Waiting for outpatient and community health care is a problem for clients and services. Specific Timely Appointments for Triage (STAT) is an evidence-based model for access and triage designed to reduce waiting time in ambulatory services.
The model’s key elements are: analysis of supply and demand; a one-off intervention to address the backlog; creation of clinician schedules which reserve new patient appointments; simplification of intake; and a shifting of caseload management to make prioritisation decisions on ongoing service delivery rather than initial intake.
The model was initially shown to be effective in two pilot trials, conducted in community rehabilitation and outpatient physiotherapy reducing waiting time by up to 30%. The model has since been evaluated in a stepped wedge cluster randomised controlled trial funded by the NHMRC and Victorian Department of Health and Human Services involving 8 sites and 3,116 patients. STAT reduced waiting time by 34% and substantially reduced variability of waiting time indicating a more equitable service. Reducing waiting lists improves efficiency for health providers, and early access to services reduces anxiety, improves quality of care and may lead to improved outcomes for patients.
What is STAT?
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1. Harding, K.E., Leggat, S.G., Watts, J.J. et al. BMC Med (2018) A model of access combining triage with initial management reduced waiting time for community outpatient services: a stepped wedge cluster randomised controlled trial. BMC Medicine. 16, 128.
2. Harding, K. E., Watts, J. J., Karimi, L., O'Reilly, M., Kent, B., Kotis, M….Taylor, N. F. (2016). Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial. BMC health services research, 16(a), 364.
3. Harding, K. E., Leggat, S., Bowers, B., Stafford, M., & Taylor, N. F. (2013). Reducing waiting time for community rehabilitation services: A controlled before and after trial. Archives of Physical Medicine and Rehabilitation, 94(3), 23-31.
4. Harding, K. E., Leggat, S., Bowers, B., Stafford, M., & Taylor, N. F. (2013). Perspectives of clinicians and patients following introduction of a new model of triage that reduced waiting time: a qualitative analysis Australian Health Review, 33(3), 324-330.
This broad program of research aims to improve outcomes for people returning to the community after rehabilitation following an illness or injury. Multi-disciplinary in focus, it includes research related to planning for discharge, oncology rehabilitation, recovering from joint replacement, translation of evidence into practice, and use of technology to support home based programs.
In 2016, a grant funded jointly by the La Trobe University Sport, Exercise and Rehabilitation Research Focus Area and the Eastern Health Foundation enabled a substantial expansion of this research program.
Effectiveness of home visits following hip fracture
La Trobe University PhD candidate Kylee Lockwood is investigating what happens to patients who return to the community after hip fracture, and the role that a pre-discharge home visit from an occupational therapist can play in improving outcomes.
Her research has shown that one in three patients at Eastern Health are readmitted within 12 months, and patients with lower levels of mobility prior to the fracture have twice the odds of being readmitted to hospital compared to those who were able to walk independently.
Kylee has gone on to conduct a randomised controlled trial involving 77 participants to compare the outcomes of patients who receive pre-discharge home visits with a group that received hospital discharge planning alone. Early results indicate that the patients who received home visits have fewer readmissions to hospital and fewer falls in the post discharge period.
2. Lockwood K, Taylor N, Harding K. pre-discharge home assessment visits in assisting patients' return to community living: a systematic review and meta-analysis. journal of rehabilitation medicine. 2015;47(4):289-99.
Physical activity after hip fracture
Outcomes after hip fracture are poor and physical activity levels are very low, but it is not known just how physically active people recovering from a hip fracture should be. In a project led by Nick Taylor, the physical activity of 60 people recovering from hip fracture in the community is being closely monitored to determine the optimum level of physical activity associated with improved function.
Outcomes from this project will then be used to inform a randomised controlled trial that aims to find out whether prescribing this level of physical activity for people recovering from hip fracture in addition to usual rehabilitation improves outcomes.
Physical activity linked to improved outcomes for cancer survivors
Cancer survivors who are more physically active have a greater chance of survival and less risk of cancer recurrence. Rehabilitation improves quality of life, mood, strength and fitness, and reduces the side effects of treatment. This series of projects led by Amy Dennett and funded by the Eastern Health Foundation and La Trobe University, aims to optimise physical activity levels of cancer survivors.
An initial nation-wide survey of access to oncology rehabilitation found that less than 0.5% of cancer survivors have access to oncology rehabilitation programs. A second study has shown that modifiable factors such as walking capacity and BMI are strongly related to physical activity, reinforcing the importance of access to rehabilitation. The team was then able to establish through a randomized controlled trial that motivational interviewing added to oncology rehabilitation may help people be less sedentary, and a supplementary qualitative study demonstrated that oncology rehabilitation helps people ‘return to normal’ during and after cancer treatment through improving functional ability, social well-being and quality of life. Findings from this research will help inform the design of future oncology rehabilitation programs.
