Melbourne dietitians' experience of Medicare policy on allied health services (strengthening Medicare; Enhanced Primary Care) in the first 12 months

Objective: To describe Victorian private practitioner dietitians’ experience of the Enhanced Primary Care (EPC) program funded under national heath insurance. Design: Dietitians’ experience of the EPC program was investigated between August 2004 and July 2005. A purposive sample of 10% (n = 15) of Victorian dietitians in private practice was interviewed via semi‐structured interviews or focus groups. Focus group/interview data were audio‐taped, transcribed verbatim and thematically analysed using NVIVO software to manage data. Subjects: Victorian dietitians. Setting: Dietetic private practice. Main outcome measures: Issues identified from narrative themes. Results: Thirteen (86%) participants were registered with the Medicare Australia and managed EPC‐referred patients. Two chose not to. All those using the program supported it but voiced frustrations experienced in the first year. Five themes emerged from narrative analysis involving difficulties with implementation in the following areas: referral issues, client preparedness, annual number of consultations limit, impact of financial cost on client and non‐reimbursed administration costs. Conclusion: For clients with chronic illness, access to dietitians in private practice under Medicare EPC is an important service. As increasing numbers of dietitians nationally work with EPC patients with chronic illness or complex care needs, there is a need for information sharing between professional groups about billing procedures and chronic care management. More dietitians need to structure practice to initiate bulk‐billing. Rigorous evaluation is needed to understand which diagnosis types can benefit from the program and to implement an evidence‐based model of chronic care improvement for dietetics consultations.     

Enhancing the dietary management of general practice patients through collaborative care: perspectives of general practitioners and dietitians

Aim:  To describe how general practitioners and dietitians view their role in the dietary management of cardiac patients and to provide insights on how to facilitate collaborative care.
Methods:  Two studies were conducted in Victoria (Australia) 2005–2006. Study One: semi-structured interviews with general practitioners. Study Two: cross-sectional quantitative surveys of general practitioners and dietitians. Study One: texts were analysed using the grounded theory approach. Study Two: frequency analysis was conducted and chi-squared test for independence was used to explore the impact of age, sex and consultation time on the role and reporting scales.
Results:  Study One: Themes arising from the interviews with 30 general practitioners showed their involvement in dietary management fell into three broad roles: 'Influencing', 'Coordinator' of referrals and dietary 'Educator'. They described dietetic education as a process that included dietary assessment, education, application of behavioural change techniques and reporting back to general practitioners. Study Two: Respondents were 248 general practitioners (30% response) and 180 dietitians (60% response). General practitioners' counselling consisted mostly of advocating for dietary change, coordinating dietetic referrals and reinforcing dietitians' recommendations. General practitioners considered dietary education as the role of dietitians. Dietitians reported a much broader role in the management of patients with some overlap with general practitioners' roles.
Conclusions:  The findings indicate the need: (i) for more structured reporting to ensure general practitioners receive appropriate information to enable them to reinforce dietetic counselling and recommendations; and (ii) to streamline the communication process in order to expedite dietitians' reports to general practitioners.     

A quality improvement nutrition screening and intervention program available to Home and Community Care eligible clients

Objective:  To develop and implement a nutrition screening and dietetic referral system for Home and Community Care (HACC) eligible clients.
Design:  Quality improvement project utilising a prospective, observational design.
Setting:  Sixteen Australian organisations caring for HACC eligible clients.
Subjects:  One thousand one hundred and forty-five HACC eligible clients (mean age 76.5 ± 7.2 years) were screened for nutritional risk during 2003–2005.
Interventions:  Nutrition screening was conducted by trained project officers, allied health staff, community care coordinators and nursing staff using a modified version of the malnutrition screening tool (MST). Dietitians performed a nutrition assessment using the scored Patient Generated-Subjective Global Assessment (PG-SGA) and provided individualised nutrition counselling for those identified to be at risk of malnutrition and agreeing to treatment.
Results:  According to the MST, 170 clients (15%) were identified as being at risk of malnutrition. Of these, 75 (44%) agreed to the dietetic referral and PG-SGA assessment, and 57 were subsequently assessed as malnourished (PG-SGA category B or C), suggesting a malnutrition prevalence between 5% and 11%. Of the 34 malnourished clients receiving multiple dietetic reviews (mean 4.1 ± 2.0 per client), 28 improved, with 17 achieving a well-nourished PG-SGA A rating.
Conclusion:  The development and implementation of a nutrition screening and referral system can identify HACC eligible clients who would benefit from services provided by a dietitian. Further research should identify the reasons why some HACC eligible clients are reluctant to be referred to a dietitian.     

