Improving Physiotherapy Services for Indigenous Children ... · Conference Presentation ± Oral...
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Improving Physiotherapy Services for Indigenous Children with Physical Disability: A Continuous Quality Improvement and Qualitative Approach by Caroline Faith Greenstein A thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Health Menzies School of Health Research and Institute of Advanced Studies, Charles Darwin University Darwin, Northern Territory May 2016
Transcript of Improving Physiotherapy Services for Indigenous Children ... · Conference Presentation ± Oral...
Improving Physiotherapy Services for Indigenous Children
with Physical Disability:
A Continuous Quality Improvement and Qualitative Approach
by
Caroline Faith Greenstein
A thesis submitted in partial fulfillment of the requirements for the
degree of Doctor of Health
Menzies School of Health Research
and
Institute of Advanced Studies, Charles Darwin University
Darwin, Northern Territory
May 2016
ii
DECLARATION
‘I hereby declare that the work herein, now submitted as a thesis for the degree of Doctor of
Health of Charles Darwin University is the result of my own investigations, and all
references to ideas and work of other researchers have been specifically acknowledged. I
hereby certify that the work embodied in this thesis had not already been accepted in
substance for any degree, and is not being currently submitted for candidature for any other
degree.’
I give consent to this copy of my thesis, when deposited in the University Library, being
made available for loan and photocopying online via the University’s Open Access
repository eSpace.’
_____________________
Caroline Greenstein
MAY 2016
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ABSTRACT
Disability is a complex phenomenon that affects more Indigenous Australians than non-
Indigenous Australians throughout their lifespan. Physiotherapists provide services integral
to children with physical disability and gross motor delay but little is known about the
particular profile, needs or experiences of Indigenous children with physical disability.
This thesis presents the first research involving physiotherapy services for Indigenous
children with physical disability or gross motor delay. The mixed methods study involved 1)
a continuous quality improvement process based on the Audit and Best Practice for Chronic
Disease model that involved one participating physiotherapy department; 2) open-ended
semi-structured interviews with previous or current clients of the participating service and
their carers and 3) a comparison and reflection of the results of the two projects.
Principal findings were:
1. The continuous quality improvement project identified weaknesses in service delivery,
and measured and identified improvements in clinical and organisational aspects of
physiotherapy care.
2. Carers of Indigenous children with physical disability experienced complex lives filled
with multiple demands. Clients and their carers valued relationships involving caring,
consistency and communication with their physiotherapists and had lives that were
influenced by their Indigenous background in ways that may not be obvious to non-
Indigenous service providers. The research highlighted the importance of effective
communication.
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3. Comparison of the findings of the two studies highlighted that the continuous quality
improvement process, while demonstrating improvements in clinical and organisational
aspects of the service, did not always reflect or address the primary concerns of Indigenous
clients. This underlined the importance of including clients in the continuous quality
improvement process so that indicators reflecting their values are included.
These findings contribute to the small body of literature on physiotherapy practice in
Indigenous healthcare, perspectives from Indigenous children and carers with physical
disability and continuous quality improvement in community-based physiotherapy.
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ACKNOWLEDGEMENTS
I am deeply, deeply grateful to all of the participants in both studies who generously shared
their time, wisdom and patience with me during the project.
I am also indebted to my supervisors David Thomas and Anne Lowell, who have generously
and unwaveringly shared their time, expertise, experience, skill, good humor, patience and
insight throughout the long and challenging research project.
I would like to acknowledge the Aboriginal and Torres Strait Islander people who are the
original owners of the lands and seas of Australia and the Nursing and Allied Health
Scholarship and Support Scheme who funded the last year of my student tuition.
I would also like to thank my parents, coworkers and clients who have put up with my
divided and sometimes compromised attention, Ross Andrews for his support and timely
advice and Cynthia Croft for her advice and generosity in sharing the continuous quality
improvement tools of One21seventy.
Finally, I would like to thank my partner Kim who stuck by me, even as the study assumed
the personality of an unwelcome household guest who overstayed its welcome and
relentlessly demanded my time and attention.
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DEDICATION
In memory of Kathy Smith and Kumanjai Foster, two people whose kindness, wisdom and
generosity of spirit have taught me so much about Australian culture, friendship and health.
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PUBLICATIONS
The present doctoral thesis incorporates the following three articles:
Greenstein, C., Lowell, A., Thomas, D. (to be submitted). Improving physiotherapy services
for children with physical disability or gross motor delay: a continuous quality improvement
approach.
Greenstein, C., Lowell, A., Thomas, D. Communication and context are important for
Indigenous children with a physical disability and their carers: a qualitative study. Journal of
Physiotherapy. 2016; 62(1): 42-7.
Greenstein, C., Lowell, A., Thomas, D. 2016 Improving physiotherapy services to
Indigenous children with physical disability: are client perspectives missed in the continuous
quality improvement approach? Australian Journal of Rural Health. DOI 10.1111/ajr.12258,
http://dx.doi.org/10.1111/ajr.12258.
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PRESENTATIONS
Part of the work for this thesis has been presented as follows:
Conference Presentation – Oral E-poster presentation
Greenstein, C., Lowell, A., Thomas, D. Improving physiotherapy services for children with
physical disability or gross motor delay: a continuous quality improvement approach.
Australian Physiotherapy Association National Conference, Paediatric Section, Gold Coast,
Queensland, Australia, 2-6 October 2015.
Conference Presentation- Oral podium presentation
Greenstein, C., Lowell, A., Thomas, D. Communication and context are important to
Indigenous children with a physical disability and their carers at a community-based
physiotherapy service: a qualitative study. Australian Physiotherapy Association National
Conference, Gold Coast, Queensland, Australia, 2 - 6 October 2015.
Conference Presentation- Oral podium presentation
Greenstein, C., Lowell, A., Thomas, D. Improving physiotherapy services for children with
physical disability: a continuous quality improvement and qualitative approach.
Australasian Academy of Cerebral Palsy and Developmental Medicine, Adelaide, South
Australia, Australia, 30 March -2 April 2016.
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AWARDS
Joanne Tubb Award – for best podium presentation by a clinician in Paediatric Section of
Australian Physiotherapy Association Conference 2015 for Communication and context are
important to Indigenous children with a physical disability and their carers at a community-
based physiotherapy service: a qualitative study
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TABLE OF CONTENTS
DECLARATION ...……. ........................................................................................................ ii
ABSTRACT……… ................................................................................................................. iii
ACKNOWLEDGEMENTS ..................................................................................................... v
DEDICATION………. ............................................................................................................ vi
PUBLICATIONS………….. ................................................................................................... vii
PRESENTATIONS ................................................................................................................. viii
AWARDS ………… .............................................................................................................. ix
TABLE OF CONTENTS ......................................................................................................... x
LIST OF FIGURES ................................................................................................................. xiii
LIST OF TABLES ................................................................................................................. xiv
ABBREVIATIONS ................................................................................................................. xv
CHAPTER 1: INTRODUCTION ......................................................................................... 1
1.1 Background………….… ................................................................................................. 2
1.2 Thesis overview ................................................................................................................ 2
1.3 Disability……………. ...................................................................................................... 3
1.4 The role of physiotherapy ............................................................................................... 5
1.5 Local context ................................................................................................................. 6
1.6 Policy context ................................................................................................................. 8
1.6.1 The Closing the Gap initiative .................................................................................. 8
1.6.2 The National Disability Insurance Scheme .............................................................. 8
CHAPTER 2: LITERATURE REVIEW ............................................................................. 10
2.1 Literature review search ................................................................................................. 10
2.2 Physiotherapy literature .................................................................................................. 12
2.3 Disability literature .......................................................................................................... 13
2.4 Themes in the literature .................................................................................................. 15
2.4.1 Service utilisation barriers ........................................................................................ 15
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2.4.2 Recommendations .................................................................................................... 17
CHAPTER 3: STUDY BACKGROUND AND DESIGN ................................................... 18
3.1 Mixed methods research in physiotherapy .................................................................... 18
3.2 Audit and Best Practice for Chronic Disease ................................................................ 18
3.3 Indigenous client perspectives ......................................................................................... 19
3.4 Research design ................................................................................................................ 20
3.5 Research aims ................................................................................................................. 20
CHAPTER 4: CONTINUOUS QUALITY IMPROVEMENT STUDY ........................... 22
4.1 Journal article: Improving community-based physiotherapy services for
Indigenous children with gross motor delay or physical disability: a continuous
quality improvement approach ............................................................................................... 22
CHAPTER 5: QUALITATIVE STUDY .............................................................................. 42
5.1 Journal article: Communication and context are important to Indigenous children
with physical disability and their carers at a community-based physiotherapy service: a
qualitative study ................................................................................................................. 42
CHAPTER 6: REFLECTIONS ON THE STUDIES COMBINED .................................. 66
6.1 Journal article: Improving physiotherapy services to Indigenous children with
physical disability: are client perspectives missed in a continuous quality improvement
approach?..................................................................................................................... ............ 66
CHAPTER 7: FINAL DISCUSSION ................................................................................... 82
7.1 Overview............................................................................................................................ 82
7.2 Implications for physiotherapy practice ........................................................................ 85
7.3 Limitations ........................................................................................................................ 87
7.4 Future research ................................................................................................................ 88
7.5 Final conclusions .............................................................................................................. 90
REFERENCES….. ................................................................................................................. 92
APPENDICES ........................................................................................................................ 103
APPENDIX 1: ETHICS APPROVAL ................................................................................. 104
APPENDIX 2: SEARCH HISTORY .................................................................................... 107
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APPENDIX 3: CONTINUOUS QUALITY IMPROVEMENT STUDY SUPPLEMENT 113
3.1 Consent form for staff participants .................................................................................... 113
3.2 Information sheet for staff participants .............................................................................. 115
3.3 Physiotherapy clinical audit tool ........................................................................................ 117
3.4 Physiotherapy clinical audit tool protocol ......................................................................... 131
3.5 Physiotherapy systems assessment tool ............................................................................. 194
3.6 Physiotherapy goal setting tool .......................................................................................... 218
3.7 Development of tool content .............................................................................................. 219
3.8 Results of clinical audit 2013 ............................................................................................. 227
3.9 Results of the systems assessment tool 2013 ..................................................................... 243
3.10 Comparison of clinical audit results between 2013/2014. ............................................... 257
3.11 Comparison of systems assessment tool results between 2013 /2014 ............................. 333
APPENDIX 4: QUALITATIVE STUDY SUPPLEMENT ................................................ 352
4.1 Consent form for children/youth and carers……………….. ............................................. 353
4.2 Information sheet for children/youth ................................................................................. 354
4.3 Information sheet for carers ............................................................................................... 356
4.4 Child/youth interview guide............................................................................................... 358
4.5 Carer interview guide ........................................................................................................ 360
4.6 Emerging codes from interviews ....................................................................................... 363
4.7 Elaborated quotes from interviews .................................................................................... 367
4.8 Theme diagram ................................................................................................................. 378
4.9 Elaboration on methodology .............................................................................................. 379
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LIST OF FIGURES
Figure 4.1 (Figure 1 in first journal article) The continuous quality improvement process .... 27
Figure 4.2 (Figure 2 in first journal article) Systems assessment tool results.......................... 34
Figure 4.3 (Figure 3 in first journal article) Recommendations to enhance the
implementation and potential use of the adapted continuous quality improvement tools ....... 37
Figure 5.1 (Figure 1 in second journal article) Box 1 Sample interview guide and prompt
questions for carers................................................................................................................... 49
Figure 5.2 (Figure 2 in second journal article) Box 2 Sample interview guide and prompt
questions for children/youth..................................................................................................... 50
Figure 5.3 (Figure 3 in second journal article) Box 3 Participants .......................................... 52
Figure 5.4 (Figure 4 in second journal article) Box 4 Recommendations for community-
based physiotherapy service providers .................................................................................... 59
Figure 6.1 (Figure 1 in third journal article) The CQI process ................................................ 72
Figure 6.2 (Figure 2 in third journal article) Systems assessment tool results: changes in staff
ratings of their health service ................................................................................................... 74
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LIST OF TABLES
Table 4.1 (Table 1 in first journal article) Physiotherapy clinical audit tools, the
One21seventy tools they were based on, and a description of the tool and modifications
made ........................................................................................................................................ 28
Table 4.2 (Table 2 in first journal article) Characteristics of physiotherapy service
Indigenous client population.................................................................................................... 32
Table 4.3 (Table 3 in first journal article) Clinical audit results reflecting changes in service
documentation ........................................................................................................................ 33
Table 6.1 (Table 1 in third journal article) Physiotherapy audit tools and the original
One21seventy audit tools.......................................................................................................... 71
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ABBREVIATIONS
AHT Allied health therapy
ABCD Audit and Best Practice for Chronic Disease
APA Australian Physiotherapy Association
COPM Canadian Occupational Performance Measure
CQI Continuous Quality Improvement
CDU Charles Darwin University
DoH Northern Territory Government Department of Health
GAS Goal Attainment Scaling
ICF International Classification of Functioning, Disability and Health
MeSH National Health Service Medical Subject Headings
NSW New South Wales
NT Northern Territory
PT Physiotherapy
SAT Systems Assessment Tool
WCPT World Conference for Physical Therapy
WHO World Health Organization
CHAPTER 1:
INTRODUCTION
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CHAPTER 1: INTRODUCTION
1.1 Background
This thesis arose out of my experience as a physiotherapist who has been working with
Indigenous clients in a community-based paediatric physiotherapy service for over ten years
in the Northern Territory (NT). As a physiotherapist at the service in question I really
wanted to know about what clients of the service needed, received, experienced and valued.
