Reflecting on culturally responsive goal achievement with indigenous clients using the Australian Therapy Outcome Measure for Indigenous Clients (ATOMIC).

INTRODUCTION: Appropriate evaluation of health services for First Australians demands culturally responsive goal setting tools that can be used by inter-professional teams. The Australian Therapy Outcome Measure for Indigenous Clients (ATOMIC) is a purpose-designed tool for measuring therapy outcomes for First Australians. The aim of this study was to establish the clinical utility of the ATOMIC by investigating its alignment with the practice perspectives of an inter-professional First Australian health service. METHODS: Using action research cycles, 12 occupational therapists and 8 speech pathologists applied two successive versions of the ATOMIC in practice. Focus group feedback after use of the first version (ATOMICv1) prompted adaptations to the tool (ATOMICv2). Therapists participated in four focus groups, two after using ATOMICv1 and two after using ATOMICv2. Focus group transcripts were analysed inductively using a qualitative description approach. RESULTS: Challenges in setting SMART goals early in therapy and defining specific measurement increments in ATOMICv1 led to therapists favouring skill-based goals that were easier to measure rather than broader daily life goals, thereby impacting on occupation- and client-centred practice. ATOMICv2 allowed goal setting at any point in therapy, evaluated goals using visual analogue scales, and gathered evidence for rating goal achievement throughout the therapy process. Therapists found the ATOMICv2 to be a culturally responsive tool that aligned with practice perspectives by foregrounding relationship building, facilitating clinical reasoning, documenting daily life changes, and providing integrated inter-professional care. CONCLUSION: The ATOMIC demonstrated good clinical utility in an inter-professional service for First Australian children. It aligned with a culturally responsive practice perspective and captured goal achievement in daily life contexts. Further research is needed to gain client perspectives across the lifespan and to investigate its application by other health professions.

Moving enhanced recovery after surgery from implementation to sustainability across a health system: a qualitative assessment of leadership perspectives.

BACKGROUND: Knowledge Translation evidence from health care practitioners and administrators implementing Enhanced Recovery After Surgery (ERAS) care has allowed for the spread and scale of the health care innovation. There is a need to identify at a health system level, what it takes from a leadership perspective to move from implementation to sustainability over time. The purpose of this research was to systematically synthesize feedback from health care leaders to inform further spread, scale and sustainability of ERAS care across a health system. METHODS: Alberta Health Services (AHS) is the largest Canadian health system with approximately 280,000 surgeries annually at more than 50 surgical sites. In 2013 to 2014, AHS used a structured approach to successfully implement ERAS colorectal guidelines at six sites. Between 2016 and 2018, three of the six sites expanded ERAS to other surgical areas (gynecologic oncology, hepatectomy, pancreatectomy/Whipple's, and cystectomy). This research was designed to explore and learn from the experiences of health care leaders involved in the AHS ERAS implementation expansion (eg. surgical care unit, hospital site or provincial program) and build on the model for knowledge mobilization develop during implementation. Following informed consent, leaders were interviewed using a structured interview guide. Data were recorded, coded and analyzed qualitatively through a combination of theory-driven immersion and crystallization, and template coding using NVivo 12. RESULTS: Forty-four individuals (13 physician leaders, 19 leading clinicians and hospital administrators, and 11 provincial leaders) were interviewed. Themes were identified related to Supportive Environments including resources, data, leadership; Champion and Nurse coordinator role; and Capacity Building through change management, education, and teams. The perception and role of leaders changed through initiation and implementation, spread, and sustainability. Barriers and enablers were thematically aligned relative to outcome assessment, consistency of implementation, ERAS care compliance, and the implementation of multiple guidelines. CONCLUSIONS: Health care leaders have unique perspectives and approaches to support spread, scale and sustainability of ERAS that are different from site based ERAS teams. These findings inform us what leaders need to do or need to do differently to support implementation and to foster spread, scale and sustainability of ERAS.

Return on investment of the Enhanced Recovery After Surgery (ERAS) multiguideline, multisite implementation in Alberta, Canada.

