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author:("duct, David")
1.  How do case managers spend time on their functions and activities? 
Case management has been a widely accepted approach to practice in various care settings. This study aimed to explore how community aged care case managers allocated their time to case management functions, how frequently they performed specific case management activities, and what factors influenced the frequency of their activities.
The study involved 154 survey participants, or 17.1 % of the target case managers in the State of Victoria, Australia. Key information collected included participants’ socio-demographic characteristics, proportions of time allocated to six core case management functions, and frequency ratings of 41 specific activities within seven case management functions. Ordinal regression analyses were performed to determine significant factors associated with participants’ frequency ratings of their activities.
Participants allocated the largest proportion of time to care coordination (22.0 %), and the smallest proportion of time to outcome evaluation (8.0 %). Over 70 % of the participants assigned high frequency ratings to 31 of the 41 case management activities. The remaining ten activities, including all four outcome evaluation activities, three needs assessment activities, one care planning activity, one care coordination activity, and one general functions-related activity were less commonly performed very frequently. The regression analyses indicated that some case manager and client factors were significantly associated with frequency ratings of nine of the ten activities aforementioned. The two main findings of the regression analyses were: First, emphasising achieving more case management goals was significantly associated with higher frequency of three outcome evaluation activities; second, longer work experience was significantly associated with higher frequency of one care coordination activity and one outcome evaluation activity.
The frequent performance of most case management activities and relative absence of factors influencing their frequency suggest a uniformity of practice in community aged care case managers’ practice. What is not clear is whether the frequency of these activities (in particular less frequent performance of outcome evaluation activities) conforms to expectations.
Electronic supplementary material
The online version of this article (doi:10.1186/s12913-016-1333-6) contains supplementary material, which is available to authorized users.
PMCID: PMC4818942  PMID: 27038618
Activities; Case management; Community aged care; Functions; Influencing factors
2.  Study protocol for a randomized controlled trial of telephone-delivered cognitive behavior therapy compared with befriending for treating depression and anxiety in older adults with COPD 
COPD is an umbrella term to describe chronic lung diseases that cause limitations in lung airflow, including emphysema and chronic bronchitis. The prevalence of depression and anxiety in people with COPD is high, although these comorbidities are often undiagnosed, untreated, or undertreated. There is a need to identify efficacious treatments for depression and anxiety in people with COPD. Cognitive behavior therapy (CBT) for the treatment of anxiety and depression has a strong evidence base. There has been some success delivering this treatment over the telephone in limited studies. The aim of this study is to evaluate the efficacy of both telephone-administered CBT and befriending on outcomes for patients with diagnosed COPD who have at least mild levels of depression and/or anxiety.
The protocol described in this paper is of a pragmatic randomized controlled trial comparing eight sessions of telephone CBT to an active social control, referred to as befriending. Primary outcome measures will include depression and anxiety symptoms, and secondary outcome measures will include quality of life, self-efficacy, and COPD symptom severity. Participants’ satisfaction with the intervention and therapeutic alliance will also be assessed. Measures will be taken pre- and postdelivery of the intervention and again at 8 weeks following the intervention.
People with COPD often have limitations to their mobility because of their breathlessness. They are often already attending many medical appointments and could be reluctant to attend for face-to-face psychological treatment. The results of this study should identify the relative efficacy of CBT delivered over the telephone to this population, which, if successful, may be a cost-effective and more palatable alternative to face-to-face treatment of depression or anxiety for this population.
Video abstract
PMCID: PMC4760208  PMID: 26929616
chronic obstructive pulmonary disease (COPD); depression; anxiety; telephone; cognitive behavior therapy (CBT); befriending
3.  Risk of death or hospital admission among community-dwelling older adults living with dementia in Australia 
BMC Geriatrics  2014;14:71.
Older people living with dementia prefer to stay at home to receive support. But they are at high risk of death and/or hospital admissions. This study primarily aimed to determine risk factors for time to death or hospital admission (combined) in a sample of community-dwelling older people living with dementia in Australia. As a secondary study purpose, risk factors for time to death were also examined.
This study used the data of a previous project which had been implemented during September 2007 and February 2009. The original project had recruited 354 eligible clients (aged 70 and over, and living with dementia) for Extended Aged Care At home Dementia program services during September 2007 and 2008. Client information and carer stress had been collected from their case managers through a baseline survey and three-monthly follow-up surveys (up to four in total). The principal data collection tools included Global Deterioration Scale, Modified Barthel Index, Instrumental-Dependency OARS, Adapted Cohen-Mansfield Agitation Inventory, as well as measures of clients’ socio-demographic characteristics, service use and diseases diagnoses. The sample of our study included 284 clients with at least one follow-up survey. The outcome variable was death or hospital admission, and death during six, nine and 16-month study periods. Stepwise backwards multivariate Cox proportional hazards analysis was employed, and Kaplan-Meier survival analysis using censored data was displayed.