Whilst this interest can be seen as a form of prurient curiosity, its impetus was to determine
how to improve the service and to evaluate my personal practices as well as those of my
department.
It was imperative to give Indigenous children and their carers a voice in this research given
the lack of any Indigenous consumer representation in peer-reviewed and grey paediatric
disability literature at the time this study was initiated.
Once the first question “What are the experiences of Indigenous children with a physical
disability and their carers with the physiotherapy services?” emerged, a cascade of other
questions followed:
o What sorts of diagnoses and conditions do the service users have?
o How is the service used by Indigenous children with physical disability?
o How is the service accessed? Who refers these clients?
o How easy is it to access the service?
o What are the needs of Indigenous children with physical disability?
o Does the service meet their needs?
o Does the service provide a standard of care consistent with available best practice
guidelines and actual practices in mainstream Australian physiotherapy?
o Can the service be improved?
o Do the clients’ experiences reflect the recorded standard of care?
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o Do the clients’ values reflect the best practice guidelines?
Whilst this is a very small study, I hope the findings can assist physiotherapists to
“practically reflect” on their clients’ needs, examine their own practices, involve their
clients, evaluate service efforts and make improvements.
1.2 Thesis overview
The first chapter discusses the impact of disability, the relevance of the study and the
literature available on the topic of physiotherapy practice for Indigenous children with
physical disability.
The second chapter contains a review of the literature available at the initiation and
development of this study.
The third chapter contains the details on the study background and design.
The fourth chapter contains an article presenting the findings of a continuous quality
improvement program conducted at one community-based paediatric physiotherapy service
2013 to 2014. The article is to be submitted for publication.
The fifth chapter contains an article presenting the findings of a qualitative study involving
interviews with previous or current clients of the same service and their carers. The article
was accepted for publication by the Journal of Physiotherapy in September 2015.
The sixth chapter contains an article reflecting on the similarities and differences between
the findings of the aforementioned studies. The article was accepted for publication by the
Australian Journal of Rural Health in September 2015.
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The final chapter concludes the thesis with a summary of the research findings, strengths and
limitations of the study. Directions for future research and implications of the findings on
policy and practice are discussed.
Appendices have been included elaborating on the methods and data associated with each
study.
1.3 Disability
Disability is a complex phenomenon that involves the interplay of psychological, biological,
social and environmental factors. The multifaceted nature of disability has attracted multiple
interpretations from broad ranging perspectives. Disability can be defined as “any
limitation, restriction or impairment which restricts everyday activities and has lasted or is
likely to last for at least 6 months.”1 However, its diverse nature can best be described as “an
umbrella term for impairments, activity limitations and participation restrictions.”2 In this
definition, the biological, psychological and social components of disability are recognised.
Impairment is considered a problem of body function or structure, activity limitation as
difficulty encountered by an individual in executing a task or action and participation
restriction as a problem experienced when involved in life experiences.2
Over fifteen percent of the global population lives with some form of disability and the
figure is growing.2 Although the number of those affected appears small when compared
with other health issues such as cardiovascular disease,3 the degree of impact on those
experiencing disability is significant.4, 5 People with a disability and their families experience
greater economic, social, educational and health disadvantages than those without disability
and are considered to be amongst the most vulnerable and marginalized people in the
world.4, 6
4
Within Australia, people with disabilities are more likely than Australians without
disabilities to have poor physical and mental health and experience increased health risk
factors.7 Australians with disabilities participate less in the labour market, require the unpaid
assistance of 2.6 million carers and form 20 percent of public housing residents.7
Indigenous Australians with disability have been considered to have a “double
disadvantage”8, 9 as they also experience greater disadvantage than non-Indigenous
Australians in the social determinants of health such as education, housing, employment,
income and service access.7
Indigenous Australians experience a higher proportion of disability throughout their
lifespan: twice as many urban Indigenous people require significant assistance within basic
essential areas such as self-care, mobility and communication compared with the rest of the
Australian population.7, 10, 11 Indigenous people are more likely to be caring for a family
member with a disability or long-term chronic condition than non-Indigenous Australians
and these Indigenous carers are younger than the national average by 12 years.11
Furthermore, Indigenous Australians with a disability experience more disadvantage than
their Indigenous counterparts; whilst Indigenous households are documented as having a
lower income than non-Indigenous households, those Indigenous households containing a
family member with a severe disability have an even lower income.7, 11
One could argue that Indigenous Australian children with a disability experience a “triple
disadvantage” due to the additional disadvantage of experiencing disability in the critical
years of development. Childhood is recognised as a period that profoundly influences
lifetime social, physical, intellectual and psychological development.12, 13 The presence of a
disability may impede children’s ability to partake in activities that assist in all areas of
development during a crucial period of brain maturation. The impact of this disadvantage
combined with less social and educational support may have a greater impact than incurring
5
a disability in later years or within a less marginalised population. Indigenous children aged
0-14 years are 1.3 times more likely to require extra assistance in self-care needs than non-
Indigenous Australians of the same age10 and have greater exposure to various
developmental health risks early in life.14
Education, often regarded as the primary occupation of childhood in allied health literature,15
is considered paramount in preparing the child for later community participation and
employment.15, 16 Indigenous student preparedness and attendance lags behind non-
Indigenous students nationally and within the NT.7, 11. 16 Indigenous Australians with a
disability experience further difficulties in acquiring education: only 16 percent complete
year 12 compared to 28 percent of Indigenous children without a disability.11 One third of
the students wanting to further their schooling were unable to continue due to lack of carer
support.11 Successful employment for Indigenous people with a disability aged 15-64 lags
significantly behind their Indigenous counterparts without a disability.11
Despite experiencing greater prevalence of disability and relative disadvantage in areas such
as education, income, employment, housing and health outcomes, Indigenous people with a
disability are less inclined than non-Indigenous people to access health and disability
support services.17 Although extensive and timely intervention is recommended,13 access
within urban and remote environments for Indigenous children is limited.5, 18
1.4 The role of physiotherapy
Physical disability, defined as an impairment that restricts an individual’s ability to perform
mobility, self-care and communication activities, affects 80 percent of Indigenous
Australians with a disability.19, 20
Physiotherapists provide a service integral to children with physical disability and gross
motor delay and may have a broad ranging impact on their developmental skills.21-24 Trained
within the umbrella of medical sciences, they assist people of all ages with movement
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disorders using evidence-based practice in areas such as exercise, education, adapted
equipment and advocacy.25, 26 Physiotherapists working with children with movement
disorders teach movement skills, provide exercises and develop activities to maximize their
physical function and enhance participation in their home and community.27 Physiotherapists
also provide health promotion, health education, and guidance to help families understand
their child’s physical problems and make informed decisions regarding the child’s medical
and surgical management.28
1.5 Local context
Currently there are multiple and inconsistent physiotherapy services throughout the country
available to children with disabilities. Most States and Territories have at least one
specialised physiotherapy (PT) service for disabled children. No Indigenous health care
organisations specialising in treating people with childhood disabilities such as cerebral
palsy could be found through an online search of Google, the website Australian
HealthInfonet and all State and Territory government websites.
The NT presents many unique features when compared with other Australian states and
territories. The Territory has a young, culturally diverse and relatively small population of
244,300.29 Twenty two percent are less than 15 years old. Twenty-seven percent of the
population is Indigenous and 25 percent of the population was born overseas. Only 1 percent
of the Australian population lives in the Northern Territory and there are only 0.2 persons
per square kilometer compared to 3.1 persons per square kilometer for all of Australia and
170 persons per square kilometer for the Australian Capital Territory.29
Most Territorians live in regional centres such as Darwin, Katherine and Alice Springs.
Darwin, the NT capital, has over half of the Territory population.30 Within the capital city of
Darwin, children with a physical disability in the community are looked after by generalised
services directed to the needs of all children. There are three main service providers. The
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community-based early intervention disability service has a physiotherapist who may see
children under age 6 years with a severe or profound disability. The public hospital
physiotherapy department looks after infants and toddlers with clubfoot. Otherwise, children
aged 0-18 years access the community-based paediatric allied health team within the Aged
and Disability division of the NT Government Department of Health (DoH). As there are no
physiotherapists hired within the education department, this team provides physiotherapy
services to students and provides support to the schools that they attend. In remote
communities within the northern part of the Northern Territory referred to as the Top End
region, the majority of the population is Indigenous and access to physiotherapy is further
limited due to lack of access and staffing.18, 31 All residents access the same therapy services
in a transdisciplinary model regardless of age and need. Children with physical needs who
reside in the Top End may have consultative input from therapists in the Remote Intensive
Paediatric Team. Children living in remote areas within the southern half of the Northern
Territory receive a transdisciplinary allied health service32 without the consultative input of a
remote intensive paediatric team.
This project focused solely on one community paediatric team serving the Darwin urban
region. The team was comprised of speech pathology, occupational therapy and
physiotherapy positions. Of the 22 positions, physiotherapists occupy 3 full time positions
and 2 part time positions. The rest of the team consisted of 7 fulltime positions for
occupational therapists, 8 fulltime positions for speech pathologists, 1 administrative officer
and 1 therapy aide. There was one manager with a speech pathology background and two
part time team leader positions occupied by a physiotherapist and speech pathologist who
each worked as therapists within the team in their remaining time. Staff members from all
disciplines presented a wide range of ages, qualifications and experience. There was a strong
collaborative work ethic throughout the team. Therapists shared training across disciplines
and often worked together within and across disciplines when visiting mutual clients
together and addressing that client’s concerns. Whilst there were Indigenous Liaison
8
Officers and Aboriginal Health Workers within the DoH and a few Indigenous Education
Officers within the Department of Education, there were no Indigenous identified positions
or staff members within the team although recently the team has had Indigenous student
cadet placements.
Within the DoH there has been a strong push towards evidence-based practice33 and DoH
has a policy on cultural safety.34 However, at the time of the study there were no systems in
place to evaluate the quality of practice, to ensure that staff knowledge was current or to
oversee the development of cultural competence. Over the years the lack of ability to engage
Indigenous clients within this team has prompted the development of a community
engagement committee and a variety of mostly unsustained efforts to link in with other
community resources such as Save the Children playgroups and the local Aboriginal
Community Controlled Health Centre.
1.6 Policy context
Over the past 10 years the Australian government has increased attention to policy
concerning Indigenous disadvantage and the disadvantage from disability.
1.6.1 The Closing the Gap Initiative
In 2008 the Australian Government, together with the states and territories, set specific
targets to address Indigenous disadvantage and outlined a framework of objectives aimed at
ensuring that services were accessible and met the needs of Indigenous Australians.35 A
commitment to target services on a regional basis in remote Australia, foster early childhood
development programs and support longer-term development in the vulnerable NT
communities was clearly stated.35
1.6.2 The National Disability Insurance Scheme
9
In 2013 the Australian Government passed the National Disability Insurance Scheme Act in
an effort to address the health and social inequities experienced by disabled Australians.36
The bill enabled funding to be allocated to Australians with disability on the basis of need
allowing them to choose the types of services and agencies that they require.37 Once
qualified for the program, individuals are required to meet with individual planners who
help identify goals, aspirations and the types of support services necessary to meet identified
goals. The service has been described as a “market-driven approach”38 as its users select
amongst the available providers offering each of these services in a consumer-oriented
model.
Indigenous Australians are more likely to have a disability yet little is known about the total
number of Indigenous people with a disability and the type and services required for their
needs as a national disability scheme is put into place.5, 17, 38-41 There is suggestion that the
present direction of a market driven approach may not be suitable for all Indigenous
Australians due to the proliferation of other issues causing disadvantage, limited availability
of services and geographical location.38 ,42, 43
Indigenous children with physical disability can experience a triple disadvantage. There are
large numbers of Indigenous people with a physical disability. Physiotherapists working
with children with gross motor delay or physical disabilities can have a significant role in the
children’s development. There is a growing body of disability literature and attention
directed towards Indigenous disadvantage as well as disability by the Federal Government.
Despite this epidemiological, socio-political and research climate, little has been published
on the physiotherapy service needs of Indigenous Australian children with gross motor delay
or physical disability or their carers.
CHAPTER 2:
LITERATURE REVIEW
10
CHAPTER 2: LITERATURE REVIEW
The literature review aimed to examine the best evidence available from published and grey
literature on physiotherapy interventions and practices for Indigenous children with physical
disability and gross motor delay. A review was conducted using standardised methods to
identify and appraise research. (Please see appendix for more detailed information on the
literature review and search strategy.)
2.1 Literature review search
An initial literature search was conducted between February 2012 and September 2013 and
revised in June 2015. Articles from peer reviewed journals were sought through online
databases including Medline, Cochrane Library, PubMed, Cumulative Index to Nursing and
Allied Health Literature (CINAHL), Academic Search Premier (EBSCO host), Education
Resource Information Centre (EBSCO host), PsycInfo (EBSCO host), Psych and Behavioral
Sciences Collection (EBSCO host), Soc INDEX (EBSCO host), Rural and Remote Health
Database (Informit), Science Direct Health and Society (Informit), Health Collection
(Informit), Humanities and Social Sciences Collection (Informit), Indigenous Australia –
ATSIC Library (Informit), Web of Science, Wiley Online Library, PEDro and OT Seeker.
The initial search examined all peer-reviewed publications pertaining to 1) Indigenous
people receiving physiotherapy and 2) physiotherapy services provided to Indigenous
people. The search was expanded outside of physiotherapy to include other disciplines with
articles related to 1) Indigenous children with a disability or physical impairment 2)
Indigenous people with a disability (receiving any service), and 3) disability services for
Indigenous people. Following the initial literature searches additional searches relating to 1)
continuous quality improvement for physiotherapy 2) continuous quality improvement for
Indigenous Australian health care 3) best practice physiotherapy were conducted. All
11
relevant information was included. Articles were excluded if they were written in a language
other than English. No articles written in an Indigenous language could be found.