Background: Enhanced Recovery After Surgery (ERAS) is a global surgical qualityimprovement initiative. Little is known about the economic effects of implementing multiple ERAS guidelines in both the short and long term. Methods: We performed a return on investment (ROI) analysis of the implementation of multiple ERAS guidelines (for colorectal, pancreas, cystectomy, liver and gynecologic oncology procedures) across multiple sites (9 hospitals) in Alberta using 30-, 180- and 365-day time horizons. The effects of ERAS on health services utilization (length of stay of the primary admission, number of readmissions, length of stay of the readmissions, number of emergency department visits, number of outpatient clinic visits, number of specialist visits and number of general practitioner visits) were assessed by mixed-effect multilevel multivariate negative binomial regressions. Net benefits and ROI were estimated by a decision analytic modelling analysis. All costs were reported in 2019 Canadian dollars. Results: The net health system savings per patient ranged from $26.35 to $3606.44 and ROI ranged from 1.05 to 7.31, meaning that every dollar invested in ERAS brought $1.05 to $7.31 in return. Probabilities for ERAS to be cost-saving were from 86.5% to 99.9%. The effects of ERAS were found to be larger in the longer time horizons, indicating that if only the 30-day time horizon had been used, the benefits of ERAS would have been underestimated. Conclusion: These results demonstrated that ERAS multiguideline implementation was cost-saving in Alberta. To produce a better ROI, it is important to consider a broad range of health service utilizations, long-term impact, economies of scale, productive efficiency and allocative efficiency for sustainability, scale and spread of ERAS implementations.

Contexte: L'initiative de récupération améliorée après la chirurgie (RAAC) est un projet international d'amélioration de la qualité en chirurgie. On en sait peu sur les retombées économiques, tant à court qu'à long terme, de la mise en œuvre de multiples lignes directrices de RAAC. Méthodes: Nous avons réalisé une analyse du rendement sur l'investissement (RSI) visant la mise en œuvre de multiples lignes directrices de RAAC (pour les opérations colorectales, pancréatiques, hépatiques ou d'oncologie gynécologique et la cystectomie) dans 9 hôpitaux albertains sur un horizon temporel de 30, 180 et 365 jours. L'incidence de la RAAC sur l'utilisation des services de santé (durée du séjour à l'hospitalisation initiale, nombre de réadmissions, durée du séjour à la réhospitalisation et nombre de visites à l'urgence, en consultation externe, chez un spécialiste et chez un omnipraticien) a été évaluée à l'aide d'un modèle multiniveau de régressions binomiales négatives à effets mixtes multivariés. Les bénéfices nets et le RSI ont été estimés à l'aide d'un processus de modélisation analytique décisionnelle. Tous les coûts ont été rapportés en dollars canadiens de 2019. Résultats: Les économies nettes du système de santé allaient de 26,35 $ à 3606,44 $ par patient, et le RSI variait de 1,05 à 7,31; chaque dollar investi dans l'initiative de RAAC a donc généré un retour sur l'investissement de 1,05 $ à 7,31 $. Les probabilités d'économie grâce au RAAC allaient de 86,5% à 99,9%. Les retombées générées augmentaient avec un horizon temporel à plus long terme, ce qui suggère que l'utilisation unique d'un horizon temporel de 30 jours aurait mené à une sousestimation des bénéfices. Conclusion: Les résultats montrent que la mise en œuvre de multiples lignes directrices de RAAC a permis des économies en Alberta. En vue d'obtenir un RSI optimal, il est important de tenir compte d'une grande variété d'utilisations des services de santé, des retombées à long terme, des économies d'échelle, de l'efficacité productive et de l'efficience des allocations pour la pérennité, la mise à l'échelle et la diffusion des projets de mise en œuvre de RAAC.

Real gains: development of a tool to measure outcomes for urban First Australian children accessing culturally responsive interprofessional therapy.

Healthcare services are accountable to their clients, communities, governments and funding sources to clearly demonstrate the effectiveness of interventions. A First Australian children's therapy service delivering culturally responsive, interprofessional collaborative practice aimed to evaluate their service. However, this process was constrained by available outcome measures which lacked the flexibility necessary for meaningful use within the dynamic and relational nature of their service delivery. This paper outlines an action research process in three cycles which was used to develop the Australian Therapies Outcome Measure for Indigenous Clients (ATOMIC) with the aim of evaluating therapy outcomes for urban First Australian children engaged in culturally responsive interprofessional therapy. Interrater reliability values of 0.995 and 0.982 were established for ATOMIC pre- and post-therapy measures, respectively, during a pilot phase involving 16 participants. Participants in the main study were 80 First Australian children aged two to 16 years who attended between two and nine interprofessional therapy sessions with occupational therapists and speech pathologists. Pre- and post-therapy ATOMIC scores confirmed progress on pre-determined functional goals across a range of skill domains. Outcomes of this study demonstrated that real gains are being made in urban First Australian children's lives following interprofessional collaborative service provision.