1. Dennett A, Peiris C, Shields N, Prendergast L, Taylor NF . Moderate intensity exercise reduces fatigue and improves mobility in adult cancer survivors: a systematic review and meta-regression. . Journal of Physiotherapy. 2016;62(2):68-82.
2. Dennett A, Shields N, Peiris C, Reed M, O'Halloran P, Taylor N. Does psycho-education added to oncology rehabilitation improve physical activity and other health outcomes? A systematic review. Rehabilitation Oncology. (in press).
Effectiveness of clinical supervision in improving patient outcomes
Clinical supervision is a process that involves an experienced health professional guiding the clinical practice of a less experienced health professional. The Australian Commission on Safety and Quality in Health Care recommends that clinical supervision be provided to health professionals to ensure the safety of patients and maintain a high quality of care. Research investigating the effects of clinical supervision on patient care has found that supervision is associated with improved care when health professionals are directly supervised during their patient interactions. However, allied health professions typically use a model of “reflective supervision” that involves reflecting on practice with a supervisor away from the patient.
David Snowdon’s research involved a comparison of physiotherapist’s adherence to hip fracture clinical guidelines when they were provided with direct supervision sessions as an addition to reflective supervision, compared with reflective supervision alone. The results showed that direct supervision significantly enhanced physiotherapist compliance and led to a higher proportion of patients with hip fracture mobilising on the day following surgery and improved walking independence by the 5th day after surgery. These results demonstrate that a direct model of clinical supervision can influence both the quality of physiotherapy care and patient outcomes.
4. Snowdon DA, Leggat SG, Taylor NF. Does clinical supervision of healthcare professionals improve effectiveness of care and patient experience? A systematic review. BMC health services research. 2017;17(1):786.
Video home exercise programs after stroke
Smart technology is increasingly accessible. Tools that are readily available on the smart phones and tablets that patients are commonly carrying in their pockets or handbags have potential to improve the experience and outcomes of rehabilitation. This project aimed to test whether the video and reminder functions on these devices can be used to improve adherence and outcomes of home exercise programs. A trial led by Kellie Emmerson allocated people recovering from stroke randomly assigned participants to receive home exercise programs using video on a tablet device or with traditional paper instruction.
The trial showed that both methods of home exercise prescription were equally effective in relation to adherence and patient outcomes. However, qualitative data obtained through interviews with people in the intervention group indicated that there were other benefits to using technology, such as the ability to look back on progress, share the rehabilitation experience with family and benefits for patients with visual or cognitive deficits who require support to follow a written program. Patients who already owned and used these devices in daily life were particularly receptive to the use of technology.
1. Emmerson KB, Harding KE, Taylor NF. Home exercise programmes supported by video and automated reminders compared with standard paper-based home exercise programmes in patients with stroke: a randomized controlled trial. Clinical rehabilitation. 2017;31(8):1068-77.
2. Emmerson KB, Harding KE, Lockwood KJ, Taylor NF. (in press). Home exercise programs supported by video and automated reminders for patients with stroke: A qualitative analysis. Australian Occupational Therapy Journal
Involving family care givers in rehabilitation
Older people admitted to hospital are at high risk of functional decline. This may be due to a combination of the illness or injury they were admitted with, the treatments undertaken and the effects of prolonged immobilisation. Physiotherapy can help, but staffing ratios in aged care programs such as Transition Care are typically low. This research led by Kate Lawler aims to understand the feasibility of training family members to assist with physiotherapy and whether this approach can improve levels of physical activity, falls-related self-efficacy, health-related quality of life and caregiver strain.
1. Lawler K, Taylor N, Shields N. Involving family members in physiotherapy for older people transitioning from hospital to the community: a qualitative analysis. Disability and Rehabilitation. 2015: 37: 2061-2069.
2. Lawler K, Taylor NF, Shields N. 2013. Outcomes after caregiver-provided speech and language or other allied health therapy: a systematic review. Archives of Physical Medicine and Rehabilitation 94:1139-1160.
People with osteoarthritis of the knee and hip may not participate in physical activities due to pain and fear of harming their joints, leading to increased risk of heart attack or stroke. Eastern Health and La Trobe University PhD candidate Jason Wallis is investigating how to help patients with severe osteoarthritis of the knee be more active and reduce their health risks. In a randomised controlled trial Jason found that participants in the intervention group, who walked for 70 minutes each week for 12 weeks, were six times more likely to lower their blood pressure to a healthy level. In other words, 10 minutes of walking per day was enough to make meaningful changes to the health of osteoarthritis patients while also improving mood and mobility.