Search terms were initially obtained with the assistance of the National Health Service
Medical Subject Headings (MeSH) keywords. They included ‘Physiotherapy
‘(physiotherapy, physical therapy), ‘Indigenous’ (Indigenous, Aborigin*, Oceanic Ancestry
Group, First Nations), ‘disability’ (physical disability, impairment, Cerebral Palsy, Muscular
Dystrophy) and children (pediatric, paediatric, babies, infants, youth). Other terms were
acquired through keywords used in articles found. (Please see appendix for more detailed
information on the search strategy.)
Searches of terms such as pediatric, children, youth, Indigenous, Aborigin*, Oceanic
Ancestry Group, disability and cerebral palsy were also conducted on the websites of
Australian Bureau of Statistics,44 Australian Institute of Health and Welfare,45 Australian
Indigenous HealthInfoNet,46 World Health Organization (WHO),47 Menzies School of
Health Research,48 One21Seventy,49 CanChild,50 Cerebral Palsy Alliance,51 Australian
Physiotherapy Association (APA),52 Council of Australian Governments53 and Australian
Government Department of Families, Housing, Community Services and Aboriginal
Affairs.54
The grey literature was further searched for any relevant literature though the NT
government website, the Charles Darwin University (CDU) library, Trove and CDU Theses
databases, the NT Health Library and other government and non-government websites
identified through bibliographic references in Australian Indigenous HealthInfoNet and
pertinent articles. Additional literature was sourced through the NT Government Aged and
Disability Darwin Urban services, Cerebral Palsy Alliance, conference papers and personal
correspondence. References were also sourced through tracking citations in identified
literature and using the ‘related article’ function in databases such as PubMed.
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2.2 Physiotherapy literature
Three relevant articles were found in the peer-reviewed physiotherapy literature pertaining
to physiotherapy practice and Australian Indigenous health. All articles were written by
physiotherapists and in the form of editorials highlighting the lack of physiotherapy research
in Indigenous health. Cotter and Maher55 in “Why the silence on Indigenous health”
discussed the lack of physiotherapy research and evidence base to inform clinical practice,
advocacy and delivery of physiotherapy services to Indigenous clients. Gates56 highlighted
the lack of Indigenous involvement in physiotherapy research and lack of outcomes based
research. Alford et al.57 noted the absence of best practice communication guidelines to
inform physiotherapists working with Indigenous clientele. The first article to appear in a
search that included all existing peer-reviewed literature in a search spanning over 30 years,
was presented by non-Indigenous clinicians, the second article was a response by an
Indigenous physiotherapist to the first article. The last article, published 8 years after the
first, highlighted and reflected the lack of movement on this issue.
Much of the available grey literature was similarly lacking in research concerning
physiotherapy interventions, practice or service delivery to Indigenous consumers or the
perspectives of Indigenous children.
In 1999 a project examining the framework for quality allied health services provision to
aged and disability populations living in remote Aboriginal communities was conducted and
included input from service providers and consumers. The project was completed by a
physiotherapist working in the region and included in depth interviews with 31 allied health
therapists and 10 medical practitioners serving the Darwin remote zones, 3 nurses serving
remote areas, a purposive sample of 6 Aboriginal Health Workers working in remote
communities and a meeting with a remote Indigenous community familiar with his
services.18 Key messages of the report emphasised that the needs of remote Aboriginal
13
people with disabilities including housing, transport, community support and family issues
needed to be addressed. It identified multiple barriers to aged and disability care service
delivery in remote Aboriginal communities including socio-economic, political, cultural,
planning and coordination issues. In addition the report highlighted barriers to remote allied
health therapy (AHT) service delivery such as inadequate personnel levels, support,
preparation for remote work and collaboration with other remote services and communities.
Although this study included the perspective of some service providers and a sampling of
service recipients and carers, no representation from the perspective of Indigenous children
was provided and the study only involved consumers from one remote community.
In 2005 the APA examined the use of physiotherapy services by Indigenous people living in
rural and remote regions by surveying physiotherapists in three regional communities across
Australia.58 Another APA study (unknown date) conducted through the APA Indigenous
Health Subcommittee surveyed Darwin-based physiotherapists by telephone interview to
acquire their perceptions of the perceived relevance and effectiveness of physiotherapy to
the Indigenous population.59 Both papers highlighted issues with underuse of physiotherapy
services by Indigenous consumers and identified barriers such as limited cultural relevance
and understanding, lack of awareness of services, lack of access due to factors such as
transport issues and limited physiotherapy staffing or services. Although the studies
contributed to an understanding of utilisation issues, they only represented the health
providers’ perspectives.
2.3 Disability literature
Disability literature involving Indigenous people throughout the world receiving
physiotherapy was also limited. Whilst there was a wide ranging and expanding international
field of literature exploring the quality of life, effectiveness of intervention, service delivery
and perspectives of those with or caring for those with disabilities such as cerebral palsy,
few involved an Indigenous population. In a systematic review of Indigenous healthcare
14
literature, Alford found scarce evidence of use of the International classification of
functioning, disability and health framework (ICF), a model that enables Indigenous
participation.60 Significantly, researchers who conducted a comprehensive audit of
Australian disability literature described the neglect of research relevant to the particular
profile, needs and experiences of Indigenous people as “a major oversight which needs to be
addressed”.41(p8)
Fewer articles still could be found providing an Indigenous perspective. Bostock33 discussed
his experience as an Indigenous Australian with an amputated limb and coined the
expression “doubly disadvantaged.” In Telling It Like it Is, a forum of Indigenous New
South Wales (NSW) residents shared their experience.61 Both of these publications reflected
the opinions of adults living in NSW. Di Giacomo et al.17 interviewed carers of Indigenous
children with a disability although this did not specifically relate to physical disabilities or
physiotherapy and was also based in NSW.
The perspectives of Indigenous children were also missing in the literature. In an extensive
review of childhood disability research, Di Giacomo et al. found few substantial peer-
reviewed articles on Indigenous childhood and disability with the exception of otitis media
research.5, 17 Most studies were focused on rural and remote regions despite 53% of the
Indigenous population living in urban settings and there was little representation of the
voices of Indigenous families, carers and children.17, 40
When expanding the search to include the perspectives of other Indigenous populations
globally a limited number of articles could be found. The articles presented a scattered
collection of subjects. Adams et al.62 conducted semi-structured interviews with mothers of
children with CP in Bangladesh and found them to be more confident with feeding
techniques after undergoing a mealtime assistance program; Pengra63 explored the impact of
culture and identity on quality of life of Lakota with developmental disabilities; and
15
Ranges64 explored quality of life of culturally diverse families with children with disabilities
in Hawai’i through application of a family quality of life scale. Begay et al.65 found that
Navajo families needed to make accommodations to support their children with disability
and understand the disabilities in a way that made sense in the context of their culture. None
of the articles included the perspectives of children, physiotherapists or children and families
receiving physiotherapy.
2.4 Themes in the literature:
2.4.1 Service utilisation barriers
Service provider and recipient alike have highlighted the lack of physiotherapy service
availability. In the Australian Institute of Health and Welfare report Allied Health
Workforces 2012, the NT was reported to have the lowest physiotherapy population of all
States and Territories with only 24.5 physiotherapists per 100,000 residents and less than a
third the ratio of NSW despite its geographical size.31 Amery,59 in a report for the APA
Indigenous Health Subcommittee, documents this issue with results from her survey of
physiotherapists located in Darwin and rural areas of the Northern Territory. A separate
report by the APA examining the utilisation of physiotherapy services in 3 separate regional
and remote areas across Australia came to a similar conclusion.58 Literature from an
Indigenous perspective is scarce but corroborates this issue.18, 38
Despite the paucity of physiotherapy research there is broad agreement from other
professional areas regarding the barriers to health service utilisation by the Indigenous
population with a wide range of issues identified. Some of these issues are briefly described
below.
Researchers and service providers alike identified a lack in number and appropriateness of
services to address the high level of disadvantage experienced by Indigenous people with a
16
disability.66, 67 Consumers reported an insufficient supply of programs, extensive waitlists,
lack of medical personnel and lack of health services.8, 9, 17, 61
Issues with access included: restricted access to transport32, 66 large geographical distances to
traverse to attend service facilities and logistical difficulties11, 68, 69 and inability to take time
off work or negotiate other competing family demands.69 Service issues included a lack of
comprehendible information about the services,9, 17, 61 inadequate referral and service
transparency,17, 61, 70 affordability69 and poor coordination between services.17, 61, 69
Cultural and language barriers have contributed to difficulties with communication. Barriers
experienced by Indigenous consumers facing non-Indigenous policy, service delivery and
research have also been attributed to differences between Indigenous and non-Indigenous
perceptions of disability and health. Ariotti,71 Reid,72 Maher,73 Senior,40 Alford,60 and Di
Giacomo17 discuss specific differences in cultural perspective in relation to health practices
and recognition of disability. Byers et al.74 and Kruske et al.75 discuss differences in
Indigenous values impacting on child rearing. Cass et al.76 and Lowell et al.77, 78 as well as
Anderson et al.79 discuss the degree of miscommunication that occurs at multiple levels of
health service delivery and its devastating impact. Misunderstandings due to the lack of
services provided in the primary language of those using the service has been highlighted in
many sources.66, 77, 78, 80 Trudgeon,80 and Lowell et al.77, 78 discuss linguistic differences and
miscommunication arising from very different languages.
Researchers and Indigenous consumers alike highlighted a mistrust of authority. The
consistently destructive or negative experiences Indigenous people have faced as a result of
contact with government departments and non-Indigenous services has been well-
documented9, 66, 67, 81 and is reflected in the few publications involving Indigenous
perspectives.17, 61, 77, 79
17
2.4.2 Recommendations
Recommendations have included: increasing Indigenous community health workers,66, 67
integrating services into the community,66 collaborating with community members,78, 82
improving communication techniques,79 using conceptual frameworks in disability policy
and research that recognize the negative effects of colonisation83 or give greater voice to
Indigenous people,60 increasing the number of physiotherapists,67 developing cultural
competency amongst non-Indigenous staff,66, 67 modifying therapy and therapy settings,67, 68,
84 providing client-centred practice85 and addressing logistical issues in therapy delivery.9, 59,
66, 84, 86 Yet, few publications could be found detailing the implementation or evaluation of
these suggestions or actually asking those who received the services, how they felt and what
they wanted.
CHAPTER 3:
STUDY BACKGROUND AND DESIGN
18
CHAPTER 3: BACKGROUND OF STUDY DESIGN
The study design was informed by the popularity of continuous quality improvement
approaches in existing Indigenous health service initiatives and the lack of Indigenous client
perspective on physiotherapy services reflected in the literature review.
3.1 Mixed methods research in physiotherapy
There has been increasing recognition of the value of combining quantitative and qualitative
approaches in physiotherapy research.87, 88 Whilst the quantitative data can offer outcome-
based results; qualitative information helps identify whether the intervention is valued and
why, insights into the requirements of implementing an intervention and how it impacts on
clients and their concerns.89 Good evidence-based physiotherapy is thought to “...integrate
the evidence with clinical expertise and with the patients’ unique biologies, values and
circumstances… evaluate the effectiveness and efficiency … and seek ways to improve
them both for next time.”90(p9)
3.2 Audit and Best Practice for Chronic Disease
Continuous quality improvement (CQI) within the health care can be defined as “a
structured organisational process for involving personnel in planning and executing a
continuous flow of improvements to provide quality health care that meets or exceeds
expectations.” 91 This approach has gained popularity in health care delivery internationally92
as well as nationally within Indigenous primary health services.93 The Audit and Best
Practice for Chronic Disease (ABCD)93 is a CQI approach that has been demonstrated to
improve service delivery within Indigenous health services in the areas of diabetes,94
rheumatic heart disease,95 preventive health services,96 primary mental health care,97
maternal health care,98 health promotion99 and child health care.97, 100 The ABCD approach
has further developed into One21seventy, the National Centre for Quality Improvement in
Indigenous Primary Health Care and its application has extended into national, State and
19
Territory policy and programs involved with Indigenous primary health care.101
The ABCD approach uses a cyclical process with a participatory action research design that
reflects a collaborative and flexible approach to health care in line with Indigenous values
and ethics. The cycle involves an audit of clinical records to examine quality of care in
relation to best practice guidelines and a structured assessment of key components of the
health service system through the use of an established systems assessment tool (SAT). This
is followed by a feedback session to staff and a staff workshop to identify and prioritise
goals and develop strategies to achieve the goals. A year later the clinical audit is repeated
and the process continues with goals and priorities reviewed and developed.102 Although the
ABCD approach has been used successfully in areas of maternal and child health care,98
chronic disease97 and health promotion,99 it has not been applied to allied health service
delivery. In publications available, it is used as a tool to investigate health service delivery
quality improvement and uptake and not as a research method in itself to explore a specific
client group as its ultimate aim.
3.3 Indigenous client perspectives
Primary health care concerns both the individual and the population.103 The WHO has
devoted years to refining an International Classification of Functioning, Disability and
Health which allows one to view the individual’s personal factors as well as the greater
world in which they operate. These aspects are addressed within a framework that includes
personal and environmental domains as well as body function, activities and participation.104
Whilst the CQI approach allows the participation of the health care provider, there is no
component enabling participation from the Indigenous consumer. The lack of representation
of Indigenous perspective on physiotherapy services in the literature is also clearly notable.