Chronic disease self-management programs for Aboriginal and Torres Strait Islander people: Factors influencing participation in an urban setting.

ISSUE ADDRESSED: Evidence suggests that participation in a Chronic Disease Self-Management (CDSM) program improves the health of clients. Many factors are known to influence participation in these programs for the broader Australian population. However, less is known about why Aboriginal and Torres Strait Islanders choose to participate. This study identifies key factors that support or enable Aboriginal and Torres Strait Islanders to participate in a CDSM program in an urban setting. METHODS: Twelve focus groups were undertaken with a total of 102 participants who were diagnosed with or at risk of chronic disease. These participants were recruited from the Work It Out program, a CDSM program comprising exercise and health education. The Work It Out program is specifically designed for Aboriginal and Torres Strait Islanders and delivered by an Aboriginal led and community-controlled organisation in South-East and Central Queensland. The study received ethical clearance through the Behavioural and Social Sciences Ethical Review Committee at The University of Queensland (Approval Number 2011001283). RESULTS: Findings indicate that key features of program design based on a culturally responsive approach influences participation. The main features are as follows: providing easy access to the program; permitting flexibility in attendance; a group environment; the approach of program staff that prioritises relationship building; personalised and integrated care; communicating result regularly; and ensuring community ownership of the program. CONCLUSION: These findings are useful to consider when designing a health program for Aboriginal and Torres Strait Islanders. Programs which are culturally responsive and include the design features identified in this study are more likely to increase participation amongst Aboriginal and Torres Strait Islanders. SO WHAT?: Increasing participation of Aboriginal and Torres Strait Islanders in CDSM programs using the design features identified in the paper may contribute significantly in closing the health disparity gap.

'Work it out': evaluation of a chronic condition self-management program for urban Aboriginal and Torres Strait Islander people, with or at risk of cardiovascular disease.

BACKGROUND: Chronic diseases disproportionately burden Aboriginal and Torres Strait Islander people in Australia, with cardiovascular (CV) diseases being the greatest contributor. To improve quality of life and life expectancy for people living with CV disease, secondary prevention strategies such as rehabilitation and self-management programs are critical. However, there is no published evidence examining the effect of chronic condition self-management (CCSM) group programs for Aboriginal and Torres Strait Islander people who have, or are at risk of, CV disease specifically. This study evaluates the Work It Out program for its effect on clinical outcome measures in urban Aboriginal and Torres Strait Islander participants with or at risk of CV disease. METHODS: This study was underpinned by a conceptual framework based on Aboriginal and Torres Strait Islander community control. Participants had at least one diagnosed CV disease, or at least one CV disease risk factor. Short-term changes in clinical outcome measures over (approximately) 12 weeks were evaluated with a quasi-experimental, pre-post test design, using paired t-tests. Factors contributing to positive changes were tested using general linear models. The outcome measures included blood pressure (mmHg), weight (kg), body mass index (kg/m2), waist and hip circumference (cm), waist to hip ratio (waist cm/hip cm) and six minute walk test (6MWT). RESULTS: Changes in several clinical outcome measures were detected, either within the entire group (n = 85) or within specific participant sub-groups. Participant's 6MWT distance improved by an average 0.053 km (95% CI: 0.01-0.07 km). The change in distance travelled was influenced by number of social and emotional wellbeing conditions participants presented with. The weight of participants classified with extreme obesity decreased on average by 1.6 kg (95% CI: 0.1-3.0 kg). Participants with high baseline systolic blood pressure demonstrated a mean decrease of 11 mmHg (95% CI: 3.2-18.8 mmHg). Change in blood pressure was influenced by the number of cardiovascular conditions participants experienced. CONCLUSIONS: Short-term improvements seen in some measures could indicate a trend for improvement in other indicators over the longer term. These results suggest the Work It Out program could be a useful model for cardiovascular rehabilitation and prevention for other urban Aboriginal and Torres Strait Islander populations.