Having previous hospital admissions was a consistent risk factor for time to death or hospital admission (six-month: HR = 3.12; nine-month: HR = 2.80; 16-month: HR = 2.93) and for time to death (six-month: HR = 2.27; 16-month: HR = 2.12) over time. Previously worse cognitive status was a consistent risk factor over time (six- and nine-month: HR = 0.58; 16-month: HR = 0.65), but no previous use of community care was only a short-term risk factor (six-month: HR = 0.42) for time to death or hospital admission.
Previous hospital admissions and previously worse cognitive status are target intervention areas for reducing dementia clients’ risk of time to death or hospital admission, and/or death. Having previous use of community care as a short-term protective factor for dementia clients’ time to death or hospital admission is noteworthy.
PMCID: PMC4057809  PMID: 24912483
Death or hospital admission; Community-dwelling; Risk factors; Dementia
4.  Cross-cultural and factorial validity of PTSD check list—military version (PCL-M) in Sinhalese language 
European Journal of Psychotraumatology  2013;4:10.3402/ejpt.v4i0.19707.
There are currently no validated instruments to assess the burden of combat-related Posttraumatic Stress Disorder (PTSD) in Sinhalese—the main spoken language in Sri Lanka.
The purpose of this research was to establish the cross-cultural and structural validity of the PTSD Check List—Military Version (PCL-M) translated into Sinhalese.
Expert committee consensus generation as well as translation–back translation approaches were used to establish the semantic, conceptual, and content equivalence of the Sinhalese and English versions of the PCL-M. Four translations of each item were made. In the absence of any “gold standard” psychometric instrument in Sinhalese to establish the criterion validity for the PCL-M (SIN), the study utilized more informal checks for assessment of validity and Sri Lankan cutoffs for caseness for PTSD to establish the psychometric strength of the translated instrument along with standard reliability analysis.
Confirmatory factor analysis was performed on PCL-M scoring of a random sample of 1,586 soldiers to examine construct validity.
Thirteen of the 17 items were selected by popular vote, and the remaining 4 through discussion and consensus. Reliability measured by Cronbach's-α was 0.944 for the total scale and 0.812, 0.869, and 0.895 for the three DSM-IV sub-scales (re-experiencing, avoidance/numbing, and hyperarousal), respectively. The desired cutoff point for the translated instrument was determined to be 44.
The five-factor model by Elhai et al. and the four-factor model by King et al. fitted best, demonstrating good fit to all three fit indices, while the four-factor model and the DSM-IV three-factor model by Simms et al. only had acceptable levels of fit for root mean squared error of approximation. χ2 difference test comparing the two better-fitting models suggests that the five-factor model by Elhai et al. has the better fit.
The PCL-M (SIN) version is suitable for use in the study of PTSD in the Sri Lankan military forces, as judged by cross-cultural and construct validity as well as reliability.
PMCID: PMC3572409  PMID: 23412918
PTSD; PCL-M; Sri Lanka Army; cross-cultural validation; factorial validity
5.  Managing mood disorders in patients attending pulmonary rehabilitation clinics 
There is good evidence for the positive benefits of pulmonary rehabilitation (PR) in the prevention of hospital admissions, lower mortality, and improved health-related quality of life. There is also increasing evidence about the impact of PR on mental health and, in particular, mood disorders. We aimed to identify how depression in chronic obstructive pulmonary disease (COPD) patients in Victoria, Australia, is being managed in PR, to identify the prevalence of depressive symptoms among COPD patients who attend PR, and to determine whether patients with depressive symptoms or anxiety symptoms dropped out of PR early.
Of 61 PR clinics, 44 were invited and 22 agreed to participate. Telephone interviews were conducted to see how depression and anxiety in COPD patients were being recognized and managed in these clinics. A total of 294 questionnaires were distributed to patients by clinic coordinators to determine the prevalence of anxiety/depression, as measured by the Hospital Anxiety and Depression Scale. Coordinators were contacted to provide information on whether respondents dropped out of rehabilitation early or continued with their treatment at 2–4 months post program.
Seven clinics were not aware of local guidelines on assessment/treatment/management of mood. Four clinics did not use any screening tools or other aids in the recognition and management of depression and/or anxiety. Overall, eight clinics participating in this study requested advice on suitable screening tools. The patient survey indicated that the mean depression score on the Hospital Anxiety and Depression Scale was 5.0 (standard deviation 3.0, range 1–13). The mean anxiety score was 5.5 (standard deviation 3.4, range 0–18). There was no evidence of a link between failure to complete rehabilitation and depression or anxiety scores, as only three of 105 patients failed to complete their rehabilitation.