While there is broad agreement on some barriers and facilitators to services from other areas,
these areas pertain to other clinical specialties, health services and geographical regions such
20
as remote NT communities and urban New South Wales. Northern Australian regional areas
are unique in their diversity and remoteness from the rest of Australia and there is agreement
that Indigenous populations are heterogeneous.105 Concepts that might suit one community
might not suit another. Subsequently, seeking the perspective of the Indigenous consumers
using the local service was paramount in this study.
3. 4 Research design
The mixed methods research design used in this study involves both CQI and qualitative
components. The ABCD CQI approach is applied to examine: how a Top End paediatric
community-based service provides services to its Indigenous clients, what services are most
used, whether the quality of care is in line with best practice and whether services can be
improved through this process. I have complemented the CQI approach with semi-
structured, open-ended interviews with Indigenous children and young adults with physical
disability and their carers who currently or have previously accessed physiotherapy services
to provide insight into their experiences with the service and growing up with a physical
disability.
Ethics approval for this project was obtained by the Human Research Ethics Committee of
Northern Territory Department of Health and Menzies School of Health Research in March
2013.
3.5 Research aims
This research aims to fill some of the gaps in the literature concerning physiotherapy
practice with Indigenous children with physical disability such as what are some of the
Indigenous perspectives on their paediatic physiotherapy services and can the ABCD CQI
process be adapted for a community-based physiotherapy team and improve services for this
client population? Potential outcomes of the study include a better equipped workforce
within the participating service more familiar with the needs of Indigenous clients with a
21
physical disability or gross motor delay and their carers, sustainable changes in practice to
improve and evaluate services provided, improved avenues for Indigenous children and their
carers to access physiotherapy services and expertise, contribution to the small collection of
research involving physiotherapy services for Indigenous clients and a contribution to the
literature on experiences of urban Indigenous children with a physical disability and their
carers.
CHAPTER 4:
CONTINOUS QUALITY IMPROVEMENT STUDY
22
CHAPTER 4: JOURNAL ARTICLE
Improving community-based physiotherapy services to Indigenous children with gross
motor delay or physical disability: a continuous quality improvement approach
Caroline Greenstein MSPT1, Anne Lowell PhD2, David Piers Thomas PhD1
1Menzies School of Health Research; 2Research Centre for Health and Wellbeing, Charles
Darwin University, Darwin, Australia
Short Title: Improving Physiotherapy for Indigenous Children
23
Abstract
There is a paucity of information on physiotherapy practice for Indigenous children. This
paper reports on the application of a continuous quality improvement approach used at one
participating community-based physiotherapy service in a Northern Australian town
providing services to Indigenous children with gross motor delay and physical disability.
Tools and processes were adapted from the Audit and Best Practice for Chronic Disease
Partnership. The process involved: (1) a clinical audit (2) a workshop in which clinicians
were presented audit findings and identified strengths and weaknesses of their health care
system (3) a meeting in which clinicians developed goals and strategies for improvement
and (4) strategy implementation. Reassessment occurred through a second clinical audit and
workshop. Three target areas were identified by clinicians about improving documentation
of: (1) information for clients with complex needs (2) hip surveillance (3) goals and
outcomes. Documentation in 70% of patients or better were required for goals to be met.
The first two goals were met. Results of the process demonstrated measurable improvements
in documentation of health care and provided information on the service usage by
Indigenous clients. The process can be adapted to local contexts and applied by other allied
health disciplines.
24
What is known about the topic?
Little is known about the quality of paediatric physiotherapy practice in Indigenous health
care.
What does this paper add?
This study demonstrates that physiotherapy service improvements can be achieved using an
adapted Audit and Best Practice for Chronic Diseases continuous quality improvement
approach.
Keywords: Aboriginal, allied health, paediatric, physical therapy; Oceanic Ancestry Group
25
INTRODUCTION
People with disability are considered some of the most vulnerable and marginalised in the
world.1 Indigenous Australian children with physical disability can be considered
particularly vulnerable due to the disadvantage they face through social determinants of
Indigenous ill health as well as the limitations experienced through having a physical
disability during the important years of childhood development. Although Indigenous
children under 14 years are 30% more likely to require extra assistance than same-aged non-
Indigenous Australians, little has been published on Indigenous childhood disability.2
Physiotherapists provide a service essential to children with physical disability and gross
motor delay. They teach movement skills and activities to maximize a child’s physical
function and participation across all environments, and provide health education and
guidance to help families understand their children’s physical problems and make informed
decisions regarding their care.3 However, little has been published on the delivery of
physiotherapy services to young Indigenous Australians with physical disability.4
In other areas of Indigenous health care, there is a growing body of evidence to support the
utility of the Audit and Best Practice for Chronic Disease (ABCD) Partnership’s continuous
quality improvement (CQI) process to improve quality of care.5 Whilst the ABCD tools have
been successfully applied in areas such as diabetes and rheumatic heart disease,5 no tools for
community-based paediatric physiotherapy services have previously been available.
This article reports on application of a CQI process based on the ABCD model to gain
information and understanding of how Indigenous children with physical disability and
gross motor delay used the participating physiotherapy service and to determine if the
quality of physiotherapy services could be improved through this process.
METHODS
26
Setting
The study was conducted in a physiotherapy service situated within a community-based
paediatric government health service in Northern Australia. The allied health team, which
also employed occupational therapists and speech/language pathologists, serviced a
population of 140,4006 and an estimated Indigenous population of 15,555.7 The team
provided early intervention allied health services to children with either mild global delay or
delays in only a few developmental areas such as communication, gross and fine motor or
social development from birth to school attendance (approximately 0-6 years). The team
also supported children from school attendance to school leaving (approximately 6-18 years)
to support areas of development with a focus on those with disabilities.
Health services located within the region included a public hospital, several public
community care centers, a non-government early intervention service and an Aboriginal
Community Controlled Health Service (ACCHS). There were approximately 5.5 positions
allocated for physiotherapists who worked with children in the region, many of which went
unfilled although it is difficult to provide vacancy rates due to fluctuations in staffing. These
positions were spread across the local hospital, a small not-for-profit early intervention
service, and a community-based public allied health service. While there were several
private physiotherapy practices established in the area, none employed paediatric
physiotherapists.
Design
The CQI process was conducted between February 2013 and May 2014. The study involved
one complete cycle of assessment, feedback, action planning, strategy implementation and
reassessment (Figure 1). In the first stage, the lead researcher identified and audited all of the
allied health team’s electronic and paper physiotherapy records for the year leading to the
audit date. In the second stage, she presented the audit results and facilitated a workshop in
which staff used a systems assessment tool (SAT) to identify strengths and weaknesses of
27
their physiotherapy service and the team in which it was situated. One month later she
presented and discussed the SAT results with the participating physiotherapy team. In the
third stage, staff identified areas to be addressed and developed goals and strategies. Finally,
staff implemented these strategies. A second audit was completed a year later followed by a
presentation of audit results, completion of a second SAT workshop and presentation of
SAT results.
Figure 1. The continuous quality improvement process
Audit Tools
Three instruments were used based on audit tools provided by the One21seventy National
Centre for Quality Improvement in Indigenous Health Care, a not-for-profit center that
continues the work of the ABCD project and provides audit tools, online data services, and
data analysis for a fee.8 Table 1 outlines descriptions of these physiotherapy tools, the
original ABCD tools and the modifications made.(The tools are also available on request.)
Assessment
Clinical Audit
Feedback
Presentation of Results
SAT Workshop
Action Planning
Goal setting
Strategies
Implementation
Strategy Implementation
28
Table 1. Physiotherapy clinical audit tools, the One21seventy tools they were
based on, and a description of the tool and modifications made.
Physiotherapy
audit tools
One21seventy
audit tools
Description of tool Modifications made
Physiotherapy
clinical audit
Tool
Child health
clinical audit tool,
version 3.1
The clinical audit tool is a form
used to collect data about how the
health department or centre delivers
service and provides care. The tool
is completed mostly through
circling the correct number or item.
The tool is designed to reflect best
practice and allow the department to
compare its performance against
key performance indicators. The
One21seventy tools are regularly
updated by specialist working
groups.
The physiotherapy tool
uses the structure of
the child health clinical
audit tool, however, the
content involves
physiotherapy services.
It has the capacity to be
reviewed and updated.
Physiotherapy
clinical audit
tool protocol
Child health
clinical audit tool
protocol, version
3.1
The clinical audit tool protocol
provides a step-by-step guide to
completing the audit tool including
how to code the items, where to
locate information within the
system, and information from the
literature to support the tool’s
content. The protocol is designed to
be used with the audit tool form
simultaneously and regularly
updated by specialist working
groups.
The physiotherapy
protocol had the same
structure but different
content relevant to the
specific team and the
discipline. It has the
capacity to be reviewed
and updated.
Physiotherapy
systems
assessment
tool
Generic systems
assessment tool,
version 1.2
The Systems Assessment Tool
provides a structured process for
participants to assess a range of
elements of their health service
system that have been demonstrated
to be important.
The physiotherapy
assessment tool was
almost identical to the
generic tool.
Modifications included
the word physiotherapy
and prompt questions
related to
physiotherapy service.
Physiotherapy
goal setting
tool
Goal setting tool
version 1.1
The goal setting tool is designed to
assist participants to record
prioritised goals, an action plan to
address the goals, a timeline to
achieve goals and responsibility for
each strategy’s implementation.
No changes to the tool
with the exception of
the word
Physiotherapy added.
29
Two senior physiotherapists from interstate facilities specialising in childhood disabilities and a
representative of the Australasian Academy of Cerebral Palsy and Developmental Medicine
provided feedback on the clinical audit. Changes were made to incorporate the reviewers’
recommendations.
The clinical audit tool and protocol were then piloted by two physiotherapists who worked with
similar clientele either within the same team or in a different region within the same health
department. Further changes were made to include the therapists’ feedback.
Reliability of audit tools
Inter-rater and intra-rater reliability were tested. Inter-rater reliability for the audit tools ranged
from 0.80-0.95 with agreement between individual audit items ranging from 0.5-1.0. Intra-rater
reliability ranged from 0.80-0.94 with agreement for individual audit items ranging from 0-1.0
agreement. (One out of the 234 audit items had 0 agreement. This item tested whether
assessment results were discussed with clients and was not recorded in most of the audit forms
examined).
Assessment
The first round of the clinical audit began in February 2013. Client records were included if they
met the following criteria: documented identification as Aboriginal and/or Torres Strait Islander,
active status on the department’s clinical recording system within the past year, and involvement
or referral to a physiotherapist within the department for gross motor delay or physical
disability. Due to the small numbers identified, all clients who met the criteria were included.
The lead researcher audited the clients’ complete electronic and paper records held and accessed
by the allied health team using the Physiotherapy Clinical Audit Tool and Physiotherapy
30
Clinical Audit Tool Protocol together as specified in the ABCD protocol (One21seventy 2012).
The results for each audit item were then presented in a report format based on the
One21seventy Child Health Result Report 2010.8 Due to the small numbers involved, raw data
accompanied the percentages for each audit item. No statistical tests of significance were
computed as we had included the entire population of interest and there was only a small
number involved.
Feedback and SAT Workshop
The lead researcher conducted a half-day workshop in May 2013 in which all four part-time and
full-time team physiotherapists attended. The lead researcher summarised the audit results and
highlighted services that stood out as being either very well or poorly documented.
Participating physiotherapists then identified strengths and weaknesses of the physiotherapy
service as well as the allied health team in which it was situated using the SAT assessment. The
participants rated five components of the health service on a scale reflecting the level of
development while the lead researcher facilitated and audio-recorded the discussion. Audio
recordings were used to transcribe the participants’ discussion and clarify participants’ ratings.
Workshop results were then presented in a report format and discussed at the next monthly team
physiotherapy meeting in June 2013
Action Planning
The team developed goals and strategies based on the audit and workshop results that were then
documented on the Physiotherapy Goal Setting Template. Three priority areas were established
with the aim to: 1) improve and streamline documentation for clients with complex needs
including background information, diagnosis, other involved providers and equipment details; 2)
improve hip surveillance radiograph documentation for clients at risk of hip dislocation; and 3)
31
improve documentation of goals and outcomes. A target was set for at least 70 percent of the
files to be well- documented in these areas.
Implementation
Strategies addressed internal team documentation processes, links with other hospitals and
facilities and professional development. Implementation occurred in the 8-month period leading
up to the second round of the clinical audit.
Reassessment
The audit was repeated in February 2014 with a second presentation and SAT workshop in
April. Workshop results were then discussed during the physiotherapy team meeting in June
2014.
RESULTS
Characteristics of clients and referrers
In 2013, 35 clients met the study criteria and 32 in 2014. Eighteen client records were included
in both audits. Client composition was similar in age, Indigenous status, diagnosis, language
preference and referral source across both years (Table 2).
32
Table 2. Characteristics of physiotherapy service Indigenous client population
Audit results
The second clinical audit highlighted positive changes in the first two priority areas: improved
documentation of services for clients with complex needs and improved hip surveillance
documentation. However, no substantial improvements were made in documentation relating to
goal setting and outcomes (Table 3).