African Americans' and Hispanics' information needs about cancer care.

Few studies have reported on African American and Hispanic (AA and H) populations' informational needs when seeking cancer care at an institution that offers clinical trials. Moffitt Cancer Center (MCC) sought to identify and examine the decision making process, the perceptions, and the preferred channels of communication about cancer care services for AA and H communities in order to develop a list of marketing recommendations. Five focus groups (N = 45) consisting of two AA and three H were conducted in four counties of the MCC catchment area in Tampa, FL. Participants were asked about their perceptions, knowledge, attitudes, and beliefs about cancer care and MCC. Focus groups were audio-recorded and verbatim transcripts were analyzed using content analysis. Similarities in responses were found between AA and H participants. Participants received general health and cancer information from media sources and word of mouth and preferred to hear patient testimonials. There were concerns about costs, insurance coverage, and the actual geographic location of the cancer center. In general, H participants were not opposed to participating in cancer clinical trials/research, whereas, AA participants were more hesitant. A majority of participants highly favored an institution that offered standard care and clinical trials. AA and H participants shared similar concerns and preferences in communication channels, but each group had specific informational needs. The perceptions and preferences of AA and H must be explored in order to successfully and efficiently increase cancer clinical trial participation.

From observation to intervention: development of a psychoeducational intervention to increase uptake of BRCA genetic counseling among high-risk breast cancer survivors.

We describe the development of a psychoeducational intervention (PEI) to increase uptake of genetic counseling targeted to high-risk breast cancer survivors. Based on previous research, scientific literature, and a review of cancer education websites, we identified potential PEI content. We then assessed the initial acceptability and preference of two booklets of identical content but different layouts, by presenting the booklets to individuals with a personal or family history of breast cancer (n = 57). The preferred booklet was evaluated by two focus groups of ten breast cancer patients who had not attended genetic counseling. The booklet was refined based on participants' feedback at each stage. Focus group participants generally found the booklet visually appealing, informative, and helpful, but some thought that it was too long. Final changes were made based on learner verification principles of attraction, comprehension, cultural acceptability, and persuasion. This project produced an interventional tool to present key constructs that may facilitate decision making about risk-appropriate genetic counseling uptake among high-risk breast cancer survivors. The process described for creating, testing, and adapting materials from a patient perspective can be used for developing other PEIs. This newly developed, unique PEI can be used in many clinical settings.

Deadly Choices™ community health events: a health promotion initiative for urban Aboriginal and Torres Strait Islander people.

The present study was an evaluation of the effectiveness of Deadly Choices™ community events for improving participants' short-term knowledge of chronic disease and risk factors, and increasing community engagement with local health services. Surveys were completed directly before and after participating in health education activities (pre and post surveys, respectively) assessing knowledge of chronic diseases and risk factors at three Deadly Choices community events and four National Aboriginal and Islander Day Observance Committee (NAIDOC) events in south-east Queensland where Deadly Choices health education activities took place. An audit trail was conducted at two Deadly Choices community events in Brisbane to identify the proportion of participants who undertook a health screen at the event who then followed up for a Medicare-funded health check (MBS item 715) or other appointment at an Aboriginal and Torres Strait Islander clinic in the local area within 2 months. Results were compared with a sample of participants who attended one Deadly Choices community event but did not complete a health screen. There were 472 community members who completed a pre and post survey. All knowledge scores significantly improved between baseline and follow up. Although based on a small sample, the audit trail results suggest individuals who participated in a health screen at the community day were approximately twice as likely to go back to a clinic to receive a full health check or have an alternative appointment compared with attendees who did not participate in a screen. Community events that include opportunities for health education and health screening are an effective strategy to improve chronic disease health literacy skills and appear to have the potential to increase community engagement with local Aboriginal and Torres Strait Islander health services.

Nursing Students' and Nurse Preceptors' Perspectives of an Ambulatory Dedicated Education Unit in Primary Care and General Internal Medicine.

