of disability regarding the NDIS and whether it will change how they work with occupational therapists; (c) to gain an understanding of the perspectives of people with lived experience of disability regarding the NDIS, and how this influences curriculum content for occupational therapy education. METHODS: A pragmatic qualitative design, underpinned by the constructivist paradigm was utilised. Demographic surveys and semi-structured interviews were completed with 10 participants who were purposively recruited. Peer debriefing and use of an audit trail were undertaken to enhance the rigour of the analysis. RESULTS: Three themes were identified: (a) Occupational therapists as gatekeepers for equipment provision; (b) experience of the NDIS (Knowledge and understanding of the NDIS; Uncertainty regarding the NDIS; Choice and control in the NDIS); (c) curriculum content for occupational therapy. CONCLUSION: The insights provided by the people with lived experience in this study inform key areas of focus for occupational therapy curriculum to adequately prepare graduates to work in the evolving NDIS environment. Involving service users in an authentic manner in curriculum design, content delivery and student assessment is crucial for "real-world" applicability of student education.

The influence of general practitioners on access points to health care in a system without gatekeeping: a cross-sectional study in the context of the QUALICOPC project in Austria.

AIM: To assess the rates of specialist visits and visits to hospital emergency departments (ED) among patients in Austria with and without concurrent general practitioner (GP) consultation and among patients with and without chronic disease. METHODS: The cross-sectional questionnaire study was conducted in the context of the QUALICOPC project in 2012. Fieldworkers recruited 1596 consecutive patients in 184 GP offices across Austria. The 41-question survey addressed patients' experiences with regard to access to, coordination, and continuity of primary care, as well demographics and health status. Descriptive statistics as well as univariate and multivariate regression models were applied. RESULTS: More than 90% of patients identified a GP as a primary source of care. Among all patients, 85.5% reported having visited a specialist and 26.4% the ED at least once in the previous year. Having a usual GP did not change the rate of specialist visits. Additionally, patients with chronic disease had a higher likelihood of presenting to the ED despite having a GP as a usual source of care. CONCLUSION: Visiting specialists in Austria is quite common, and the simple presence of a GP as a usual source of care is insufficient to regulate pathways within the health care system. This can be particularly difficult for chronic care patients who often require care at different levels of the system and show higher frequency of ED presentations.

The impact of governance in primary health care delivery: a systems thinking approach with a European panel.

BACKGROUND: Enhancing primary health care (PHC) is considered a policy priority for health systems strengthening due to PHC's ability to provide accessible and continuous care and manage multimorbidity. Research in PHC often focuses on the effects of specific interventions (e.g. physicians' contracts) in health care outcomes. This informs narrowly designed policies that disregard the interactions between the health functions (e.g. financing and regulation) and actors involved (i.e. public, professional, private), and their impact in care delivery and outcomes. The purpose of this study is to analyse the interactions between PHC functions and their impact in PHC delivery, particularly in providers' behaviour and practice organisation. METHODS: Following a systems thinking approach with data obtained through a three-round European Delphi process, we developed a framework that captures (1) the interactions between PHC functions by analysing correlations between PHC characteristics of participating countries, (2) how actors involved shaped these interactions by identifying the actor and level of devolution (or fragmentation) in the analysis, and (3) their potential effect on care delivery by exploring panellists' opinions. RESULTS: A total of 59 panellists from 24 countries participated in the first round and 76% of the initial panellists (22 countries) completed the last round. Findings show correlations between governance, financing and regulation based on their degree of decentralisation. This is supported by panellists, who agreed that the actors involved in health system governance determine the type of PHC financing (e.g. ownership or payment mechanisms) and regulation (e.g. competences or gatekeeping), and this may impact care delivery and outcomes. Governance in our framework is an overarching function whose impact in PHC delivery is mediated through the degree of decentralisation (both delegation and devolution) of PHC financing and regulation. CONCLUSIONS: The application of this approach in policy implementation assessment intends to uncover limitations due to poor accountability and commitment to shared objectives. Its application in the design of health strategies helps foresee (and prevent) undesired or unexpected effects of narrow interventions. This approach will assist in the development of the realistic and long-term policies required for health systems strengthening.

