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Aim To review changes in utilisation of dietetics services through the Medicare Chronic Disease Management program over the last decade and describe patient uptake in 2013. Methods Dietetics service data were extracted from published Medicare statistics for the periods (i) January 2004 to December 2013 and (ii) January to December 2013. Data comprised individual dietetics services by state and patient demography, and group services data for provider professions regarding type 2 diabetes: dietitians, diabetes educators and exercise physiologists. t-test was used to investigate the association of dietetics' individual service utilisation and workforce statistics. Results Individual dietetics Chronic Disease Management consultations in private practice have increased annually since 2004. Dietetics has remained the third largest provider. In 2013, a total of 302 910 individual consultations were conducted; 7% of allied health consultations. Likewise, individual services for Indigenous Australians increased since 2008. Utilisation of group services for type 2 diabetes comprised

Aim: Uptake of Medicare-funded chronic disease management items has increased exponentially since the programme commenced in 2004. We aim to report on national utilisation of the five most referred of 13 allied health services and to examine patient uptake rates. Methods: Annual statistics generated from national Medicare billing data from January 2010 to December 2010 were extracted from the Medicare public database and compared by profession, state and per capita population. Results: The five most utilised individual services were: (in decreasing order) podiatry, physiotherapy, dietetics, chiropractic and speech pathology. They provided 94% of all allied health consultations nationally, on referral from general practitioners. Per capita utilisation revealed wide variation in uptake by state and territory; some states had far less services than the national average. Patterns of referral instanced by age range and gender of clientele differed between professions. Most dietetics clients were middle aged (45-74years) and this fits with expectations of chronic disease incidence. There was inequity of access to group services for the management of type 2 diabetes, with most services (85%) provided in South Australia and New South Wales. Conclusion: Dietetics providers have maintained and improved their referral rate and continue to be the third most utilised Medicare chronic disease management allied health service. Six years into the programme, further exploration is warranted to understand the reasons for wide variation in rates of patient uptake for the service provider professions. © 2012 The Authors. Nutrition & Dietetics

Aim: Nutrition screening is increasingly conducted in hospitals during the patient admission process. We aimed to explore the ease of use of two tools in the conduct of screening by nutrition technicians (NTs), and to compare validity. The tools are Malnutrition Universal Screening Tool (MUST) and Modified Malnutrition Screening Tool (Mod-MST). Methods: A sample of 262 consecutive adult hospital patients in medical wards was screened during December 2008 to January 2009. Trained NTs used both tools to screen each patient. Dietitians who were blinded to screening results then assessed each patient using Subjective Global Assessment as a reference tool. Time taken for screening was recorded and ease of tool use was explored in interviews with technicians. Results: The specificity of MUST and Mod-MST was 85% and 83%, respectively, with sensitivity of 80% and 77%. Both tools were easy to use and could be applied to all patients, including those unable to answer interview questions. However, the MUST took two to three times longer to complete (5–7 min) using objective data. The Mod-MST collected subjective data that required interpretation by technicians. Conclusion: Specificity and sensitivity of the two tools were less than optimum at ≤85%, as some patients would be misclassified. Both tools were valid and feasible to use with all medical patients, including those with whom communication cannot be established. The Mod-MST is recommended, as choice of malnutrition screening tool needs to balance efficacy with time taken to be useful for mass screening programs.

Aim: Dietitian and general practitioner collaboration in the nutrition care of a patient is important to assist patients to achieve their nutrition goals. This paper aims to review the published literature on dietitians' correspondence practices with recipient general practitioners regarding nutrition interventions recommended to patients. Methods: A literature search was conducted of publications from 1995 to December 2009. Key words were used to search the electronic databases Medline, CINAHL Plus, ProQuest, PsycINFO and Google Scholar. Twenty papers that addressed this topic were selected by two authors for inclusion in the review. Results: There is evidence that dietitians often fail to provide general practitioners with formalised correspondence that describes dietitians' nutrition interventions with patients. Doctors report they lack patient information via dietitians' correspondence. Information about nutrition care of hospital patients often remains within hospital records. Doctors prefer standardised letter formats with content presented succinctly. The letter should include a nutrition diagnosis, agreed goals, a plan for ongoing dietetic visits and instructions for a general practitioner's supportive actions. Conclusion: Dietitians need skill in drafting reports or letters useful for general practitioners by selecting content of value to doctors and using a suitable style. Implementation of shared electronic records in Australia will facilitate information transfer to help realise collaborative patient care. Further investigations of dietitian–general practitioner correspondence are warranted to determine best practice.

