Building the capacity of family day care educators to promote children’s social and emotional wellbeing : an exploratory cluster randomised controlled trial

Background: Childhood mental health problems are highly prevalent, experienced by one in five children living in socioeconomically disadvantaged families. Although childcare settings, including family day care are ideal to promote children’s social and emotional wellbeing at a population level in a sustainable way, family day care educators receive limited training in promoting children’s mental health. This study is an exploratory wait-list control cluster randomised controlled trial to test the appropriateness, acceptability, cost, and effectiveness of “Thrive,” an intervention program to build the capacity of family day care educators to promote children’s social and emotional wellbeing. Thrive aims to increase educators’ knowledge, confidence and skills in promoting children’s social and emotional wellbeing.
Methods/Design: This study involves one family day care organisation based in a low socioeconomic area of Melbourne. All family day care educators (term used for registered carers who provide care for children for financial reimbursement in the carers own home) are eligible to participate in the study. The clusters for randomisation will be the fieldworkers (n = 5) who each supervise 10-15 educators. The intervention group (field workers and educators) will participate in a variety of intervention activities over 12 months, including workshops; activity exchanges with other educators; and focused discussion about children’s social and emotional wellbeing during field worker visits. The control group will continue with their normal work practice. The intervention will be delivered to the intervention group and then to the control group after a time delay of 15 months post intervention commencement. A baseline survey will be conducted with all consenting educators and field workers (n = ~70) assessing outcomes at the cluster and individual level. The survey will also be administered at one month, six months and 12 months post-intervention commencement. The survey consists of questions measuring perceived levels of knowledge, confidence and skills in promoting children’s social and emotional wellbeing. As much of this intervention will be delivered by field workers, field worker-family day care educator relationships are key to its success and thus supervisor support will also be measured. All educators will also have an in-home quality of care assessment at baseline, one month, six months and 12 months post-intervention commencement. Process evaluation will occur at one month, six months and 12 months post-intervention commencement. Information regarding intervention fidelity and economics will also be assessed in the survey.
Discussion: A capacity building intervention in child mental health promotion for family day care is an essential contribution to research, policy and practice. This initiative is the first internationally, and essential in building an evidence base of interventions in this extremely policy-timely setting.

Shared care for chronic eye diseases : perspectives of ophthalmologists, optometrists and patients

Objective: To report the perspectives of optometrists, ophthalmologists and patients on a model of shared care for patients with chronic eye diseases.

Design, setting and participants: Qualitative study of a model of shared care between optometrists and ophthalmologists for patients with stable age-related macular degeneration, diabetic retinopathy and glaucoma, trialled by the Royal Victorian Eye and Ear Hospital in Melbourne during 2007–2009. Semi-structured interviews were conducted with optometrists, ophthalmologists and patients at completion of the project to obtain their perspectives on this model.

Results: Seventeen optometrists submitted expressions of interest to participate, and 12 completed web-based training modules and clinical observerships and adhered to specified examination and reporting protocols. All five participating ophthalmologists and 11 of the optometrists were interviewed. Ninety-eight patients participated and 37 were interviewed. Optometrists not only met ophthalmologists’ expectations but exceeded them, appropriately detecting and referring patients with additional, previously undetected conditions. Patients reported savings in travel time and were satisfied with the quality of care they received. Optometrists, ophthalmologists and patients indicated a general acceptance of shared care arrangements, although there were some issues relating to interprofessional trust.

Conclusions: Shared care between local optometrists and hospital-based ophthalmologists can help to reduce patient waiting time for review and offers an opportunity for these two groups of eye care professionals to collaborate in providing localised care for the benefit of patients. However, trust and relationship building need to be further developed.

Barriers to the detection and management of depression by palliative care professional carers among their patients : perspectives from professional carers and patients' family members

Introduction: Clinical depression is highly prevalent yet underdetected and poorly managed within palliative care settings.

Objectives: This qualitative study explored the identification, monitoring, and management of symptoms of depression in patients receiving palliative care from 2 juxtaposed perspectives that are of care providers and care recipients' family members. Examining the barriers that restrict professional carers detecting and managing depression in their patients was a central focus of the study.

Methods: Focus groups were held with 18 professional carers, including 8 holding managerial positions, across 2 palliative care services, 1 regional and 1 metropolitan, which provided both inpatient and community-based care. Individual interviews were conducted with 10 family members of patients who had received or were receiving palliative care through these services.

Results: Thematic analysis of these data identified that both professional carers and family members perceived that depression is a wide-spread concern for patients receiving palliative care; however, numerous barriers were identified that affect professional carers’ ability to identify depression. These included knowledge and training deficits, low self-efficacy, prioritization of physical concerns and time constraints, patient/family characteristics, and system/process issues. These themes (and related subthemes) are discussed in this article.