Discussion: Awareness of management guidelines for depression and anxiety in COPD patients was variable across the clinics recruited into our study. We found no link between compliance with rehabilitation and depression, but our sample had limitations.
Future research needs to investigate how best to encourage more use of available guidelines regarding integrating psychological and psychosocial support to supplement the exercise and education that are currently offered routinely by all PR clinics studied in Victoria, Australia.
PMCID: PMC3540906  PMID: 23319857
chronic obstructive pulmonary disease; depression; anxiety; pulmonary rehabilitation
6.  Effects of case management in community aged care on client and carer outcomes: a systematic review of randomized trials and comparative observational studies 
Case management has been applied in community aged care to meet frail older people’s holistic needs and promote cost-effectiveness. This systematic review aims to evaluate the effects of case management in community aged care on client and carer outcomes.
We searched Web of Science, Scopus, Medline, CINAHL (EBSCO) and PsycINFO (CSA) from inception to 2011 July. Inclusion criteria were: no restriction on date, English language, community-dwelling older people and/or carers, case management in community aged care, published in refereed journals, randomized control trials (RCTs) or comparative observational studies, examining client or carer outcomes. Quality of studies was assessed by using such indicators as quality control, randomization, comparability, follow-up rate, dropout, blinding assessors, and intention-to-treat analysis. Two reviewers independently screened potentially relevant studies, extracted information and assessed study quality. A narrative summary of findings were presented.
Ten RCTs and five comparative observational studies were identified. One RCT was rated high quality. Client outcomes included mortality (7 studies), physical or cognitive functioning (6 studies), medical conditions (2 studies), behavioral problems (2 studies) , unmet service needs (3 studies), psychological health or well-being (7 studies) , and satisfaction with care (4 studies), while carer outcomes included stress or burden (6 studies), satisfaction with care (2 studies), psychological health or well-being (5 studies), and social consequences (such as social support and relationships with clients) (2 studies). Five of the seven studies reported that case management in community aged care interventions significantly improved psychological health or well-being in the intervention group, while all the three studies consistently reported fewer unmet service needs among the intervention participants. In contrast, available studies reported mixed results regarding client physical or cognitive functioning and carer stress or burden. There was also limited evidence indicating significant effects of the interventions on the other client and carer outcomes as described above.
Available evidence showed that case management in community aged care can improve client psychological health or well-being and unmet service needs. Future studies should investigate what specific components of case management are crucial in improving clients and their carers’ outcomes.
PMCID: PMC3508812  PMID: 23151143
Case management; Community aged care; Effects; Systematic review
7.  Signs of progress in the Australian post-2000 COPD experience, but some old problems remain 
This study aims to describe current trends in Australia regarding chronic obstructive pulmonary disease (COPD) mortality and morbidity rates, and in its treatment and prevention from 2000 to 2010. The study’s purpose is to better define future directions in curbing COPD. People with COPD and their caregivers who attend patient support groups (n = 21), pulmonary rehabilitation group coordinators (n = 27) within Victoria, and the Australian Lung Foundation provided informed feedback. COPD was a leading underlying cause of death in both sexes during these years. Nevertheless, mortality rates declined from 1980 to 2007, with rates for males almost halving. Its prevalence has also substantially declined. Smoking rates have declined in age groups over 40 years old in both sexes. The COPD-X Plan provides evidence-based guidelines for the management of COPD. Many government, professional, and community initiatives have been recently implemented to promote the Plan. Two studies—one conducted before and one conducted after the publication of the COPD-X Plan—report some progress, but there are still very considerable departures from evidence-based practice. The Australian Lung Foundation estimates that only 1% of patients who could benefit from pulmonary rehabilitation programs have suitable access to such programs. A common priority for all informants was that there needed to be greater awareness of—and a more positive orientation to—COPD in both the Australian and health professional communities. The study concluded that substantial reductions in COPD and smoking cessation rates contrast with more limited progress toward adopting other aspects of evidence-based practice. The “good news” story concerning reductions in COPD disease with improving smoking cessation rates could form the basis for suitable media campaigns.
PMCID: PMC3379871  PMID: 22745535
COPD; disease trends; community perceptions; health services planning
8.  Child Health Partnerships: a review of program characteristics, outcomes and their relationship 
Novel approaches are increasingly employed to address the social determinants of health of children world-wide. Such approaches have included complex social programs involving multiple stakeholders from different sectors jointly working together (hereafter Child Health Partnerships). Previous reviews have questioned whether these programs have led to significant improvements in child health and related outcomes. We aim to provide definitive answers to this question as well as identifying the characteristics of successful partnerships.