2013 2014
Eligible clients 35 32
Male gender 60% 63%
Most common diagnosis Cerebral palsy (31%) Cerebral palsy (34%)
Median age
(range)
5 years, 5 months
(11 months-18 years,3 months)
6 years
(6 months -15 years, 10 months)
Indigenous status: clients Aboriginal (91%)
Torres Strait Islander (3%)
Both (6%)
Aboriginal (84%)
Torres Strait Islander (6%)
Both (9%)
Indigenous status:
primary carers
Indigenous family (69%) Indigenous family (63%)
Preferred language English (49%)
Not Stated (43%)
Aboriginal English (3%)
Indigenous and English (3%)
English (78%)
Indigenous (13%)
Not Stated (3%)
Aboriginal English (3%)
Indigenous and English (3%)
Main referral source Educators (23%)
Physiotherapists (17%)
Nurses (17%)
Other allied health (11%)
Educators (31%)
Physiotherapists (6%)
Nurses (6%)
Other allied health (22%)
33
Table 3. Clinical audit results reflecting changes in service documentationa
aPercentage of recorded items followed by actual number documented over available records
Systems Assessment Tool results
The SAT reflected improvements in all five components of the participating health service
between 2013 and 2014 (Figure 2).
2013 2014
Documentation for clients with complex needs
Gross motor functional classification system
Manual ability classification system
Cerebral palsy type and typography
Epilepsy
Intellectual impairment
Communication impairment
Visual impairment
Hearing impairment
Surgical intervention
Medical interventions
Functional Mobility Scale
Wheeled mobility description
Wheeled mobility seating description
Wheeled mobility and seating funding source
Orthotic description
62%
58% (7/12)
0% (0/10)
91% (10/11)
58% (7/12)
42% (5/12)
83% (10/12)
83% (10/12)
75% (9/12)
42% (5/12)
92% (11/12)
27% (3/11)
89% (8/9)
33% (3/9)
89% (8/9)
70% (8/10)
92%
92% (11/12)
100% (11/11)
100% (12/12)
58% (7/12)
75% (9/12)
100% (12/12)
100% (12/12)
100% (12/12)
58% (7/12)
100% (12/12)
100% (10/10)
100% (9/9)
100% (9/9)
100% (9/9)
100% (12/12)
Hip surveillance
Date of hip x-ray in past year
Results of hip x-ray in past year
10%
20% (2/10)
0% (0/10)
89%
89% (8/9)
89% (8/9)
Goal setting and outcomes
Goals set
Outcomes recorded
34%
39% (12/31)
29% (4/14)
62%
29% (4/14)
71% (5/7)
34
Figure 2. Systems assessment tool results
The Physiotherapy Systems Assessment Tool results reflect the changes in staff ratings of their
health service between the first and second audits.
Targets
Improvements were recorded both directly and indirectly related to the goal setting process.
Retrieval of hip radiographic and medical information was achieved through gaining access to
the hospital database and obtaining training from local physiotherapists in hip radiographic
interpretation. Information regarding client medical histories, equipment and other involved
providers was located more easily through changes to documentation practices which involved
regularly updated summary sheets, reorganisation of client files and consistency of filing
placement.
The third target area (goal setting and outcomes) did not improve and was influenced by a
number of issues including: changes to service delivery preventing follow up to children who
4.7
1.2
2.1
2.6
4.35
6.45
2.5
6.5
7
7.7
0 2 4 6 8 10
Organizational influence andintegration
Links with the community, otherhealth services and other services
and resources
Self-management Support
Information Systems and DecisionSupport
Delivery System Design
Key: 0-2 reflects limited support; 3-5 basic support; 6-8 good support; 9-11 full support
Second Audit
First Audit
35
did not have physical disability and deemed to have only mild needs, lack of communication
with external providers such as schools to determine if goals were met, and resource limitations
such as staff turnover within the team.
DISCUSSION
This study was the first to apply the ABCD CQI process within the field of physiotherapy or
Indigenous childhood disability research. In discussing the findings, some of the study strengths
and limitations are highlighted as well as questions that arose from the findings.
Strengths
The clinical audit provided information about the service clientele, referral pathway,
documented needs of the clients, and services received. The workshop following the
presentation of audit results encouraged physiotherapy team participation and highlighted staff’s
unique insights into the data and challenges they faced in delivering the service. The SAT used
within the workshop enabled participants to reflect on cultural awareness, government records
systems and external relationships with other departments and service providers that influenced
service delivery. The goal setting tool and implementation enabled participants to target,
improve and evaluate the quality of physiotherapy services delivered to Indigenous children in a
structured way. The lead researcher, as a member of the team, may have stimulated greater
improvement due to her presence, availability and familiarity with the CQI tools and processes.
Limitations
The CQI process was very time and labor-intensive for one lead researcher working within a
small team greatly affected by staffing changes and may be difficult to maintain in departments
affected by similar staffing fluctuations. The clinical audit tool was designed to gain an
understanding of consumer characteristics as well as to investigate quality of care and was
36
subsequently longer and more complicated than many similar ABCD audit tools. Documentation
may not reflect what is actually done within interventions such that services provided within an
appointment are not recorded well as suggested by other CQI literature. Wise et al.9 have also
suggested including Indigenous service users in the CQI process. Elsewhere we have reported
on interviews with carers and clients and noted differences to our results in this audit.10, 11
The population was very small although of sufficient size to satisfy the ABCD model
requirement of 30 records. Subsequently, improvement was difficult to measure in
documentation that pertained to a smaller portion of clients, such as those using electric
wheelchairs. The records of 18 clients were audited in both years and while most audit items
pertained only to recordings of the previous 12 months, there were a small number of
overlapping audit items such as referral source and gender.
Improvements may have occurred for reasons unrelated to CQI efforts such as new team
administrative processes and additional resourcing within external services, such as those
services involved in lending equipment, which coincided with this study.
Importantly, bias introduced by a lead researcher working as a clinician in the participating
service potentially influenced the findings. Although efforts were made to reduce bias
throughout the process such as coding the client records when completing audit forms and
tables, the lead researcher was responsible for calculating and tabulating audit results,
highlighting strengths and weaknesses during the results presentation, documenting and
calculating SAT results, and facilitating the goal setting discussion.
The presence of the lead researcher within the team may also have influenced implementation of
CQI strategies. On an individual level, she may have been more careful about documentation
37
and practices. As part of a group, her presence and relationship to her coworkers may have
influenced their participation either through an ongoing awareness of CQI efforts or having
access to a person familiar with CQI documentation practices.
Similar results can be found in other CQI literature. Improvements in targeted clinical services,
health service systems, and communication with external services have been reported.5, 9
Similarly, barriers to success such as limited staff capacity, high staff turnover and lack of
mechanisms for engagement with external domains are also reported.5, 9 12 Recommendations for
potential use and implementation of the adapted tools are included in Figure 3.
Figure 3. Recommendations to enhance the implementation and potential use of the
adapted CQI tools.
Recommendations
Further develop tool with input of previous or current Indigenous
clients.
Use small part of the physiotherapy clinical audit tool and protocol to
target a specific service provided to reduce the amount of resources
required. For instance, if interested in improving assessments to clients
with cerebral palsy, they could complete the general information and
the relevant section of the audit.
Integrate CQI process into annual team planning and development
activities to reduce demands placed on physiotherapists during their
daily operations.
Develop stronger links with external specialist organisations that could
share their written clinical guidelines to be put into audit form. This
would strengthen the audit tool and enable local, rural therapists to
maintain, consistent documented practice with members of these
organisations.
Team management to ensure appropriate infrastructure is available to
support CQI activities by engaging either a senior clinician or external
service.
Development and implementation of policy that supports better
linkages with non-health care organisations such as Indigenous
organisations, schools and community groups.
38
Questions
These findings also provoked some questions. The small number of clients who did not identify
English as their preferred language and the lack of documentation regarding preferred language
in 2013 deserves attention particularly in light of the value placed on effective communication in
the physiotherapy, disability and Indigenous health literature.4, 13, 14 This lack of representation
may be truly reflective of the urban population or might indicate a lack of access or engagement
of those who do not speak English as a first language.
The absence of physiotherapy referrals from the only Indigenous controlled health service or
Indigenous officers within the health and education departments should also be explored given
the literature supporting Indigenous peoples’ engagement in health and disability care.4, 13, 14
The small number of Indigenous children accessing the physiotherapy service did not reflect the
large numbers suggested in the disability population statistics.15 Whether this inconsistency
reflects barriers to service access cited in other literature such as carers’ lack of awareness about
the service, inability to attend appointments due to transport or schedule issues, different family
priorities, or mistrust of government services requires further investigation.13, 14
In addition, there is the question of whether the clinical audit might best have been conducted by
someone externally. An external auditor may have reduced bias, had more time or focus to
determine essential service strengths and weaknesses, and enabled the lead researcher to direct
more efforts towards participatory interpretation of the data with the other physiotherapists.
However, this would have also reduce the opportunity for the lead researcher to intimately
explore the audited records.
39
Conclusion
This adapted ABCD CQI model offered a practical service improvement process with
measureable outcomes in the largely unaddressed area of physiotherapy practice in Indigenous
health care. Changes were made which resulted in improved clinical documentation, which is
useful in improving the care of clients with complex needs.
The ABCD process has been used successfully by other professions dealing with chronic
disease. It has potential to be used by other allied health professions developing their own
content within the clinical audit tool and protocol. The physiotherapy tools also have the ability
to be modified or adapted to local contexts and populations. This CQI process, however, is time
intensive for a small team affected by changes in staffing and other resources. Resource
allocation should be considered when adopting this process.
Conflicts of Interest
The lead researcher was a physiotherapist at the participating organisation. This relationship was
discussed within the article.
40
REFERENCES
1. World Health Organization. Ten facts on disability 2013 [updated September 2013;
cited 2015 14 April]. Webpage]. Available from:
http://www.who.int/features/factfiles/disability/en/.
2. DiGiacomo M, Davidson PM, Abbott P, Delaney P, Dharmendra T, McGrath S, et al.
Childhood disability in Aboriginal and Torres Strait Islander peoples: a literature review.
International Journal for Equity in Health [Internet]. 2013 [cited 2013 13 March]; 12(7).
Available from: http://www.equityhealthj.com/content/12/1/
3. Australian Physiotherapy Association. Paediatric group 2015 [cited 2013 12 August].
Available from:
http://www.physiotherapy.asn.au/APAWCM/The_APA/National_Groups/Paediatric/APAWCM
/The_APA/National_Groups/Paediatric.aspx?hkey=6a7afaa3-42ba-467f-86d1-258248b8cfaf.
4. Alford V, Remedios L, Ewen S, Webb G. Communication in Indigenous healthcare:
extending the discourse into the physiotherapy domain. Journal of Physiotherapy.
2014;60(2):63-5.
5. Schierhout G, Brands J, Bailie R. Audit and Best Practice for Chronic Disease
Extension Project 2005–2009: Final Report. Melbourne: The Lowitja Institute, 2010.
6. Australian Bureau of Statistics. Regional Population Growth, Australia 2013-2014 2015
[updated 31 March 2015; cited 2015 25 May]. Available from:
http://www.abs.gov.au/ausstats/[email protected]/mf/3218.0/.
7. Australian Bureau of Statistics. Aboriginal and Torres Strait Islander population
projections by Indigenous regions 2015 [cited 2015 25 May]. Available from:
http://stat.abs.gov.au//Index.aspx?QueryId=1114.
8. One21seventy. One21seventy National Centre for Quality Improvement in Indigenous
Primary Health Care 2015 [cited 2015 3 July]. Available from:
http://www.one21seventy.org.au/about-us/our-history.
9. Wise M, Angus S, Harris E, Parker S, T. National appraisal of continuous quality
improvement initiatives in Aboriginal and Torres Strait Islander primary health care Melbourne:
The Lowitja Institute, 2013.
10. Greenstein C, Lowell A, Thomas DP. Communication and context are important to
Indigenous children with physical disability and their carers at a community-based
physiotherapy service: a qualitative study. Journal of Physiotherapy. in press.
41
11. Greenstein C, Lowell A, Thomas DP. Improving physiotherapy services to Indigenous
children with physical disability: are client perspectives missed in the continuous quality
improvement approach? Australian Journal of Rural Health. in press.
12. Newham J, Schierhout G, Bailie R, Ward PR. ‘There’s only one enabler; come up, help
us’: staff perspectives of barriers and enablers to continuous quality improvement in Aboriginal
primary health-care settings in South Australia. Australian Journal of Primary Health. 2015:-.
13. Centre for Disability Research and Policy. Report of audit of disability research in
Australia Sydney: Faculty of Health Sciences, University of Sydney, 2014.
14. Productivity Commission. Disability care and support: draft report vol 1 & 2. Canberra:
Productivity Commission; 2011.
15. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander people
with disability: wellbeing, participation and support. In: Australian Institute of Health and
Welfare, editor. Canberra: Australian Institute of Health and Welfare,; 2011.
CHAPTER 5:
QUALITATIVE STUDY
42
CHAPTER 5: JOURNAL ARTICLE
Communication and context are important to Indigenous children with physical disability
and their carers at a community-based physiotherapy service: a qualitative study
Caroline Greensteina, Anne Lowellb, David Thomasa
aMenzies School of Health Research; bResearch Centre for Health and Wellbeing, Charles
Darwin University, Darwin, Australia
Short Title: Indigenous clients share their physiotherapy experiences
43
Abstract
Question: What are the experiences of Indigenous children with physical disability and their
carers, of their community-based physiotherapy service? What factors influence their
experiences of the physiotherapy service and how could the service be improved?
Design: A qualitative study using in-depth, semi-structured open-ended interviews consistent
with the researchers’ interpretivist perspectives and ethical principles of Indigenous health
research. Interviews were audio-recorded, transcribed and coded for themes with qualitative
research software using inductive analysis. The interviews were then checked for transcription
accuracy and the themes were confirmed with the participants.
Participants: Nine parents and foster carers of children with physical disability aged 0 to 21
years, five children and youth with physical disability aged 8 to 21 years.