Suitability of the German version of the Manchester Triage System to redirect emergency department patients to general practitioner care: a prospective cohort study.

OBJECTIVES: To investigate the suitability of the German version of the Manchester Triage System (MTS) as a potential tool to redirect emergency department (ED) patients to general practitioner care. Such tools are currently being discussed in the context of reorganisation of emergency care in Germany. DESIGN: Prospective cohort study. SETTING: Single centre University Hospital Emergency Department. PARTICIPANTS: Adult, non-surgical ED patients. EXPOSURE: A non-urgent triage category was defined as a green or blue triage category according to the German version of the MTS. PRIMARY AND SECONDARY OUTCOME MEASURES: Surrogate parameters for short-term risk (admission rate, diagnoses, length of hospital stay, admission to the intensive care unit, in-hospital and 30-day mortality) and long-term risk (1-year mortality). RESULTS: A total of 1122 people presenting to the ED participated in the study. Of these, 31.9% (n=358) received a non-urgent triage category and 68.1% (n=764) were urgent. Compared with non-urgent ED presentations, those with an urgent triage category were older (median age 60 vs 56 years, p=0.001), were more likely to require hospital admission (47.8% vs 29.6%) and had higher in-hospital mortality (1.6% vs 0.8%). There was no significant difference observed between non-urgent and urgent triage categories for 30-day mortality (1.2% [n=4] vs 2.2% [n=15]; p=0.285) or for 1-year mortality (7.9% [n=26] vs 10.5% [n=72]; p=0.190). Urgency was not a significant predictor of 1-year mortality in univariate (HR=1.35; 95% CI 0.87 to 2.12; p=0.185) and multivariate regression analyses (HR=1.20; 95% CI 0.77 to 1.89; p=0.420). CONCLUSIONS: The results of this study suggest the German MTS is unsuitable to safely identify patients for redirection to non-ED based GP care. TRIAL REGISTRATION NUMBER: U1111-1119-7564; Post-results.

Bridging the Gap: Connecting Resident Assistants and Suicidal Residents Through Gatekeeper Training.

One hundred sixty-two resident assistants (RAs) at a large southeastern university were randomly assigned to attend either a specialized 1-hr training program in suicide prevention (intervention group) or a stress and time management skills training program (control group). The results failed to show the suicide prevention training program had any impact on RA intervention behaviors, resident help-seeking behaviors, or RA perceptions of resident distress and suicidality 4 months following training. Results are interpreted and discussed in relation to strengthening suicide prevention training programs on college campuses.

Facilitating mental health research for patients, clinicians and researchers: a mixed-method study.

OBJECTIVES: Research registers using Consent for Contact (C4C) can facilitate recruitment into mental health research studies, allowing investigators to contact patients based on clinical records information. We investigated whether such a register was useful for mental health research, seeking the perspectives of patients and research investigators. SETTING AND DESIGN: In 2012, a C4C register was developed in a large secondary mental health provider within the UK; almost 9000 patients have joined. This mixed-method study audited the effectiveness of the register. PARTICIPANTS: A 'mystery shopper' exercise was conducted, and patients (n=21) were recruited to ask clinicians about the availability of research opportunities. Structured interviews were conducted with patients (n=52) about their experiences of being on the register. Similar interviews were conducted with 18 investigators from 19 studies, who had attempted to use the register to recruit participants. OUTCOME MEASURES: The impact of C4C on study recruitment, and whether it helped patients learn about research. RESULTS: So far, the register has provided 928 individuals with 1085 research opportunities (in 60% of cases, the individual agreed to participate in the study). Clinicians were willing to link patients to research opportunities, but often lacked information about studies. For patients, the register provided opportunities which they may not otherwise have; 27 of 52 had participated in studies since joining the register (18 participating for the first time). Most investigators used the register to supplement recruitment to their studies, but described problems in prescreening potential participants from a clinical record for complex studies. CONCLUSIONS: Although the register helped investigators recruit for studies, and provided patients with research opportunities, clinicians' input is still useful for identifying suitable participants. C4C registers should be adapted to provide clinicians with automatically updated information on local studies allowing them to match patients on their caseload with active studies.