Conclusions: Specialized training in depression is recommended for professional carers in order to improve their depression-related knowledge, detection skills, and self-efficacy. The ultimate goal of such training is to increase the rate of recognition of depression that in turn will lead to appropriate treatment for depressed patients.

Radiotherapy management of patients diagnosed with glioma in Victoria (1998–2000) : a retrospective cohort study

This study aimed to describe the radiotherapy (RT) management and subsequent outcome in a cohort of patients with newly diagnosed glioma. Treatment details were obtained via a questionnaire completed by neurosurgeons, radiation and medical oncologists who treated patients diagnosed with glioma in Victoria during 1998–2000. Patients were identified by using the population-based Victorian Cancer Registry. Over the study period, data on 828 patients were obtained, of whom 612 (74%) were referred for consideration of RT. Radiotherapy was given to 496 patients as part of their initial treatment and to an additional 10 patients at the time of tumour recurrence or progression. The median age was 72 (16–85) years. Median overall survival (OS) was 9.2 (standard error (SE) 0.6) months for the entire group. Median OS was 29.1 (SE 8.0) and 7.4 (SE 0.4) months for all patients with histological confirmation of World Health Organization Grades III (anaplastic astrocytoma) and IV (glioblastoma multiforme) histology, respectively. A total of 47 different RT dose fractionation schedules were identified. This is the largest survey detailing management of glioma with RT, published to date. A marked variation in dose fractionation schemes was evident. While current best practice involves the use of chemotherapy in conjunction with RT for glioblastoma multiforme, advances in patient care may be undermined by this variation in the use of RT. Clinical trials relevant to an ageing population and evidence-based national clinical guidelines are required to define best practice.

Implementation of a quality care management system for patients with arthritis of the hip and knee

The Orthopaedic Unit of the Repatriation General Hospital (RGH) in Adelaide, South Australia has implemented a quality care management system for patients with arthritis of the hip and knee. The system not only optimises conservative management but ensures that joint replacement surgery is undertaken in an appropriate and timely manner. This new service model addresses identified barriers to service access and provides a comprehensive, coordinated strategy for patient management. Over 4 years the model has reduced waiting times for initial outpatient assessment from 8 to 3 months and surgery from 18 to 8 months, while decreasing length of stay from 6.3 to 5.3 days for hips and 5.8 to 5.3 days for knees. The service reforms have been accompanied by positive feedback from patients and referring general practitioners in relation to the improved coordination of care and enhanced efficiency in service delivery.

What is known about the topic? Several important initiatives both overseas and within Australia have contributed significantly to the development of this model of care. These include the UK National Health Service ‘18 weeks’ Project, the Western Canada Waiting List Project, the New Zealand priority criteria project, the Queensland Health Orthopaedic Physiotherapy Screening Clinic, and most importantly the Melbourne Health–University of Melbourne Orthopaedic Waiting List Project where a wide range of models were explored across Victorian hospitals from 2005 and the Multi-Attribute Prioritisation Tool (MAPT) was developed, validated and tested. This project became the Osteoarthritis Hip and Knee Service (OAHKS) and was operationalised in the Victorian healthcare system from 2012. These initiatives examined and addressed various aspects of management systems for patients with arthritis of the hip and knee in their particular setting.

What does this paper add? The development of this system is an extension of what is already known and is the first to encompass a comprehensive and coordinated strategy across all stages of the care management pathway for this patient group. Their management extends from the initial referral to development and implementation of a management plan, including surgery if assessed as necessary and organisation of long-term post operative follow up as required. By detailing the elements, key processes and measurable outcomes of the service redesign this paper provides a model for other institutions to implement a similar initiative.

What are the implications for practitioners? An important aspect of the design process was practitioner acceptance and engagement and the ability to improve their capacity to deliver services within an efficient and effective model. Intrinsic to the model’s development was assessment of practitioner satisfaction. Data obtained including practitioner surveys indicated an increased level of both satisfaction with the redesigned management service, and confidence in it to deliver its intended improvements.

Nursing care practices following a percutaneous coronary intervention : results of a survey of Australian and New Zealand cardiovascular nurses

Background: Although there is high-level evidence to guide optimal medical care for percutaneous coronary interventions, there are less explicit guidelines to support nurses in providing care. Aim: This study describes the practice standards and priorities of care of cardiovascular nurses in Australia and New Zealand. Method: Item generation for the survey was informed by an integrative literature review and existing clinical guidelines. A 116-item Web-based survey was administered to cardiovascular nurses, via electronic mail lists of professional cardiovascular nursing organizations, using a secure online data collection system. Results: Data were collected from March 2008 to March 2009. A total of 148 respondents attempted the survey, with 110 (74.3%) completing all items. All respondents were registered nurses with an average of 12.3 (SD, 7.61) years of clinical experience in the cardiovascular setting. A range of practice patterns was evident in ambulation time after percutaneous coronary intervention, methods of sheath removal, pain relief, and patient positioning. Respondents consistently rated psychosocial care a lower priority than other tasks and also identified a knowledge deficit in this area. Conclusion: This survey identified diversity of practice patterns and a range of educational needs. Increasing evidence to support evidence-based practice and guideline development is necessary to promote high-quality care and improved patient outcomes.