Communication competence within dietetics: dietitians' and clients' views about the unspoken dialogue – the impact of personal presentation

Background:  Although client communications are affected by clients' assumptions about professionals' characteristics drawn from dress attire, little is known about how this dialogue operates in dietetics. The present study aimed to describe how dietitians and their clients interpret this dialogue and to explore the implications for practice.
Methods:  A purposive quota sample of dietitians ( n  = 46) from 21 health services in one state of Australia and a quota of their adult patients ( n  = 34) were interviewed about dietitians' nutrition education roles. Semi-structured interviews were transcribed and identified themes developed into a questionnaire to survey Australian dietitians. Analysis used frequencies and nonparametric statistics ( P  <0.05). Triangulation of the results obtained from the studies revealed a strong agreement between data sources.
Results:  Dietitians' dress attire was perceived as a key source of nonverbal communications by dietetics clients. This was recognised by 75% of the 256 dietitians who were surveyed nationally. Dietitians favoured a professional style (i.e. skirt or slacks, with top). Many clients rejected formal dress (i.e. suit, high heels) as being a potential communication barrier. Some clients viewed dietitians' bodily size/shape as a role model. Implications of dietitians' presentation (i.e. how you look) were important to both clients and dietitians.
Conclusion:  Dress style is implicated in nonverbal communication dialogues between the dietitian and client. As a matter of competence and to maintain congruency in communication, dietitians should be aware of their clients' preferences for formality of dress, and conduct their attire accordingly.     

Compulsory continuing professional development: a questionnaire-based survey of the UK dietetic profession

Background:  Continuing professional development (CPD) for Health Professions Council (HPC) registrants became mandatory in July 2006. Some health professions have identified external barriers to CPD participation, and other research suggests that mandatory CPD can devalue learning. The present study aimed to investigate current CPD practices of UK dietitians and to identify their attitudes towards the new mandatory requirement.
Methods:  UK Dietitians were asked to participate in an online questionnaire made available via an advert placed on the British Dietetic Association's website and in an electronic newsletter.
Results:  Of 206 respondents, 98.1% kept a CPD portfolio. Those who had undertaken the 'ABC' placement model (23.7%) were more likely to keep their portfolio up to date ( P  = 0.006). Only 41.3% dietitians were confident that they would currently meet the minimum CPD requirement, whereas 77.2% believed they would comply by the first audit in 2010. Some 50.5% dietitians considered their CPD time commitment insufficient due to obstacles such as workload and time constraints. A total of 96.1% respondents acknowledged the importance of undertaking CPD, with the introduction of a mandatory system appearing to provide the motivation to engage in CPD.
Conclusions:  UK dietitians are currently engaging in CPD. There is, however, concern regarding achievement of the compulsory requirement for the HPC 2010 audit. The findings show barriers exist to engaging in CPD activities and to maintaining a portfolio. These issues could be addressed with the introduction of protected time for CPD.     