[Quality management in emergency departments: Lack of uniform standards for fact-based controlling]. / Qualitätsmanagement in der Notaufnahme: Fehlende einheitliche Standards zur kennzahlenbasierten Steuerung.

BACKGROUND: The general high occupancy of emergency departments during the winter months of 2014/2015 outlined deficits in health politics. Whether on the regional, province, or federal level, verifiable and accepted figures to enable in depth analysis and fact-based controlling of emergency care systems are lacking. OBJECTS: As the first step, reasons for the current situation are outlined in order to developed concrete recommendations for individual hospitals. METHODS: This work is based on a selective literature search with focus on quality management, ratio driven management, and process management within emergency departments as well as personal experience with implementation of a key ratio system in a German maximum care hospital. RESULTS AND CONCLUSION: The insufficient integration of emergencies into the DRG systematic, the role as gatekeeper between inpatient and outpatient care sector, the decentralized organization of emergency departments in many hospitals, and the inconsistent representation within the medical societies can be mentioned as reasons for the lack of key ratio systems. In addition to the important role within treatment procedures, emergency departments also have an immense economic importance. Consequently, the management of individual hospitals should promote implementation of key ratio systems to enable controlling of emergency care processes. Thereby the perspectives finance, employees, processes as well as partners and patients should be equally considered. Within the process perspective, milestones could be used to enable detailed controlling of treatment procedures. An implementation of key ratio systems without IT support is not feasible; thus, existing digital data should be used and future data analysis should already be considered during implementation of new IT systems.

[Improving Health Care for Patients with Somatoform and Functional Disorders: A Collaborative Stepped Care Network (Sofu-Net)]. / Verbesserte Versorgung von Patienten mit somatoformen und funktionellen Störungen: Ein koordiniertes gestuftes Netzwerk (Sofu-Net).

The management of somatoform disorders in primary care is often limited due to low diagnostic accuracy, delayed referral to psychotherapy and overuse of health care. To address these difficulties, this study aimed to establish a collaborative stepped health care network (Sofu-Net). Sofu-Net was established among 41 primary care physicians, 35 psychotherapists and 8 mental health clinics. Baseline assessment in primary care showed elevated psychopathology and deficits in health care among patients with somatoform symptoms. Network partners provided positive evaluations of Sofu-Net.

Gatekeeping practices of music therapy academic programs and internships: a national survey.

BACKGROUND: Gatekeeping safeguards access to the practice of a profession to ensure the quality of clinical services. It involves selective admission, continuous evaluation, and timely and ethical decisions in response to trainees with severe professional competency problems (SPCP). To date, little information is available concerning gatekeeping practices in the field of music therapy. OBJECTIVE: This study investigated the extent and outcomes of gatekeeping practices across academic programs and National Roster internship sites approved by the American Music Therapy Association. Specifically, it examined the prevalence of trainees with SPCP, program-wide precautionary measures, common indicators of trainees with SPCP, remedial strategies, and supports and barriers to effective management. METHODS: Thirty-two academic program directors and 77 internship directors completed an online survey. Responses were compiled into aggregate form (frequencies & percentages) for analysis. Chi-square tests with Yates' correction were applied to compare the differences between academic programs and internships. RESULTS: A significantly higher percentage of academic programs (93.8%) reported having at least one trainee with SPCP over the past 5 years than did internships (66.2%). The most common indicators of competency problems included inadequate music skill development, emotional instability, limited communication skills, deficient interpersonal skills, defensiveness in supervision, and lack of insight. Typical remedial methods included referral to personal therapy, increased supervision, and repetition of practicum or extension of internship. CONCLUSIONS: Issues regarding trainees with SPCP are frequently addressed by academic and internship program directors. Improving clarity within professional guidelines and establishing more rigorous and consistent standards across training programs are recommended.