1. Wallis J, Webster K, Levinger P, Fong C, Taylor N. A pre-operative group rehabilitation programme provided limited benefit for people with severe hip and knee osteoarthritis. Disability & Rehabilitation. 2014;36:2085-90
2. Wallis J, Webster K, Levinger P, Singh P, Fong C, Taylor N. The maximum tolerated dose of walking for people with severe osteoarthritis of the knee: a phase I trial. Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society. 2015
3. Wallis J, Webster K, Levinger P, Singh P, Fong C, Taylor N. A walking program for people with severe knee osteoarthritis did not reduce pain but may have benefits for cardiovascular health: a phase II randomised controlled trial. Osteoarthritis and cartilage. 2017;25(12):1969-79
4. Wallis JA, Webster KE, Levinger P, Singh PJ, Fong C, Taylor NF. Perceptions about participation in a 12-week walking program for people with severe knee osteoarthritis: a qualitative analysis. Disabil Rehabil. 2017:1-7
Total joint replacement is a common operation for people with severe hip and knee osteoarthritis. Despite the operation being very successful in reducing pain, levels of physical activity typically do not improve after surgery. This is a concern as sustained low levels of physical activity increase the risk of cardiovascular disease. PhD student Lyndon Hawke is investigating interventions that might be used to improve physical activity and other outcomes after lower-limb total joint replacement.
One of the key roles of the Allied Health Clinical Research Office is to foster a culture of research among allied health professionals. But is investing in research a worthwhile endeavour? What are the benefits, and what are the barriers? What strategies are most likely to be effective?
A series of projects led by staff of the Allied Health Clinical Research Office and in collaboration with members of the Allied Health Clinical Research Committee have sought to answer some of these questions, both to inform our own strategic direction and to contribute to knowledge in these areas. So what have we learned?
There is an association between a strong research culture and improved organisational performance
A systematic review of the literature published by our team in Australian Health Review in 2016 demonstrated that organisations that demonstrate a research culture by investing in research, participating in research and/or providing research opportunities for staff are more likely to have improved performance on measures including patient mortality, staff satisfaction and retention, and organisational efficiency.
About 1 in 7 allied health clinicians is “very interested” in research
Understanding the nature of the allied health workforce was an important place to start in designing strategies to help build a research culture. Our first survey of allied health professionals at Eastern Health was conducted with 132 participants in 2007. The Research Spider survey tool was used to examine clinicians’ level of research experience and level of research interest across ten core areas. Overall, allied health professionals rated themselves as having ‘little research experience’, and as a group had only had ‘some interest’ in research. However, fifteen percent were very interested in research. The findings support the development of strategies to target these ‘very interested’ clinicians to foster the next generation of allied health researchers.
A follow up survey was conducted in 2015 to see if changes can be measured at an organisational level, 10 years after the introduction of the allied health clinical research office. Results indicate that although research interest is similar across the two cohorts, in 2015 the clinicians who identified as being interested reported higher levels of experience in some domains. These results suggest that the introduction of the research office has led to more opportunities
Taylor NF, Harding KE, Porter J, Horne-Thompson A, Wallis J, Kerridge G, Wilby A, Joy A, Kaminski MR, Sheats J, Wilson E. (in press). Evaluating the introduction of an allied health clinical research office at a health service on research participation, interest and experience of allied health professionals. Journal of Allied Health (available soon).
Small group training and mentoring is an effective way to help clinicians “Step into Research”
Since 2008, the Allied Health Clinical Research Office has run the “Stepping into Research Training Scheme”, a program that uses a combination of small group training and one to one mentoring to take participants through the process of writing a systematic review of the literature. Two evaluations of the program, one completed with the first cohort to complete the program and another reporting 6 year follow up have demonstrated that the program results in measurable research outputs, is well received by participants and mentors, and has been successfully translated to another health service setting.
Harding, K. E., N. Shields, M. Whiteside and N. F. Taylor (2016). "A Great First Step into Research": Stepping Into Research Is an Effective and Sustainable Model for Research Training in Clinical Settings: A Report of 6-Year Outcomes. J Allied Health 45(3): 176-182.
A cultural shift is required to improve the uptake of Evidence based practice in allied health
Evidence-based practice(EBP) is a key principle in the delivery of effective and high-qualityhealthcare. This study used 8 focus groups ofalliedhealthprofessionals and managers to explore the attitudes andbarriersto EBP. The findings showed that EBP was not highly valued bycliniciansand managers or viewed as a core component of clinical care, with activities directly related to moving patients through the hospital system viewed as higher priorities. Lack of skills and resources and difficulty associated with implementingevidenceintopracticewere furtherbarriers.
Achieving higher uptake of EBP amongalliedhealthclinicians requires a cultural shift, placing higher value on these activities despite the challenging context of constant pressures to increase patient flow.