Results: The data generated three themes, which informed practice recommendations: carers of
children with physical disability experience increased demands and complexity in their lives;
relationships involving caring, consistency and communication are important to consumers
using the physiotherapy service; and being Indigenous influences consumers’ experiences in
ways that may not be obvious to non-Indigenous service providers. The issue of communication
underpinned the participants’ experiences throughout these themes.
Conclusion: The research highlighted the importance of effective communication, developing
relationships, viewing the child wholistically and recognising the influence of being Indigenous
on clients’ healthcare needs and experiences. The results suggested that community-based
physiotherapists adopt a family/person-centred, context-specific approach when working with
44
Indigenous children with a physical disability and their carers.
What is already known on this topic:
Indigenous Australian children experience higher rates of disability than their non-Indigenous
peers. The needs and experiences of these children and their carers in accessing physiotherapy
services are not well understood.
What this study adds:
When accessing physiotherapy services, carers of Indigenous children with a disability value
relationships involving caring, consistency and communication. Being Indigenous influences
these consumers’ experiences in ways that may not be obvious to non-Indigenous service
providers.
Keywords: Qualitative research, Oceanic Ancestry Group, Physical Therapy (Specialty),
Disabled Persons, Child, Caregiver
45
INTRODUCTION
Indigenous Australians experience a higher rate of disability throughout their lifespan when
compared with their non-Indigenous counterparts.1 Although accurate statistics are difficult to
obtain,2 Indigenous Australians are twice as likely, and Indigenous children are 30% more
likely, to have a disability than non-Indigenous Australians of the same age, with the majority
having a physical disability.2
Although the World Health Organization describes people with disability as among the most
marginalised and vulnerable populations in the world,3 Indigenous Australians with a disability
are considered to be ‘doubly disadvantaged’ due to the additional disadvantage in socially
determined areas of health.4 Indigenous children with disability can be considered to have a
‘triple disadvantage’ due to the additional limitations they may experience during their critical
early years of development when they are most vulnerable.
Despite this added disadvantage, little has been published about the needs and experiences of
Indigenous children with a physical disability and their carers.5-7 No research reflecting the
perspectives of Indigenous children with a physical disability could be found in Australian
literature. This deficit was highlighted in a recent audit of disability research commissioned by
the National Disability Research and Development Agenda. This audit recommended dedicating
funding to ‘stimulating disability research that addresses the needs and experiences of
Aboriginal and Torres Strait Islander carers’7 and research that pertains to the ‘experiences of
people with disability as specialist service users’.7
Physiotherapy has a role to play in supporting children with disability by providing ‘treatment,
management and education to enhance the participation of children aged 0 to 18 years’.8
However, there is no published peer-reviewed physiotherapy literature, to date, exploring
46
practice for Indigenous Australians with physical disability. The few articles addressing
physiotherapy practice in Indigenous healthcare have been editorials and letters noting the
scarcity of attention to Indigenous health,9 outcomes,10 or communication guidelines11 in
physiotherapy research.
Therefore, the research questions for this study were:
1. What are the experiences of Indigenous children with physical disability and their
carers, of their community-based physiotherapy service?
2. What factors influence their experiences of the physiotherapy services and how could
the service be improved?
METHOD
Design
A qualitative research design using open-ended, semi-structured, in-depth interviews was chosen
to provide a means of exploring the experiences of children with a physical disability and their
carers, who have used a community-based physiotherapy service.
The design of the study was informed by the Indigenous values and ethics highlighted in the
National Health and Medical Research Council guidelines12 and reflects an interpretivist
theoretical position.13 Semi-structured, in-depth interviews were conducted to enable the
participants to delve deeper into topics that they considered to be important in a flexible and
iterative process. Interviews were guided by a set of questions based on a feedback tool designed
for Indigenous consumers with chronic health conditions.14 Participants were selected to reflect
a diversity of perspectives, and the research process recognised the power dynamics inherent
between the service provider/researcher and the participant/service user.15 We ensured that
participants knew their care would not be disadvantaged if they chose not to participate or
47
withdrew from the study and used a semi-structured interview in which the participant could
control the topics discussed and the depth in which they were discussed. We also met
participants after each interview was transcribed and analysed to discuss emerging themes and
offered to meet later to share the results of the study. This study was limited to a specific
community-based physiotherapy service due to the researchers’ beliefs that more impact could
be made on a service in which both researcher and participants were involved, reflecting the
principle of reciprocity.12
The study was part of a larger research project combining a continuous quality improvement
approach and client interviews to examine and improve physiotherapy service provision at the
participating facility where the principal researcher was a non-Indigenous physiotherapist.
Participants
Participants were recruited from a community-based physiotherapy service within a regional
town in northern Australia with a population of 140,40016 and an estimated Indigenous
population of 15,500.17 The physiotherapy service consisted of a maximum of four
physiotherapists situated in a larger paediatric team that included speech/language pathologists
and occupational therapists. Health services located within the area included a hospital, a non-
government early intervention service, several public community care centres and an Aboriginal
community controlled health service.
Participants met inclusion criteria if they were either: 1) children/youth with a physical disability
aged 8 to 21 years, identified as an Indigenous Australian, and capable of participating in an
interview or 2) carers looking after Indigenous children or young adults who had a physical
disability and were aged 0 to 21 years. Participants were excluded if they had since moved
interstate, were not cognitively capable of participating or communicating, aged under 8 years,
48
or were undergoing stressful circumstances in their lives in which the additional demands of an
interview request may have been detrimental. People that met the criteria were identified
through the physiotherapy records as previous or current clients of the service.
To ensure confidentiality from staff in the clinic and other members of the community, the
principal researcher individually approached by telephone or in person the carers who satisfied
the criteria. Participants who were unknown to the researcher were screened through their
primary therapist to find out if they were interested in being contacted. Participant selection was
initially conducted using purposive sampling, as the principal researcher sought a diverse group
of participants with a range of experiences who were ‘… able to articulate what they have lived
through, or describe their embodied experiences.’18
Emerging themes influenced the participants
who were selected; as new concepts emerged, participants who could enable further exploration
of these concepts were approached.15
Data collection
Each interview occurred at the time, date and location of the participant’s choice. An interview
guide was used to provide a general list of topics for conversation (see Box 1 and Box 2).
Interviews were audio recorded and transcribed verbatim either by a professional service or the
first author. Carers were interviewed independently of their children in all but one interview;
children were interviewed with their carers present. The principal researcher checked all
transcripts for accuracy by comparing the audio recording with the transcript. A paper copy of
the emerging themes and associated transcript were also reviewed with the participant to
confirm themes and allow the participant to clarify, modify, introduce or elaborate on any
further topics. Interviews were conducted until coding saturation was reached.15 Memos and a
journal were maintained to document the process, decisions concerning participant selection and
interview topic inclusion.15
49
Figure 1 Box 1 Sample interview guide and prompt questions for carers
Client story
How did you become involved with this physiotherapy service?
What have been the good things about the physiotherapy service?
What have been the bad things?
Participation in Care
Have you required any help from your physio to understand your child’s physical
issues?
Did the physio give you information that you understand about your child’s issues and
treatment options?
Did you get asked about your concerns for your child?
Did you get asked what areas you would like the physio to work on?
Did you have a say in what type of physiotherapy treatment? (For example, were you
asked what areas you would like the physio to work on and where sessions were held?)
Respectful Care
Did the physio ask you about your language, culture and beliefs when providing care
for your child?
How did you feel about this?
Did you feel staff responded to your needs as an Indigenous person?
Did the physiotherapist ask you about your home and family when planning your care?
Did you feel comfortable asking questions if you needed to?
Care Providers
Do you feel that your care was well organised?
Have you had different physiotherapists involved?
If so, did you get the same messages and advice about your child’s condition and
physiotherapy activities?
Did you get linked in with other care providers (e.g. Occupational Therapists, doctors,
disability coordinators?)
Follow Up
Did the physiotherapist or the office remind you when your child’s next physio
appointment was?
Was this helpful? Do the physios contact you when you have not been able to attend an
appointment?
Advice
If you were talking to a physiotherapist who was just starting to work with children,
what advice would you give them ?
What do you think could be done to make the service better?
50
Figure 2 Box 2. Sample interview guide and prompt questions for children/youth
Data analysis
Transcripts were examined using inductive analysis. Emerging codes were identified and
recorded using qualitative analysis softwarea. Throughout the process, interview data were
constantly compared, which stimulated the development and refinement of the themes. In this
way, data collection and data analysis occurred simultaneously and informed the sampling and
interview topics introduced. During this process, codes were grouped into several themes that
were further distilled into three main themes. A journal was maintained and memos were
entered into the software to document the coding process.
Comfortable/Introductory Questions
How old are you?
Were you born in this town?
Where do you go to school?
Do you like school?
Client story
Do you remember when you started seeing a physio from my team?
Was he or she scary? Mean? Confusing? Nice?
What sort of stuff did you do with him/her?
What things did you like about physio?
What things were bad with physio?
What do you think I could do to make the service better
Participation in Care
Do you feel comfortable talking/asking questions to your physio?
Do you ever get asked what you would like to work on?
Are you given a choice of activities?
Do you prefer to see the physio at his/her office, school or home?
Does this depend on things you work on?
Experiences
What do you like to do after school and on weekends?
Do you like your (ankle foot orthotics, wheelchair, walking device)?
What do you like most/least about school?
What physio activities do you like: Swimming, exercises, bicycling, playing ball
games?
51
RESULTS
Fourteen of the 17 people who were invited to participate took part in the study, constituting
eight client families (see Box 3). Two parents and one child declined the invitation. Four
children and one youth (one male, four females aged 12 to 19 years) with neurological
conditions participated. Diagnoses included: cerebral palsy Gross Motor Function Classification
System II to IV135 (n = 3), spina bifida (n = 1), and a rare non-progressive neurological condition
(n = 1). These participants demonstrated varying mobility, speech and cognitive abilities, but all
were deemed suitable to voice their perspectives. The nine participating carers (one male, eight
females) included four parents and five foster carers in long-term, organised care arrangements.
This group included carers of the participating children/youth as well as carers of other children
with cerebral palsy that did not meet the eligibility requirement or were no longer in the service
area. All participants spoke English at home. Two participants also spoke an Indigenous
language but learned English at school and did not wish for an interpreter to be present. All
participants were Indigenous, with the exception of two non-Indigenous parents and one non-
Indigenous foster carer, and had been involved with the physiotherapy service for at least a year.
We cannot present more detailed information about functional mobility without compromising
the confidentiality so important with this vulnerable population.
52
aPseudonyms have been used to ensure confidentiality
Figure 3 Box 3. Participantsa
Themes
The following themes were identified through the iterative and inductive analysis process.
Lives filled with complex and multiple demands
Discussions associated with this theme garnered the greatest number and most emotional
responses. All carers described lives filled with multiple and complex demands relating to
raising children with a physical disability, with most describing physically and emotionally
taxing experiences. Carers described juggling numerous appointments:
I think it was 9 days straight [of medical appointments]. (Foster mother of Tiana, age 9)
Many carers described stress associated with arranging and attending appointments:
… it takes me over an hour to get each child ready, I’ve got to feed each child, I’ve got to
prepare their meals, then I’ve got to get all their outfits out. … I’m doing this on an empty
1 Betty
2 Mother of Betty
3 Mother of Ariel
4 Ellen
5 Mother of Ellen
6 Noah
7 Mother of Noah
8 Foster Mother of Tiana
9 Foster Father of Tiana
10 Katy
11 Foster Mother of Katy
12 Foster Mother of Brandon and Steve
13 Mary
14 Mother of Mary
53
stomach … I may not be able to have a bath, just dress myself and I’ll take off out the door… if I
feel stressed getting ready and then I come to my appointment and I feel like I’m not being
[present] you know? (Mother of Noah, age 13)
A few carers also described appointments that were extremely stressful:
… [the doctors] said that Ariel’s hips were showing that they were slightly out of [joint] when
they had her x-ray … because now I’m freaking out like, ‘oh God what’s wrong with her hips?’
… I remember when Ariel had her first x-ray, she screamed. So there’s no way she would have
been in the right position. I was pregnant so I wasn’t allowed in, so my husband took her in and
she screamed, I could hear her screaming from the waiting room, so there’s no way in the world
she would have been laying nicely for them to take the x-ray. (Mother of Ariel, age 4)
Other carers described the demands that followed in their wake:
It's really hard to try and meet all of those recommendations; at one stage we had physio
recommendations and we had OT recommendations, the optometrist gave us recommendations.
She went to Hearing and they said ‘She may need grommets, you've got to follow up with this.’
You go to everybody and everybody gives you negativity and you just think ‘Where is it going to
end, I'm a human, there's only so much I can do?’ (Mother of Betty, age 12)
There was the challenge of balancing their children’s needs with their changing health status:
And that priority changes all the time with us because then her health improves and she's back
on track, so then we go back into the worrying about her learning and her long-term
54
independence and life skills, all those sorts of things. Our priorities change all the time for her…
(Mother of Betty, age 12)
Carers also described efforts to balance the needs of their other children:
Pull on a trolley and push the wheelchair at the same time, try and keep two little girls together.
I've got to leave all that to run after them and things like that. It takes a lot out of me, and I don't
feel like doing anything. (Mother of Noah, age 13)
The need to negotiate their children’s experience within the greater community was also
identified by some carers. This included ensuring participation without being made to feel
different by children and others in the community, dealing with gaps in information within
school curricula that were pertinent to their children’s needs, and preparing their children
mentally (especially those with cognitive delay) for appointments with unfamiliar service
providers, especially doctors.