A comprehensive literature search identified 11 major Child Health Partnerships in four comparable developed countries. A critical review is focused on various aspects of these including their target groups, program mechanics and outcomes.
Results and Conclusions
There was evidence of success in several major areas from the formation of effective joint operations of partners in different partnership models to improvement in both child wellbeing and parenting. There is emerging evidence that Child Health Partnerships are cost-effective. Population characteristics and local contexts need to be taken into account in the introduction and implementation of these programs.
PMCID: PMC2908613  PMID: 20565798
9.  The effects of an area-based intervention on the uptake of maternal and child health assessments in Australia: A community trial 
Recognition of the importance of the early years in determining health and educational attainment and promotion of the World Health Organization Health for All (HFA) principles has led to an international trend towards community-based initiatives to improve developmental outcomes among socio-economically disadvantaged children. In this study we examine whether, Best Start, an Australian area-based initiative to improve child health was effective in improving access to Maternal and Child Health (MCH) services.
The study compares access to information, parental confidence and annual 3.5 year Ages and Stages visiting rates before (2001/02) and after (2004/05) the introduction of Best Start. Access to information and parental confidence were measured in surveys of parents with 3 year old children. There were 1666 surveys in the first wave and 1838 surveys in the second wave. The analysis of visiting rates for the 3.5 year Ages and Stages visit included all eligible Victorian children. Best Start sites included 1,739 eligible children in 2001/02 and 1437 eligible children in 2004/05. The comparable figures in the rest of the state were and 45, 497 and 45, 953 respectively.
There was a significant increase in attendance at the 3.5 year Ages and Stages visit in 2004/05 compared to 2001/02 in all areas. However the increase in attendance was significantly greater at Best Start sites than the rest of the state. Access to information and parental confidence improved over the course of the intervention in Best Start sites with MCH projects compared to other Best Start sites.
These results suggest that community-based initiatives in disadvantaged areas may improve parents' access to child health information, improve their confidence and increase MCH service use. These outcomes suggest such programmes could potentially contribute to strategies to reduce child health inequalities.
PMCID: PMC2674040  PMID: 19320980
10.  Impact of telephone triage on emergency after hours GP Medicare usage: a time-series analysis 
The Australian government sponsored trials aimed at addressing problems in after hours primary medical care service use in five different parts of the country with different after hours care problems. The study's objective was to determine in four of the five trials where telephone triage was the sole innovation, if there was a reduction in emergency GP after hours service utilization (GP first call-out) as measured in Medicare Benefits Schedule claim data. Monthly MBS claim data in both the pre-trial and trial periods was monitored over a 3-year period in each trial area as well as in a national sample outside the trial areas (National comparator). Poisson regression analysis was used in analysis.
There was significant reduction in first call out MBS claims in three of the four study areas where stand-alone call centre services existed. These were the Statewide Call Centre in both its Metropolitan and Non-metropolitan areas in which it operated – Relative Risk (RR) = 0.87 (95% Confidence interval: 0.86 – 0.88) and 0.60 (95% CI: 0.54 – 0.68) respectively. There was also a reduction in the Regional Call Centre in the non-Metropolitan area in which it operated (RR = 0.46 (95% CI: 0.35 – 0.61) though a small increase in its Metropolitan area (RR = 1.11 (95% CI: 1.06 – 1.17). For the two telephone triage services embedded in existing organisations, there was also a significant reduction for the Deputising Service – RR = 0.62 (95% CI: 0.61 – 0.64) but no change in the Local Triage centre area.
The four telephone triage services were associated with reduced GP MBS claims for first callout after hours care in most study areas. It is possible that other factors could be responsible for some of this reduction, for example, MBS submitted claims for after hours GP services being reclassified from 'after hours' to 'in hours'. The goals of stand-alone call centres which are aimed principally at meeting population needs rather than managing demand may be being met only in part.
PMCID: PMC2151763  PMID: 17927836
11.  Impact of standalone and embedded telephone triage systems on after hours primary medical care service utilisation and mix in Australia 
The Australian government sponsored five local trials aimed at addressing problems in after hours (AH) primary medical care (PMC). The study's objective was to determine if the four trials, where telephone triage was the sole innovation, led to a reduction in AH service utilisation and change in service mix towards AH GP clinics. Changes in utilisation and mix of AH GP clinic and home visits, ED and ambulance use were monitored in the trial areas, and in a national sample to adjust for the effects of secular trend. Pre- and post-trial telephone surveys of two separate random samples of approximately 350 AH PMC user households in each area were conducted.