Aim: To explore private practice dietitians’ experiences of Medicare Chronic Disease Management allied health program operations, particularly regarding workplace environments, patient management practices and acceptance of the program. Methods: A cross-sectional national survey was administered electronically in 2008. All private practice members of Dietitians Association of Australia were invited to participate. A 38-item questionnaire asked about referrals, patients, fees, billing and participant demographics. Descriptive statistics, c 2 and Spearman’s rank order correlation coefficient were used for analysis (if P < 0.05). Results: There were 356 (47%) dietitian participants; 94% were Medicare providers. Most (75%) worked in private practice 20 hours per week (median 12.0) and half (47%) in sole practices. Medicare referrals made up 0–100% of their practices. Patients were seen as complex because of their chronic conditions. Many dietitians reported inability to complete initial patient education within funded consultation time. Consultation time was often increased and patients were required to pay more than the scheduled fee. Fees were lower for follow-up consultations. Dietitians’ acceptance of the Medicare-Plus Chronic Disease Management program was low. Conclusion: Current Medicare policy arrangements provide insufficient initial consultation time for counselling; and available frequency of follow-up consultations is low. As a consequence, eligible patients have limited access to low-cost dietetics services. The results support a need for review of the Medicare-Plus Chronic Disease Management policy for dietetics interventions and alignment with other counselling services to better meet the needs of providers and also of patients with chronic conditions and diet-related risk factors.

Aim: To examine process evaluation methods used by Australian dietitians in nutrition education of individual clients. ndi_1334 87..93 Methods: A qualitative–quantitative design was used. A purposive sample of 46 clinical dietitians working in Victorian hospitals, community or private practice attended audio-recorded focus groups or an in-depth interview. Themes identified were used to develop a questionnaire to survey Australian dietitians asking about client education strategies and evaluation methods. Two hundred and fifty-eight dietitians (16%) responded to a Web-based questionnaire. Criterion for extraction of results was 70% agreement. Descriptive statistics, chi-squared and Spearman’s rank order correlation analyses were used (if P 0.05). Results: Eleven process evaluation strategies were used by 84% of dietitians. Results clustered into a typology of four evaluation strategies: evaluating planning of the intervention; evaluating assimilation of new information; evaluating intention to change behaviour; and determining a patient’s satisfaction with a consultation. Only two methods were used ‘often’ by more than half the respondents, indicating a wide range in choice of strategies. Seven of 11 strategies in use evaluated information assimilation. There was no significant difference by work category, state of employment or seniority. Evaluative questions to be answered are: Did they agree to it? Did they learn it? Will they use it? What has changed? Conclusion: Process evaluation is best achieved by simultaneous teaching and evaluation. Dietitians may benefit from further skills training to more fully utilise patient-centred planning. Further investigation is warranted to define best practice.

Aim: Issues of trust are important factors that affect communication in professional–client relationships. This paper aims to explore trust in communication from the viewpoint of both clients (the truster) and dietitians. Methods: The qualitative research techniques were based on grounded theory. Purposive samples of 46 dietitians and 34 of their adult outpatients were drawn from health services (hospitals, community services and private clinics) in one state of Australia. Clients from eight centres were aged from 21 to 80+ years. Audio-recorded in-depth interviews and focus groups were used to gather data. Transcribed narratives were open-coded and examined for deviant cases. Themes identified in dietitian and client data sets describing clients' trust were compared. Results: The themes identified confirmed a typology of trust (from the perspective of the truster) present in the health care literature. Clients' trust was derived from institutional context or reputation. Interpersonal trust perceived in verbal and non-verbal communications with a dietitian were in evidence. Dietitians' value attributes of integrity and respect were identified as traits that help build trust and demonstrate dietitians' professionalism. The findings were built into a concept model of trust. Conclusions: Behaviours shown that convey a sense of acceptance, understanding and individual management may lead to positive communication, and hence help build a client's trust in a professional. The link between trust, performance and dietetics clients' outcomes should be investigated further.