BACKGROUND: The sustainability of prelicensure nursing clinical learning models within ambulatory care is dependent on strong partnership and the availability of ambulatory nurse preceptors. Evaluation of preceptor and student satisfaction with ambulatory clinical experiences is necessary to identify program strengths and opportunities. METHOD: Nursing students' and nurse preceptors' perceptions of an ambulatory dedicated education unit (DEU) in primary care and general internal medicine practices were measured from 2021 to 2023. RESULTS: Students' survey responses indicated a high level of agreement for 20 (90.9%) of 22 items in 2021, 35 (100%) of 35 items in 2022, and 32 (91.4%) of 35 items in 2023. Preceptor responses demonstrated favorable agreement with all of the work-life satisfaction across the 3 years of the survey, with the exception of one question on the 2021 survey. CONCLUSION: Nursing students and staff nurse preceptors found the ambulatory DEU teaching and learning experience to be positive and satisfying. [J Nurs Educ. 2024;63(3):171-177.].

They are what they eat? Ensuring our children get the right nutrients.

Finally, we need to shift our food culture. People need to understand food marketing, where their food comes from and how to cook it. More importantly, we, as health professionals, need to make sure that we are all saying the same thing. Messages are delivered by lots of different people and if a new mother is hearing a different message from the worker in the children's centre, their health visitor or their midwife, then they are going to ignore it and go elsewhere for their information. Age appropriate, consistent messages are therefore something we really need to deliver.

Revitalizing the infection prevention workforce with a fellowship program for underrepresented groups.

Infection preventionist (IP) positions are difficult to fill, and future workforce shortages are anticipated. The IP field has less racial and ethnic diversity than the general nursing workforce or patient population. A targeted fellowship program for underrepresented groups allowed the recruitment and training of IPs while avoiding staffing shortages.

Closing the gap: Supporting occupational therapists to partner effectively with First Australians.

BACKGROUND/AIM: Occupational therapists need to be able to work competently with all clients, including First Australians. Currently, there are no national standards for occupational therapists working with First Australian clients. This article presents current issues in practice and education with First Australians and makes recommendations for the future. METHODS: A survey of 41 occupational therapists working with, or interested in First Australian health issues was conducted at a workshop held at the Australian National Occupational Therapy Conference in 2008. Results of the workshop group discussions were also collated. RESULTS: Several themes emerged from both survey data and discussions. A substantial proportion of participants rated their confidence and competence to work with First Australians as low to moderate. Higher levels of perceived confidence and competence were associated with current experience in the field. Discussions centred around six major themes: building relationships, service provision and design, education and training of occupational therapists, increasing First Australian representation within occupational therapy, professional issues and political issues. These themes were further collapsed into areas of action, which could be taken by individuals, managers, researchers and professional bodies to improve practice with First Australians. CONCLUSIONS: Occupational therapists will benefit from coordinated efforts, on individual and systemic levels, to work more effectively, and in partnership with, First Australians. Such developments should include guidelines for practice, education and research; professional development and networking opportunities; and improved collaboration, especially with First Australian partners, on a national level.

Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada.

Importance: Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. Objective: To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. Design, Setting, and Participants: This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. Interventions: Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. Main Outcomes and Measures: Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. Results: A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). Conclusions and Relevance: The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.

Indigenous Austalians and physical activity: using a social-ecological model to review the literature.

This paper aims to present what is currently known about Indigenous Australians and their engagement in physical activity and to then challenge some of the 'taken-for-granted' ways of thinking about promoting or researching physical activity with Indigenous Australians. Major health, education and sport databases, as well as government websites were searched using the key terms of physical activity, sport, leisure, recreation, Indigenous and Aboriginal/Aborigine. A social-ecological model of health was adapted and used as an organizing framework to synthesize the literature. It is concluded that socioecological models can be valuable tools for understanding and promoting issues related to physical activity engagement for a range of populations but they may require complementary critical insights, including those from Indigenous perspectives. Productive theoretical spaces where Western and Indigenous knowledges come together can assist health educators to consider the complexity and diversity of Indigenous people's lived experiences when planning and implementing programs.

Learning from the past, looking to the future: Exploring our place with Indigenous Australians.

This paper aims to explore ways in which we as occupational therapists in Australia can participate in enabling a different and better future for all Australians. In doing so, it is necessary to explore our history and our cultures, both individually and collectively as a profession, and to understand the ways in which these shape who we are and what we do. As occupational therapists, we have valuable knowledge and skills that have the potential to contribute in a positive way to the health and educational outcomes of Indigenous Australians. As a profession operating in Australia, we also have a responsibility to reach this potential. This paper aims to present some of these contributions and to provide examples of practical and culturally safe ways in which we can take action.