Obsessive compulsive disorder : integration of cognitive-behaviour therapy and clinical psychology care into the primary care context

In primary care, evidence-based psychological treatments for obsessive compulsive disorder (OCD), such as cognitive behaviour therapy (CBT), have not been readily available. We aimed to develop models of care for OCD that account for barriers to access and can be integrated into general practice settings. Multiple methodologies and sources were utilised, including literature reviews, a reference group, focus groups, interviews and questionnaire responses from consumers, psychologists and/or GPs. It was found that there were similarities and some differences among stakeholders in attitudes and knowledge about OCD, and views about treatment and assessment in primary care. Three models of care for patients with OCD were developed and integrated into a treatment program operating through a division of general practice. Participating GPs preferred referral to a specialist clinic, irrespective of participation in an educational program about OCD. Based on these findings, it is suggested that effective integration of specialist CBT treatments for OCD into primary care is possible if the needs and views of all stakeholders are accounted for.

Improving transfer of mental health care for rural and remote consumers in South Australia

In Australia, it is commonplace for tertiary mental health care to be provided in large regional centres or metropolitan cities. Rural and remote consumers must be transferred long distances, and this inevitably results in difficulties with the integration of their care between primary and tertiary settings. Because of the need to address these issues, and improve the transfer process, a research project was commissioned by a national government department to be conducted in South Australia. The aim of the project was to document the experiences of mental health consumers travelling from the country to the city for acute care and to make policy recommendations to improve transitions of care. Six purposively sampled case studies were conducted collecting data through semistructured interviews with consumers, country professional and occupational groups and tertiary providers. Data were analysed to produce themes for consumers, and country and tertiary mental healthcare providers. The study found that consumers saw transfer to the city for mental health care as beneficial in spite of the challenges of being transferred over long distances, while being very unwell, and of being separated from family and friends. Country care providers noted that the disjointed nature of the mental health system caused problems with key aspects of transfer of care including transport and information flow, and achieving integration between the primary and tertiary settings. Improving transfer of care involves overcoming the systemic barriers to integration and moving to a primary care-led model of care. The distance consultation and liaison model provided by the Rural and Remote Mental Health Services, the major tertiary provider of services for country consumers, uses a primary care-led approach and was highly regarded by research participants. Extending the use of this model to other primary mental healthcare providers and tertiary facilities will improve transfer of care.

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care out-reach service on acute health care utilisation

Background: Over the last decade, high demand for acute health care services by long-term residents of residential care facilities (RCF) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include: comprehensive care planning, management of intercurrent illness and rapid access to acute care substitution services.Objective: To evaluate whether the RECIPE service decreased acute health care utilisation.Design: A retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment.Setting: A 300 bed metropolitan teaching hospital in Australia and 73 RCF within its catchment.Subjects: There were 1327 patients enrolled in the service with a median age 84 years, 61% were female. Methods: Data was collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative dataset. Primary outcomes change in admission rates, length of stay and beddays per quarter.Results: In the two years prior to enrolment the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (p=0.046). Prior to enrolment the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (p=0.003). Conclusions:This study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates.

Barriers to primary care clinician adherence to clinical guidelines for the management of low back pain: protocol of a systematic review and meta-synthesis of qualitative studies.

INTRODUCTION: Low back pain is the highest ranked condition contributing to years lived with disability, and is a significant economic and societal burden. Evidence-based clinical practice guidelines are designed to improve quality of care and reduce practice variation by providing graded recommendations based on the best available evidence. Studies of low back pain guideline implementation have shown no or modest effects at changing clinical practice. OBJECTIVES: To identify enablers and barriers to adherence to clinical practice guidelines for the management of low back pain. METHODS AND ANALYSIS: A systematic review and meta-synthesis of qualitative studies that will be conducted and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement guidelines. Eight databases will be searched using a priori inclusion/exclusion criteria. Two independent reviewers will conduct a structured review and meta-synthesis, and a third reviewer will arbitrate where there is disagreement. This protocol has been registered on PROSPERO 2014. ETHICS AND DISSEMINATION: Ethical approval is not required. The systematic review will be published in a peer-reviewed journal. The review will also be disseminated electronically, in print and at conferences. Updates of the review will be conducted to inform and guide healthcare translation into practice. TRIAL REGISTRATION NUMBER: PROSPERO 2014:CRD42014012961. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014012961.