Aim: The present study examined dietitians’ and clients’ perceptions of competence required for the process of nutrition education of individuals and used results to validate performance criteria. Methods: A sequential qualitative–quantitative design was used. A quota sample of dietitians in one Australian state (n = 46; 12%), working in hospital, community or private practice, attended a focus group or interview. A quota of their clients (n = 34) from eight centres was interviewed. Participants were asked about dietitians’ skills and attributes. Audio-taped data were transcribed verbatim and open-coded to identify themes; results were used to develop an 88-item questionnaire asking about educational strategies, counselling skills and professional attributes. Australian dietitians in the targeted population (n = 258; 16%) responded to a Web-based survey in 2006. Descriptive statistics were used for ranked data and between-group relationships were examined using c 2 . Criterion for item acceptance was 70% agreement. Results: Results from two phases of research and from dietitians and clients revealed agreement about dietitians’ desirable nutrition education skills. In the questionnaire results, no significant differences were found in educational strategies used by employment category, by year of qualification or experience. Forty-two performance criteria were confirmed and clustered into an eight-step process model. Underpinning skills of ‘nutrition knowledge’, ‘professional and ethical values’ and ‘communication skill’ were identified as necessary attributes and are described. Conclusions: Performance criteria for nutrition education of individuals were confirmed as valid. A process model is presented, which describes a proficient practice level. This should be evaluated further as a nutrition education and counselling practice assessment tool.

Aim: To examine outcome measures used by Australian dietitians in evaluating their nutrition education of individual patients. Methods: A sequential qualitative—quantitative design was used. First, a purposive sample of 46 clinical dietitians working in Victorian hospitals, community or private practice attended an audio-recorded focus group or in-depth interview. Transcribed narratives were open-coded to identify themes and results used to develop a questionnaire to survey Australian dietitians nationally to ask about patient education strategies and evaluation methods. In 2006, 258 dietitians (16%) responded to a Web-based questionnaire. Criterion for extraction of results was 70% agreement on response items when measured on a 5-point scale. Descriptive statistics were used and between-group analyses were conducted using c 2 and Spearman’s rank order correlation (if P < 0.05). Results: Nine outcome measures were confirmed as valid in the categories of direct nutrition outcomes, clinical and health status outcomes and patient value-based care outcomes. There was no significant difference in practice by work category, or time since qualification. Evaluation was most commonly performed prospectively at completion of a consultation, or as part of review consultations. The most common barrier to outcomes research was a lack of time. However, a lack of research skill or health team collaboration may also be a barrier as dietitians did not routinely research or report on outcomes for groups of patients, with potential to identify possible practice improvements. Conclusion: Research training may be needed. Further investigation is recommended to develop best practice policies for dietetics outcomes research.

Aim: To critically examine Australian dietitians' experiences of nutrition education and counselling dilemmas arising from their training, competence and experience in education of individual clients. Methods: Participants were a self-selected sample of Australian dietitians who were working with clients in community, hospital, private practice or other employment. They responded to a researcher-developed Web-based questionnaire asking about skills required for education and counselling of individual clients in 2006. Data were collected electronically and descriptive statistics used to compare response distributions, and open-ended responses were examined by content and thematic analysis. Results: Of 258 respondents, half-qualified to enter dietetics since 1998. There was a change in the focus of practice from information-giving (as taught 30 years ago) to use of two-way communication. Dietitians aimed to use counselling, together with discussion and instruction, as methods for educating and interacting with clients. Four-fifths of dietitians recently qualified (1998–2006) were satisfied with their initial preparation for nutrition education and counselling roles. However, many commented that training courses were too focused on knowledge acquisition rather than skills development in nutrition counselling. Planned skill development in employment was described and dietitians were in favour of a system of mandatory counselling topics within continuing professional development CPD in order to improve counselling skill proficiency and aim for expert skills. Conclusion: Practising dietitians' perceptions indicated a need for greater focus on development of expert nutrition education and counselling skills, both in initial training and in the workplace, because these were seen as key skills for practice in the 21st century.

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.