Harding, K., J. Porter, A. Horne-Thompson, E. Donley and N. Taylor (2014). "Not enough time or a low priority? Barriers to Evidence-Based Practice for allied health clinicians." Journal of Continuing Education in the Health Professions 34(4): 224-231.
Judi Porter has led a program of research exploring malnutrition in hospitalised patients since 2010. This included the first Eastern Health malnutrition prevalence audit, followed by clinical trials investigating the effect of higher energy menus, and the implementation of Protected Mealtimes, on the nutritional intake of patients. Qualitative research exploring the mealtime culture and environment has been integral to understanding factors that underpin mealtime practice. These projects have been run in conjunction with undergraduate & higher degrees nutrition and dietetics students from Monash University.>
1. Porter J. The perspectives of patients and their families remain largely unheard in mealtime assistance research. Evidence-based nursing. 2017:ebnurs-2017-102682.
2. Porter J, Haines T, Truby H. Implementation of protected mealtimes in the subacute setting: stepped wedge cluster trial protocol. Journal of advanced nursing. 2016;72(6):1347-56.
3. Porter J, Haines TP, Truby H. The efficacy of Protected Mealtimes in hospitalised patients: a stepped wedge cluster randomised controlled trial. BMC Medicine. 2017;15(1):25.
4. Porter J, Ottrey E, Huggins CE. Protected Mealtimes in hospitals and nutritional intake: Systematic review and meta-analyses. International journal of nursing studies. 2017;65:62-9.
5. Porter J, Wilton A, Collins J. Mealtime interruptions, assistance and nutritional intake in subacute care. Australian Health Review. 2015. https://www.ncbi.nlm.nih.gov/pubmed/26476460.
Many inpatients receive little or no rehabilitation on weekends. This project led by Nick Taylor, Casey Peiris and Tash Brusco aimed to determine the effect of providing additional Saturday rehabilitation during inpatient rehabilitation on functional independence, quality of life and length of stay compared to 5 days per week of rehabilitation, and to find out whether this intervention was cost effective. This trial randomly allocated 996 rehabilitation inpatients to receive additional allied health services from Monday to Saturday or usual-care rehabilitation services from Monday to Friday. Provision of an additional day of rehabilitation from physiotherapy and occupational therapy on a Saturday led to reduction in length of stay of about 2 days, and clinically significant improvements in functional independence and quality of life, with benefits sustained 6 months after discharge from rehabilitation. Saturday rehabilitation allied health services were cost effective with benefits to the patient and savings to the health service, providing strong evidence in support of providing additional physiotherapy and occupational therapy for inpatient rehabilitation on a Saturday.
2. Peiris CL, Shields N, Brusco NK, Watts JJ, Taylor NF. (in press). Additional physical therapy services reduce length of stay and improve health outcomes in people with acute and sub-acute conditions: an updated systematic review and meta-analysis Archives of Physical Medicine and Rehabilitation (accepted 5 March 2018).
3. English C, Shields N, Brusco NK, Taylor N, Watts JJ, Peiris C, Bernhardt J, Crotty M, Esterman A, Segal L, Hillier S. 2016. Additional weekend therapy may reduce length of rehabilitation stay after stroke: An individual patient data meta-analysis. Journal of Physiotherapy 62(3):124-129.
4. Brusco NK, Watts JJ, Shields N, Taylor NF. 2015. Is cost effectiveness sustained after weekend inpatient rehabilitation? 12 month follow up from a randomized controlled trial. BMC Health Services Research 15:165, impact factor 1.66.
5. Brusco NK, Watts JJ, Shields N, Taylor NF. 2014. Are weekend inpatient rehabilitation services value for money? An economic evaluation alongside a randomized controlled trial with a 30 day follow up. BMC Medicine 12:89.
6. Brusco NK, Taylor NF, Watts JJ, Shields N. 2014. Economic evaluation of adult rehabilitation: a systematic review and meta-analysis of randomized controlled trials in a variety of settings. Archives of Physical Medicine and Rehabilitation 95:94-116.
7. Peiris CL, Shields N, Brusco NK, Watts JJ, Taylor NF. 2013. Additional Saturday rehabilitation improves functional independence and quality of life and reduces length of stay: a randomized controlled trial. BMC Medicine 11:198, impact factor 6.679.
9. Peiris CL, Taylor NF, Shields N. 2012. Additional Saturday allied health services increase habitual physical activity among patients receiving inpatient rehabilitation for lower limb orthopedic conditions: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 93: 1365-1370.
10. Taylor NF, Brusco NK, Watts JW, Shields N, Peiris C, Sullivan N, Kennedy G, Teo CK, Farley A, Lockwood K, Radia-George C. 2010. A study protocol of a randomised controlled trial incorporating a health economic analysis to investigate if additional allied health services for rehabilitation reduce length of stay without compromising patient outcomes. BMC Health Services Research 10(1): 308.
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