Increasing dietetic referrals: Perceptions of general practitioners,practice nurses and dietitians

Aim: To examine Australian private practice dietitians' relationships with general practitioners and practice nurses as a factor that influences dietetic referrals. Methods: Semistructured telephone interviews and an online survey were conducted with Australian private practice dietitians (n = 52 and n = 90, respectively) between April and May 2008. Semistructured questionnaires were conducted with general practitioners (n = 11) and practice nurses (n = 12) from the ‘GP Access’ Division of General Practice between March and July 2007. Results: General practitioners' relationships with dietitians were believed to be the primary influencing factor on referral, provided by 81% of survey dietitians and 25% of interview dietitians. The most common means of initially forming relationships with general practitioners were face‐to‐face introduction (48%) and introductory letters (37%). Patient feedback via letter, fax or email was the most popular method of maintaining relationships with general practitioners (77%). Meeting with general practitioners in person was believed to be the most effective activity in building relationships with general practitioners and increasing referral rates (42%). Referral was made easier for general practitioners by providing paper (37%) or electronic (19%) referral forms and contact details (19%). The majority of general practitioners and dietitians believed that the ‘Allied Health Services Under Medicare’ made it easier to refer to a dietitian. Conclusions: Dietetic referrals can be encouraged through good relationships between general practitioners, practice nurses and dietitians. Private practice dietitians would benefit from cultivating relationships with general practitioners and practice nurses through personal contact and providing good patient feedback.     

Is inequity undermining Australia's ‘universal’ health care system? Socio‐economic inequalities in the use of specialist medical and non‐medical ambulatory health care

Objectives: To quantify need-adjusted socio-economic inequalities in medical and non-medical ambulatory health care in Australia and to examine the effects of specific interventions, namely concession cards and private health insurance (PHI), on equity.
Methods: We used data from a 2004 survey of 10,905 Australian women aged 53 to 58 years. We modelled the association between socio-economic status and health service use — GPs, specialists, hospital doctors, allied and alternative health practitioners, and dentists — adjusting for health status and other confounding variables. We quantified inequalities using the relative index of inequality (RII) using Poisson regression. The contribution of concession cards and PHI in promoting equity/inequity was examined using mediating models.
Results: There was equality in the use of GP services, but socio-economically advantaged women were more likely than disadvantaged women to use specialist (RII=1.41, 95% CI:1.26–1.58), allied health (RII=1.21,1.12–1.30), alternative health (RII=1.29,1.13–1.47) and dental services (RII=1.61,1.48–1.75) after adjusting for need, and they were less likely to visit hospital doctors (RII=0.74,0.57–0.96). Concession cards reduced socio-economic inequality in GP but not specialist care. Inequality in dental and allied health services was partly explained by inequalities in PHI.
Conclusions and implications: Substantial socio-economic inequity exists in use of specialist and non-medical ambulatory care in Australia. This is likely to exacerbate existing health inequalities, but is potentially amenable to change.     

Contribution of Australian cardiologists, general practitioners and dietitians to adult cardiac patients' dietary behavioural change

Aim:  To investigate the use of behavioural change techniques by cardiologists, general practitioners and dietitians in adult cardiac patients within 12 months of their cardiac event.
Method:  Quantitative cross-sectional surveys. Frequency analyses were conducted on the respondents' answers to questionnaire items. Chi-squared test of independence compared responses of the three professional groups on the questionnaire items. Analyses of variance were conducted to explore the impact of the independent variables: age, sex and time worked on the behavioural change techniques used by the respondents.
Results:  The respondents included 248 general practitioners (30% response), 189 cardiologists (47% response) and 180 dietitians (60% response). General practitioners and cardiologists acted mainly as advocates for dietary change in the dietary management process. Dietitians provided nutrition knowledge and a range of techniques to assist dietary behavioural change. Cardiologists and dietitians shared little nutrition information with general practitioners (cardiologists with general practitioners = 8%, dietitians with general practitioners = 49%).
Conclusion:  The present study shows that cardiac patients may have insufficient access to knowledge of nutrition and techniques to assist them with dietary behavioural change.     