Relationships: consistency, communication and caring
Comments from the children and carers reflected the value that they placed on having a
consistent and caring relationship with their therapist. All nine of the participants who were
asked preferred to have one physiotherapist for a longer time rather than dealing with multiple
therapists. Carers felt that it was important for the child to feel comfortable with the therapist
and activities, and to have consistency of care:
Because they [the children] get scared and then they forget what they’re doing and they’re not
happy to go because it was someone new there. (Foster mother of Brandon, age 12)
55
They emphasised the need for the therapist to get to know the child, see the child wholistically
and be in a position to see change over time:
… she understands the situation because she has been there since day one and she knows Ariel
now. And she knows Ariel better than the paediatricians or anybody else because she’s worked
the most with Ariel and she knows, you know. (Mother of Ariel, age 4)
Participating children emphasised the importance of having their therapist speak to them about
their condition, show them pictures and demonstrate their exercises. They preferred the
therapists to include their foster carers or parents, meet their families, and make the sessions fun.
Four of the five children enjoyed the sessions; one child did not like physiotherapy and felt that
exercise was boring:
… we can sit down and talk about the exercise, about learning about it and doing it and helping
my leg. (Betty, age 12)
When I was … [with] the same people all the time because when youse did it, you made it fun
and happy and put a – let out a good vibes, it was good. (Ellen, age 19)
Responses regarding positive experiences with the physiotherapy service highlighted the
importance of their relationship with their physiotherapist. They described their therapists as
open, approachable and helpful, and described successful instances when therapists were easily
reached, easy to talk to and collaborative:
56
When I talk to you and the ball rolls and I just come out with this and that, I would not speak
like that with anyone else, because they kept it strict with me every time I went there. (Mother of
Noah, age 13)
Carers who highlighted negative experiences described therapists’ lack of caring,
communication and willingness to see children in the context of their family environment.
Carers also felt excluded in their own children’s care:
So I asked her, ‘How would you like to sit on a seat that was made of plastic for 4 hours?’… and
she just fobbed it off … And I refused to go along with that, I am after her [Tiana’s] comfort, not
her [physiotherapist’s] stupidity. (Foster father of Tiana, age 9)
Being Indigenous influences lives
Indigenous culture emerged as an influence that intrinsically shaped consumers lives through
cultural practices and expectations:
… these boys, have to go through their culture and Brandon’s supposed to go through it, man
business … that’s most important for these boys. Steve [previous foster child with physical
disability] went through it, I made sure Steve went through it, he’s well known now…’ (Foster
mother of Brandon, age 12)
Being Indigenous makes it a bit harder, especially the cultural stuff… I’ve missed out a bit on
my father’s side [through lack of physical mobility]. I haven’t got the chance to do all those
things that I probably would have done, but sometimes it’s hard if you’ve got a disability to keep
up with the cultural perspective of traditions… like the cultural dances and going out hunting
and the women, when they go looking for fruits and periwinkles and stuff…’(Ellen, age 19)
57
and conduct:
… when we have children with disabilities or low IQs that consistency of knowing a face and
being able to approach them because in the Indigenous culture to look at someone and give an
answer showing that eye respect is not something that these children do.’ (Foster mother of
Katy, age 16)
In addition, Indigeneity left participants exposed to the external social forces of racism in the
wider community, which may influence their expectations of and willingness to access
government services. Two carers described overt racism, such as seeing racist Facebook
comments and having hate messages sent to them. Others perceived racism within the healthcare
systems:
There was one physio, it just felt like because I was coloured, she thought I wasn’t going to take
care of the equipment, that’s what it felt like …’ (Mother of Noah, age 13)
We are left waiting at the bottom of the line [at hospital clinic]. Other people would be treated
before Tiana ‘cause she’s only an Aboriginal.’ (Foster father of Tiana, age 9)
Carers also actively ensured that their children knew how to handle racism:
… and I tell her ‘we know, don’t forget, like if someone is being racist to you, you can always
get them back to us [i.e., come and tell us]. That way people can’t be racists to you.’ And I tell
them what to be expecting. I tell them what kind of words to be expecting … my Mary knows, my
Jordan knows when someone is being racist to them. (Mother of Mary, age 17)
58
This influence is often hidden from a service provider’s view, but can be a very damaging part
of the participants’ experience:
I feel a bit discriminated against yes I do. I can tell the difference, experienced through that life,
who is slightly different with racial and who is not. … I can tell the difference, the tone is
different, just having no time, the looking at me. When they're looking at me, it’s just like they
don't feel like it, I can tell. So them things makes my day really horrible and it’s hard to deal
with my children when I feel upset like that. (Mother of Noah, age 6)
The issue of communication underpinned all themes and influenced the experiences of the
children and families, interpersonal practices and organisational systems. Positive interactions
with the children and carers were influenced by the timing, content and way in which topics
were raised or managed. Good organisational communication between the therapist and other
departments assisted with linking services, accessing equipment or advocating for the child’s
needs, as well as helping carers relay their needs to unfamiliar service providers. Conversely,
carers identified the lack of communication as their number one concern when experiences were
negative.
Although the main themes were shared, not all people wanted the same service delivery or
interpreted a given phenomenon in the same way. For instance, one carer welcomed a more
directive service delivery style, whilst another felt disempowered by it. Similarly, one carer
regarded imposed school expectations as racist, whilst another carer felt it respectful to have her
child held to the same standards as non-Indigenous students. The findings of this study point to a
number of recommendations at an individual and organisational level (see Box 4) and are
supported in physiotherapy literature and standards.20, 21
59
Figure 4 Box 4. Recommendations for community-based physiotherapy service providers
Individual Level
Develop Personal Attributes:
Openness
Respectfulness
Patience with families
Ability to see situations wholistically
Non-judgementality
Flexibility
Actions:
Actively listen
Tailor language to client’s need
Spend time to ensure shared understanding of information
Allow time for clients to form thoughts, ask questions and develop trust
Practice two-way communication.
Develop cultural (including gender-related) awareness
Recognise and develop both clinical and practice skills
Speak with children (who are interested) about their bodies and activities (use
pictures and other media as needed).
Make activities pleasant- fun for the child, include child’s family, ensure that
siblings attended to so that carer can attend to session
Organisational Level
Intra-Organisational
Maintain same therapist with client to ensure consistency of care
Ensure that all therapists attend cultural awareness or cultural competency course
Develop systems enabling staff cohesion which allow familiar therapists to overlap
with new therapists taking on clients’ care during staff transitions
Develop systems to encourage easy service access for carers
Allow flexibility in location service provided
Ensure good documentation and handovers
Inter-Organisational
Develop open lines of communication with Indigenous health and other services
Support joint client appointments between therapists and other involved health
providers
Support video-conferencing into clients’ interstate appointments
60
DISCUSSION
These themes parallel similar findings in other areas of health and disability research. However,
this is the first study to represent the views of Indigenous children and carers using
physiotherapy services. Non-Indigenous and Indigenous populations consistently report
complex, multiple demands and stress associated with raising children with a physical
disability.1, 6, 22, 23 Literature also supports the value placed on relationships by Indigenous
children and carers receiving other health services,24 as well as by non-Indigenous children and
carers receiving physiotherapy.25, 26 The pervasive and sometimes unrecognised influence of
Indigenous culture as well as racism on relationships, values and healthcare experiences is
reflected in allied health,24 disability6, 27 and cross-cultural research.28
The importance of communication within Indigenous healthcare is highlighted in other
literature. Alford emphasised its importance in physiotherapy practice in Indigenous health;11
whilst Cass, Lowell and others wrote of the absence of effective communication and its
devastating consequences in other areas of Indigenous health.29 Significantly, the Australian
Physiotherapy Council Standards of Care states that tailored, culturally appropriate
communication is a physiotherapy standard and human right for all clients.21
There were several limitations to this study. The design involved a small sample within one
service, which limits its generalisability. Twelve of the 14 participants spoke English as a
preferred language, so the findings may not reflect the experiences of populations whose
primary language is not English. While the children’s views were represented, few of their
quotations were included, as their interviews involved more non-verbal responses and much less
detailed verbal content.
The study only included those willing to use the physiotherapy service and participate in the
study and therefore does not highlight the needs of those unable or unwilling to use the service.
61
As most participants were female, the representation of a male perspective is limited. The
inherent power imbalance between the service provider and consumer may have prevented
participants from sharing how they truly felt (or compelled them to provide a response believed
to please the interviewer). Furthermore, the research was inevitably influenced by the
enculturated view of a non-Indigenous physiotherapist.
Future research would benefit from an Indigenous physiotherapist exploring a similar population
to provide a shared Indigenous and physiotherapy perspective. To get a wider view, future
research should also include a younger population of Indigenous paediatric physiotherapy
consumers in other demographic or healthcare settings. Data could also be explored through
other frameworks such as the International Classification of Functioning, Disability and Health30
or the Indigenous Standpoint Theory,27 which places the context of Indigenous culture and
history more centrally within analysis.
Whilst community-based services adapt to a national effort to reshape disability services and
support fiscal responsibility, physiotherapists are in a position to improve their service provision
in ways that are not entirely resource dependent. Carers and children described positive
situations when their physiotherapists were open and easy to talk to, worked to their interests
instead of forcing another agenda, listened to and gave them time and information to make
choices either independently or in collaboration with the therapist, and provided useful
information or training promptly when requested. Physiotherapy skills that could improve the
experience of Indigenous children and carers include the ability to build partnerships with them,
understand the demands and complexity in their lives, and appreciate how being Indigenous may
influence their healthcare needs and experiences.
The results of this study do not point to a specific physiotherapy clinical practice, but suggest
62
that community-based physiotherapists adopt a person/family-centred, context-specific
approach. This involves developing relationships and effective communication skills in
collaborative pathways, in which knowledge is understood, shared and valued by both therapist
and client.
Footnotes: a NVivo software, QSR International Pty Ltd, Version 10.5, Melbourne, Australia.
Ethics approval: The Human Research Ethics Committee of the Northern Territory
Department of Health and Menzies School of Health Research approved this study. All
participants gave written informed consent before data collection began. (HREC-2012-1912).
Competing interests: Nil.
Source(s) of support: Funding from the Nursing and Allied Health Scholarship and Support
Scheme assisted with student tuition of principal researcher during the last year of completion of
this study.
Acknowledgements: We are deeply grateful to all those who participated in this project.
Provenance: Not invited. Peer-reviewed.
Correspondence: Caroline Greenstein, Menzies School of Health, Australia,
63
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1. Australian Institute of Health and Welfare. Australia's welfare 2013. In: Australian
Institute of Health and Welfare, editor. Australia’s welfare series no11. Canberra: Australian
Institute of Health and Welfare; 2013. p. 1-526.
2. Biddle N, Al-Yaman F, Gourley M, Gray M, Bray JR, Brady B, et al. Indigenous
Australians and the National Disability Insurance Scheme: The extent and nature of disability,
measurement issues and service delivery models Centre for Aboriginal Economic Policy
Research (CAEPR) Australian National University (ANU); 2012 [cited 2015 5 May]. Available
from: http://press.anu.edu.au/titles/centre-for-aboriginal-economic-policy-research-
caepr/indigenous-australians-and-the-national-disability-insurance-scheme/.
3. World Health Organization. Ten facts on disability 2013 [updated September 2013;
cited 2015 14 April]. [Webpage]. Available from:
http://www.who.int/features/factfiles/disability/en/.
4. Bostock L. Access and equity for the doubly disadvantaged. Aboriginal and Islander
Health Worker Journal. 1991;15(4):10-5.
5. Di Giacomo M, Davidson PM, Abbott P, Delaney P, Dharmendra T, McGrath SJ, et al.
Childhood disability in Aboriginal and Torres Strait Islander peoples: a literature review.
International Journal for Equity in Health [Internet]. 2013 [cited 2015 30 July]; 12(7). Available
from: http://www.equityhealthj.com/content/12/1/7.
6. Di Giacomo M, Delaney P, Abbott P, Davidson PM, Delaney J, Vincent F. 'Doing the
hard yards': carer and provider focus group perspectives of accessing Aboriginal childhood
disability services. BMC Health Services Research [Internet]. 2013 [cited 2015 28 June];
13(326). Available from: http://www.biomedcentral.com/1472-6963/13/326.
7. Centre for Disability Research and Policy. Report of audit of disability research in
Australia Sydney: Faculty of Health Sciences, University of Sydney, 2014.
8. Australian Physiotherapy Association. Paediatric group 2015 [cited 2013 12 August].
Available from:
http://www.physiotherapy.asn.au/APAWCM/The_APA/National_Groups/Paediatric/APAWCM
/The_APA/National_Groups/Paediatric.aspx?hkey=6a7afaa3-42ba-467f-86d1-258248b8cfaf.
9. Cotter P, Maher P. Why the silence on Indigenous health? Australian Journal of
Physiotherapy. 2005;51(4):211-2.
64
10. Gates R. Indigenous health research needs to change focus. Australian Journal of
Physiotherapy. 2006;52(1):59-60.
11. Alford V, Remedios L, Ewen S, Webb G. Communication in Indigenous healthcare:
extending the discourse into the physiotherapy domain. Journal of Physiotherapy.
2014;60(2):63-5.
12. National Health and Medical Research Council. Values and ethics: guidelines for ethical
conduct in Aboriginal and Torres Strait Islander health research. In: National Health and
Medical Research Council ARC, editor. Canberra: Commonwealth of Australia,; 2003.
13. Saks M. Researching health: qualitative, quantitative and mixed methods First ed. Los
Angeles: SAGE; 2007.
14. Gooley R. The clients' perception of the quality of chronic condition care systems
assessment tool (SAT) September 2012.