Some types of AH PMC use became more frequent in both of the standalone services using nurse-administered proprietary call centre software, which were aimed at better addressing population need (Statewide call centre; Regional call centre). Service use overall (95%CI: 1.03–1.83) and GP clinic use (95%CI: 1.07–2.00) increased in the metro area of the Statewide call centre and in GP clinic (95%CI: 1.04–2.14) and home visits (95%CI: 1.03–3.91) in the non-metro area of the Regional call centre. Service mix only changed in the non-metro area of the Regional call centre with increased contact in GP home visits (95%CI: 1.02–4.38). Levels of use remained unchanged in both embedded services using other than proprietary software, which were established to support the GP workforce (Deputising service; Local triage centre). Service mix only changed in the Deputising service with a change away from AH GP clinics in both contact (95%CI: 0.39–0.97) and frequency (95% CI: -2.12 – -0.7).
Bearing in mind limitations in estimating AH PMC utilisation levels and mix, it is concluded that the impacts of telephone triage were generally smaller in Australia than reported elsewhere. There were different impacts on levels of service utilisation and service mix in standalone call centres and embedded services. Impacts of telephone triage on service utilisation and mix are influenced by the type of telephone triage offered, the goals of the agency providing the service, as well as local factors. (345 words)
PMCID: PMC1334205  PMID: 16343354
12.  Comparison of the uptake of health assessment items for Aboriginal and Torres Strait Islander people and other Australians: Implications for policy 
Health Assessment (HA) items were introduced in 1999 for Aboriginal and Torres Strait Islander people aged at least 55 years and all Australians aged over 75 years. In 2004 a new item was introduced for HAs among adult Aboriginal and Torres Strait Islander people aged 15–54 years. The new item has been applauded as a major policy innovation however this enthusiasm has been tempered with concern about potential barriers to its uptake. In this study we aim to determine whether there are disparities in uptake of HA items for Aboriginal and Torres Strait Islander people compared to other Australians.
The analysis was based on Health Insurance Commission data. Indigenous status was ascertained based on the item number used. Logistic regression was used to compare uptake of HA items for older people among Aboriginal and Torres Strait Islander people compared to other Australians. Adjustments were made for dual eligibility. Uptake of the HA items for older people was compared to the uptake of the new item for Aboriginal and Torres Strait Islander people aged 15–44 years.
Our analyses suggest a significant and persistent disparity in the uptake of items for older patients among Aboriginal and Torres Strait Islander people compared to other Australians. A similar disparity appears to exist in the uptake of the new adult Aboriginal and Torres Strait Islander HA item.
Further engagement of primary care providers and the community around the uptake of the new HA items may be required to ensure that the anticipated health benefits eventuate.
PMCID: PMC1239906  PMID: 16150154
13.  Strengthening Medicare: Will increasing the bulk-billing rate and supply of general practitioners increase access to Medicare-funded general practitioner services and does rurality matter? 
Recent increases in the bulk-billing rate have been taken as an indication that the Federal government's Strengthening Medicare initiative, and particularly the bulk-billing incentives, are 'working'. Given the enduring geographic differences in the supply of general practitioners (GPs) it is timely to reconsider the impact that this increase in the provision of 'free care' will have on access to Medicare-funded GP services in rural and urban areas of Australia. Utilisation has been modelled as two different stochastic processes: the decision to consult and the frequency of consultation.
In the decision to consult model the supply of FFS GPs is a more important predictor of utilisation than the bulk-billing rate. Paradoxically the modelling predicts that ceteris paribus increases in either GP supply or the bulk-billing rate appear to have perverse effects in some areas by decreasing utilisation. In the frequency of consultation model, GP density is not a predictor and increasing the bulk-billing rate will unambiguously increase the frequency of consultation across all areas. In both models, the positive impacts associated with changes in supply and cost are constrained outside the inner metropolitan area by reduced geographic accessibility to Medicare-funded GP services. The modelling also shows that people are more likely to consult a GP in areas of high socioeconomic disadvantage, although socioeconomic status is not a predictor of frequency of consultation.
Bulk-billing rates and the supply of FFS GPs are important features of the Australian health care system that are, potentially, amenable to policy manipulation. The implications of this research are that government policies designed to achieve similarity in these characteristics across geographic areas will not result in equity of access because they fail to address problems caused by geographic inaccessibility in rural and remote areas. Attempting to increase bulk-billing rates in some of these areas may, in fact, reduce access to FFS GP services.
PMCID: PMC1215471  PMID: 16111496

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