Dietitians as lactation educators/consultants

This experience illustrates opportunities for dietitians on several levels. In a broad sense, it suggests the opportunity for a private practice built on group education in an area of normal nutrition. In addition, it demonstrates lactation education/counseling as an acceptable activity for dietitians with appropriate experience and training. There is clearly a public health need for more information and support to increase the incidence of successful, enjoyable breast feeding. Dietitians can and should be at the forefront of such efforts.     

Dietetic service provision for burn care in the United Kingdom: are nutrition support standards being met?

Background:  Catabolism and lean body mass losses in severe burn injury present an extreme challenge to the dietitian. A high level of nutritional intervention is often required, but service levels have not been described in the UK. This study aimed to identify levels of current dietetic services with respect to burns and to assess adequacy against existing nutrition support standards.
Methods:  A postal survey of 34 UK dietetic departments known to provide care to burned adult and paediatric admissions was undertaken. Data were collected on burns settings, hospital service characteristics, staffing and caseload issues, and absence cover. Comparison was made between funding and activity to National Health Service standards for the nutritional care of inpatients.
Results:  The response rate was 71% and data were analysed for 20 departments Clinical settings were either burn units or plastic surgery wards. Dietetic care was provided to critically ill burned patients in 16 hospitals. Most hospitals had no dietetic funding assigned for burn care. The funding deficit for critical care compared to recommendations was 5.9 full-time equivalents and no individual hospital met funding standards. Thirty-seven percent of dietitians were unable to provide daily follow up for critically ill patients. Absence cover was limited in 60% of cases. Approximately one-third of dietitians were members of a nutrition support team.
Conclusions:  Compared to national guidelines for nutrition support, deficiencies of dietetic service provision exist within UK burns settings. This is further reinforced when practice is compared with existing multi-professional burns management standards.     

Dietetic practice in the management of gestational diabetes mellitus: A survey of Australian dietitians

Aim: To examine current Australian dietetic practice in the management of gestational diabetes, to identify models of dietetic care and to determine the need for national evidence‐based dietetic practice guidelines for gestational diabetes. Methods: A 55‐item cross‐sectional survey of Australian dietitians practicing in the area of gestational diabetes was undertaken. Participants were recruited via Dietitians Association of Australia interest group membership, public and private hospital maternity and diabetes services across Australia. The survey examined dietetic service provision, interventions, management recommendations, postnatal care, current guideline use and the perceived need for Australian evidence‐based dietetic management guidelines. Results: A total of 220 eligible dietitians participated in the survey. The majority (77%) reported that all women with gestational diabetes attending their service were referred to a dietitian. Group (33%) and individual consults (93%) were provided and 67% provided one to two dietetic consults per client. Fifty‐four per cent (54%) believed that their service currently offered adequate antenatal dietetic interventions and 8% adequate postnatal follow up for women with gestational diabetes. There were differences in the implementation of medical nutrition therapy by Australian dietitians in regards to nutrient recommendations. However, consistency was seen in key components of nutrition education. Dietitians perceived that there was a need for evidence‐based gestational diabetes dietetic practice guidelines (86%) and nutrition recommendations (87%). Conclusion: The survey results strongly indicate there is a need for evidence‐based gestational diabetes practice guidelines and nutritional recommendations and provide baseline data for future practice of Australian dietitians working in gestational diabetes.     

A study of the attitudes and perceived barriers to undertaking clinical governance activities of dietitians in a Welsh National Health Service trust