Occupational therapists prefer combining multiple intervention approaches for children with learning difficulties.

BACKGROUND/AIM: Research to date has not fully explored how occupational therapists provide intervention for children with learning difficulties in their day-to-day practice. The purpose of this study was to provide an in-depth description of the approaches and techniques used and how they are applied and combined to meet the complex and multifaceted needs of these children. METHODS: In-depth interviews and short questionnaires were completed by seven occupational therapists who had provided intervention to children with learning difficulties. Observations of therapy sessions were also conducted. Thematic analysis gained insight into the approaches and techniques therapists used and how these were applied in practice. RESULTS: Therapists use a wide range of approaches in various combinations because they feel that these best meet the needs of individual children. Sensory-based and cognitive approaches were most frequently drawn from and combined with other approaches such as visual information analysis, biomechanical and psychosocial approaches added for particular purposes. Approaches were usually combined simultaneously within an activity or session. CONCLUSIONS: Therapists create their own 'multimodel' approach in order to best meet the needs of their clients. They are able to articulate the theoretical basis behind these choices, although lack of clarity exists about the frames of reference being used.

Does attending Work It Out - a chronic disease self-management program - affect the use of other health services by urban Aboriginal and Torres Strait Islander people with or at risk of chronic disease? A comparison between program participants and non-participants.

Work It Out is a holistic chronic disease self-management program for urban Aboriginal and Torres Strait Islander people in Queensland, which is part of an integrated and comprehensive system of care for chronic disease management. This study examines differences in primary healthcare services use between Work It Out participants and non-participants. This retrospective observational study of services use, analysed data extracted from the clinical medical records system and Work It Out program assessments. General practitioner and allied health services use were compared among the participants and non-participants using logistic regression models and zero-truncated Poisson and negative binomial regression models. Compared with non-participants, Work It Out participants were more likely to use GP management plans, GP team care arrangements, GP mental health consultation and subsequent allied health services. Among those who used the services more than once, Work It Out participants had higher service use rates than non-participants for Aboriginal and Torres Strait Islander health assessments, GP management plans, team care arrangements and podiatry, physiotherapy and dietetic services. Engagement in Work It Out can facilitate the use of primary healthcare services, which are important for chronic disease management for urban Aboriginal and Torres Strait Islander people.

Understanding and negotiating: reasoning processes used by an occupational therapist to individualize intervention decisions for people with upper limb hypertonicity.

PURPOSE: To describe the processes used by an experienced occupational therapist to make individualized intervention choices to support functional goal achievement for people with upper limb hypertonicity. METHOD: This qualitative case study involved participant observation of assessment sessions, interviews with clients and an occupational therapist, and document review. Participants included one occupational therapist and five clients with upper limb hypertonicity. Thematic analysis was conducted to yield results. RESULTS: Processes used by the therapist included seeking information about the past, present and future, forming a temporary clinical picture, and developing a shared understanding about achievable goals and preferred interventions. Establishing a strong therapeutic relationship and tailoring the provision of information in response to each client's situation and experience was seen as important. These strategies aimed to optimize clients' ability to be an active participant in decision-making, to commit to the chosen intervention and to manage their hypertonicity in the long term. CONCLUSIONS: A holistic understanding of the client's situation provided a basis for negotiating achievable goals and determining preferred interventions.

Factors influencing therapists' interventions for children with learning difficulties.

BACKGROUND: Occupational therapists use a range of intervention approaches with children with learning difficulties. PURPOSE: This study aimed to identify factors influencing therapists' clinical decisions when choosing and combining these interventions. METHODS: Seven occupational therapists participated. Data were collected through in-depth interviews, short questionnaires, and therapy observations and analysed thematically. FINDINGS: Therapists used a combination of child, therapist, and service-related factors to individually tailor a combination of intervention techniques drawn from different theoretical approaches. Therapists also used embedded practices with all children to engage and motivate them, promote task mastery, encourage application of strategies at home and school, and evolve intervention through ongoing evaluation. IMPLICATIONS: The child and family's home and school context and, to a lesser extent, the therapist's past experience and service context are primary factors considered when choosing interventions. Therapists continually move between theoretical and practical levels of thinking to best meet each child's needs.