Background  Previous studies of National Health Service (NHS) employees have identified barriers to undertaking clinical governance activities. Little of this research has investigated dietitians; however, where dietitians were included, generally positive attitudes towards research and evidence-based practice were reported alongside the identified barriers.
Methods  A quantitative, whole population census was undertaken via a questionnaire distributed to 54 dietitians employed by Gwent Healthcare NHS Trust.
Results  Dietitians reported positive attitudes towards clinical governance; however, barriers to undertaking clinical governance activities were identified. The main barriers included lack of time, inadequate funding, the view that direct patient care should always be prioritised over clinical governance activities and inadequate research and critical evaluation skills.
Conclusions  Findings were similar to those reported in previous studies of NHS staff. Where comparison was possible, all of the barriers identified were reported at lower levels than in previous studies. As the study was purely quantitative in nature, no understanding was gained regarding the nature of identified barriers or what factors influenced the dietitians' attitudes and perceptions. For further in-depth analysis of these factors, a qualitative study is recommended. As the study comprised a whole population census, the findings cannot be generalized to the dietetic profession as a whole, or to other staff groups within or outside of the study Trust.     

Marketing the dietetics profession to consumers and stakeholders: A social and professional imperative

(Nutr Diet 2005;62:158–160) In the present paper we argue that despite the potential impact of dietetic practice on public health, the use of professional dietetic services appears to be stagnant. To redress this position, dietitians may need to increase their use of marketing activities to promote the value of the profession. We discuss the different roles of the Dietitians Association of Australia and of individual members in marketing activities, provide an overview of the key components of a marketing plan and strategy, and outline specific steps that dietitians can take to actively promote their services. We argue that promotion of the dietetic profession may ultimately contribute to better health through nutrition for the Australian population.     

Use of pregnancy counselling services in Australia 2007–2012

Objective : To assess the uptake of Medicare Benefit payments for non‐directive pregnancy support counselling which commenced in November 2006. Methods : Counts of services for pregnancy counselling from 1 July 2007 to 30 June 2012, where a Medicare rebate was paid, were used to calculate age‐, state‐ and provider‐specific rates per 100,000 women aged 15–44 years, and rates per 100,000 births for each study year. Results : Rates of Medicare rebates for pregnancy counselling were low, with a mean of 90.6 services per 100,000 women recorded over the study period. GP services were accessed most frequently, while services provided by allied health professionals averaged less than 5% of those for GPs. The overall rate of services fell in all jurisdictions except Victoria/Tasmania, although services provided by allied health professionals remained steady or rose in all jurisdictions over the study period. Conclusions : There has been a low uptake of pregnancy counselling covered by the Medicare Benefits Item numbers introduced in 2006, especially for services provided by allied health professionals. Due to a lack of available data, the impact on abortion rates is unknown. Implications : Provision of Medicare rebates for pregnancy counselling does not appear to be an effective way of assisting women with unintended pregnancies.     

Measuring rural allied health workforce turnover and retention: What are the patterns,determinants and costs?

Objectives: To measure variations in patterns of turnover and retention, determinants of turnover, and costs of recruitment of allied health professionals in rural areas. Design: Data were collected on health service characteristics, recruitment costs and de‐identified individual‐level employment entry and exit data for dietitians, occupational therapists, physiotherapists, podiatrists, psychologists, social workers and speech pathologists employed between 1 January 2004 and 31 December 2009. Setting: Health services providing allied health services within Western Victoria were stratified by geographical location and town size. Eighteen health services were sampled, 11 participated. Main outcome measures: Annual turnover rates, stability rates, median length of stay in current position, survival probabilities, turnover hazards and median costs of recruitment were calculated. Results: Analysis of commencement and exit data from 901 allied health professionals indicated that differences in crude workforce patterns according to geographical location emerge 12 to 24 months after commencement of employment, although the results were not statistically significant. Proportional hazards modelling indicated profession and employee age and grade upon commencement were significant determinants of turnover risk. Costs of replacing allied health workers are high. Conclusions: An opportunity for implementing comprehensive retention strategies exists in the first year of employment in rural and remote settings. Benchmarks to guide workforce retention strategies should take account of differences in patterns of allied health turnover and retention according to geographical location. Monitoring allied health workforce turnover and retention through analysis of routinely collected data to calculate selected indicators provides a stronger evidence base to underpin workforce planning by health services and regional authorities.