15. Charmaz K. Constructing Grounded Theory : A Practical Guide through Qualitative
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16. Australian Bureau of Statistics. Regional Population Growth, Australia 2013-2014 2015
[updated 31 March 2015; cited 2015 25 May]. Available from:
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17. Australian Bureau of Statistics. Aboriginal and Torres Strait Islander population
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18. Liamputtong P. Qualitative Research Methods. Third ed. South Melbourne, Victoria:
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19. Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content validity of the expanded
and revised Gross Motor Function Classification System. Developmental Medicine & Child
Neurology. 2008;50(10):744-50.
20. Higgs J, Smith M. Contexts of Physiotherapy Practice. Chatwood: Elsevier; 2009.
21. Australian Physiotherapy Council. Australian Standards for Physiotherapy:Safe and
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22. Hayles E, Harvey D, Plummer D, Jones A. Parents' experiences of health care for their
children with cerebral palsy. Qualitative Health Research [Internet]. 2015 Feb 23 [cited 2015 30
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with physical disability in Kenya: potential links between caregiving and carers' physical health.
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26. Schreiber J, Benger J, Salls J, Marchetti G, Reed L. Parent perspectives on rehabilitation
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28. Taylor K, Guerin P. Health care and Indigenous Australians: cultural safey in practice.
South Yarra: Palgrave Macmillan; 2010.
29. Cass A, Lowell A, Christie M, Snelling PL, Flack M, Marrnganyin B, et al. Sharing the
true stories: improving communication between Aboriginal patients and healthcare workers.
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health (ICF) 2015 [updated 31 October; cited 2015 3 July]. Available from:
http://www.who.int/classifications/icf/en/.
CHAPTER 6:
REFLECTIONS OF THE STUDIES COMBINED
66
CHAPTER 6: JOURNAL ARTICLE
Improving physiotherapy services to Indigenous children with physical disability: are
client perspectives missed in the continuous quality improvement approach?
Greenstein, Caroline1, Lowell Anne2, Thomas, David Piers3
1Menzies School of Health Research, Charles Darwin University, Darwin
John Mathews Building (Bldg 58)
Rocklands Drive, Casuarina NT 0810 Australia
PO Box 41096 Casuarina NT 0811, Australia
Home: 61 08 xxxxxxxxMobile: xxxxxxxxxx
2Research Centre for Health and Wellbeing, Charles Darwin University, Darwin
Ellengowen Drive, Casuarina, NT 0810
3Menzies School of Health Research, Charles Darwin University, Darwin
John Mathews Building (Bldg 58)
Rocklands Drive, Casuarina NT 0810 Australia
Short title: Improving physiotherapy services to Indigenous children
67
Abstract
Objective: To compare the outcomes of two cycles of continuous quality improvement (CQI) at
a paediatric physiotherapy service with findings from interviews with clients and their carers
using the service.
Design: Case study based at one paediatric physiotherapy service
Setting: Community-based paediatric allied health service in Northern Australia.
Participants: Forty-nine clinical records and four staff at physiotherapy service, five Indigenous
children with physical disability aged 8-21 years, nine carers of Indigenous children aged 0-21
years (current or previous clients).
Interventions: The CQI process based on the Audit and Best Practice for Chronic Disease
involved a clinical audit; a workshop where clinicians assessed their health care systems,
identified weaknesses and strengths, and developed goals and strategies for improvement; and
reassessment through a second audit and workshop. Twelve open-ended, in-depth interviews
were conducted with previous or current clients selected through purposive and theoretical
sampling. CQI and interview results were then compared.
Main outcome measure: Comparison of findings from the two studies
Results: Both CQI and interview results highlighted service delivery flexibility and therapists’
knowledge, support and advocacy as service strengths and lack of resources and a child-friendly
office environment as weaknesses. However, the CQI results reported better communication and
68
client input into the service than the interview results.
Conclusion: The CQI process, while demonstrating improvements in clinical and organisational
aspects of the service, did not always reflect or address the primary concerns of Indigenous
clients and underlined the importance of including clients in the CQI process.
Keywords: Aboriginal, allied health, Oceanic Ancestry Group, paediatric, physical therapy
(specialty)
69
What is already known on this subject:
The ABCD CQI approach has been successful in other areas of Indigenous health care.
There is a dearth of literature on outcome-oriented approaches to improving
physiotherapy services to Indigenous children with physical disability.
What this study adds:
The ABCD CQI approach can improve physiotherapy service provision but does not
completely reflect the primary concerns of its clients.
Indigenous clients should be included in the CQI process.
70
INTRODUCTION
Within Australia there has been a growing movement to improve the quality of Indigenous
health service delivery using the Audit and Best Practice for Chronic Diseases (ABCD)
continuous quality improvement (CQI) approach.1, 2 This approach has been successfully applied
in areas such as diabetes,3 child health4 and rheumatic heart disease.5 However, no such tools for
childhood disability have been developed till now.
Indigenous children with physical disability are considered especially vulnerable due to the
disadvantages experienced by having a disability at an early age and socially determined
factors.6, 7 Despite this, there is limited allied health research reporting outcomes of efforts to
improve services or reflecting the perspectives of this population.7
In this paper we report on a research project to improve services to Indigenous children with
physical disability at a community-based physiotherapy service. We combined an adaptation of
the ABCD CQI approach with client interviews. In particular, we reflect on what may have been
missed if we had undertaken a CQI process alone.
METHODS
Setting
The study was conducted within a community-based paediatric physiotherapy team servicing a
regional town in Northern Australia with a population of 140,400 people8 including 15,555
Indigenous residents.9 Health services located within the area included a hospital, public
community care centres, an Aboriginal Community Controlled Health Service and non-
government early intervention service. There were four allocated physiotherapy positions within
a larger paediatric allied health team of 23 positions containing speech/language pathologists
and occupational therapists. An additional 2 physiotherapists worked with children at the early
71
intervention service and the public hospital. Despite several private allied health practices within
the town, none employed paediatric physiotherapists.
Design
A mixed method design limited to a specific physiotherapy service was used in the belief that
more impact could be made at one service in which the lead researcher, service providers and
clients were involved. The first part of the study involved an outcomes-based participatory
action CQI process within this physiotherapy service. The second part involved qualitative
research using interviews to enable in-depth exploration of physiotherapy services from clients’
viewpoints. The combined CQI and interview results were then explored in terms of
implications for practice.
CQI Component
The lead researcher adapted the ABCD CQI process to suit a small project confined to one
service. The ABCD clinical audit tool and protocol, systems assessment tool (SAT) and goal-
setting tool were also adapted for use within a paediatric physiotherapy service (Table1).
TABLE 1: Physiotherapy audit tools and original One21seventy audit toolsa
Physiotherapy Audit Tools One21seventy Audit Tools
Physiotherapy Clinical Audit Tool Child Health Clinical Audit Tool, version 3.1
Physiotherapy Clinical Audit Tool
Protocol
Child Health Clinical Audit Tool Protocol
version 3.1
Physiotherapy Systems Assessment Tool Systems Assessment Tool version 1.2
Physiotherapy Goal Setting Tool Goal Setting Tool version 1.1
aOne21seventy is the national non-profit organisation that developed from the ABCD
partnership.
72
The audit tool had multiple items to investigate clinical processes of care such as
musculoskeletal and neurological assessments. The SAT provided a structured assessment
enabling physiotherapists to identify strengths and weaknesses of their service as a group within
a workshop. A CQI cycle was completed over the first year, which included identifying and
auditing files that met inclusion criteria, presentation of audit results and a SAT workshop with
all physiotherapists on the team, goal setting and strategy development and strategy
implementation. A second audit, results presentation and SAT workshop were conducted the
following year with results compared (Figure 1).
FIGURE 1: The CQI process
Interviews
Concurrently and after the completion of the CQI project, the lead researcher conducted open-
ended in-depth interviews with clients. Participants were selected through purposive and
theoretical sampling to reflect the lead researcher's interpretivist perspective.10 Indigenous
•Goal setting
•Strategies
•Implementation
•Presentation ofResults
•SAT Workshop
•Clinical Audit
Assessment Feedback
Action Planning Implementation
73
children/youth who were aged 8-21 years, previously or currently accessed the physiotherapy
service, and were cognitively capable of participating in an interview and carers of Indigenous
children/youth aged 0-21 years were interviewed until saturation was achieved.
RESULTS
CQI results
Thirty-five records were audited in the first year and 32 records in the second year. All records
that met the criteria were audited with 18 records included in both audits. The CQI audit
highlighted many weaknesses in practice, including hip surveillance for clients with cerebral
palsy or severe physical disability, documentation of classification systems for children with
cerebral palsy, and client goals and outcomes. The SAT reflected a service with strengths
concentrated within the area of service delivery systems, including staff development, team
cohesion and flexible appointment system design. Weaknesses were exposed relating to linkages
with the community and external services. The iterative process and goal-setting led to changes
in internal team documentation processes, professional development, links with other hospitals
and facilities, documentation of hip surveillance and items relating to clients with complex
needs. However, no improvements were achieved in the area of client goal-setting and
outcomes. The SAT also reflected improvement in other areas of the service’s organisational
system (Figure 2).
74
FIGURE 2: Systems assessment tool results: changes in staff ratings of their health service
Client perspectives
Twelve interviews were conducted with nine carers and five children/youth comprising eight
clients. Clients shared some of the CQI issues but were predominantly concerned with factors
outside the area of medical expertise. Participant comments highlighted the multiple demands
and complexities of raising children with physical disability, influences of being Indigenous on
their life and health care experiences, value placed on having good and consistent relationships
with service providers, and the importance of effective communication.
7.7
7
6.5
2.5
6.45
4.4
2.6
2.1 1.2
4.7
0
2
4
6
8Delivery system design
Information systems and
decision support
Self-management support
Links with the
community, other health
services and other services
and resources
Organisational influence
and integration
Second Audit First Audit
Key: 0-2 reflects limited support; 3-5 basic support; 6-8 good support; 9-11 fully developed support.
75
Comparison of the two research approaches
CQI and interview results agreed on certain strengths and weaknesses of the physiotherapy
service: (i) Flexible service delivery was identified as a strength by physiotherapists during the
SAT workshop. Within the interviews, clients valued their therapists’ ability to provide
continuity of care with interstate services and offer appointments at home, school or the office.
(ii) Knowledge, support and advocacy were considered strengths within the service. Client
participants appreciated physiotherapists’ expertise during physiotherapy appointments as well
as their support for clients during appointments/processes with other services. (iii) Clients’ lack
of access to information about community, disability and other health services or resources was
highlighted as a weakness by physiotherapists in the SAT workshop as well as during client
interviews. (iv) Lack of a child/family-friendly environment within the allied health facility was
also identified by both physiotherapists and clients.
CQI and interview results also reflected areas of disagreement: (i) Communication was depicted
as a strength in the SAT workshop through items such as client follow-up and routine client
engagement in assessment and documentation. The clinical audit tool presented good
documentation in items involving physiotherapy/client discussions of assessment results.
However, some carers described inadequate communication with physiotherapists and
highlighted this as the main factor in negative experiences. (ii) Client input into service delivery
was a small area of the SAT covered under client satisfaction. In this item, participating
physiotherapists described good, routine systems for assessing client satisfaction. However,
some clients described feelings of disempowerment with lack of opportunity to provide input
into their child’s care. The audit tool provided a mixed picture of actual care; some client
records were better documented than others. There was also evidence that the audit results
reflected better processes of care than clients actually experienced. For instance, the audit
76
indicated that physiotherapists documented discussions of assessment results with their clients
well. However, some comments made in the interviews suggested otherwise.
Discussion
Previous quality improvement studies have included interviews to identify factors contributing
to program success11 or barriers to follow-up on Indigenous specific assessment items.12
However, client interviews are not always included and there has been little reflection of what is
missed when they do not occur. In reflecting on our research findings we offer the following
considerations.
Client Inclusion
The ABCD CQI approach has been considered well-suited to Indigenous health services due to
its focus on participation, service users, and capacity building consistent with Indigenous
values.13 The clinical audit tool has a section on attendance to examine levels of client
engagement. The SAT has items concerning cultural competence, service user participation
within care planning and self-management education and support for families. Primary health
care principles recognise that services must be adapted to fit with local conditions which are
influenced by the dynamic interplay between service users, service providers, local histories and
health status.14 However, this study revealed a significant gap between what is reflected in the
CQI process and client interviews. The difference between the CQI’s clinical and organisational
focus and the clients’ focus on interpersonal skills such as effective communication was
highlighted through comparison of findings. The study also demonstrated that service providers
and service users might interpret the same service experience differently. Our results illustrate
the need to include service users in the CQI process to ensure their views are represented and
their concerns addressed.
77
Cultural competency
Interview comments suggest that clients currently experience barriers within their health care
system including perceptions of racism, a history of negative experiences, transport issues and
lack of support. This demonstrates an ongoing need for service providers to pursue cultural
competency training, ensure follow up, and find ways to identify and address these issues in the
local context.
Whilst there is broad recognition of barriers to service access in other literature,15 they are not
adequately assessed by the CQI tools. The SAT offered a small section on culturally sensitive
practice constituting one of eight subitems of one component of the entire assessment. The
clinical audit tool did not adequately capture level of engagement due to its design as well as
changes within the service’s admission process over the course of the study. Furthermore, whilst
some participants relayed experiences of racism within the health care system, it was unclear
how much this occurred in their experiences with the physiotherapy service. Physiotherapists
within the SAT workshop did not completely agree on items related to cultural competence
while clients offered a variety of perspectives on their care within their interviews.
Strengths
The two elements of the study complemented each other in many ways. The CQI component
offered a way to identify and address weaknesses within clinical practice and the broader health
care system and to measure efforts to improve the system. The qualitative component offered
the rich detail of clients’ perspectives and greater understanding of how they experienced
services. Combining the results illuminated aspects of service delivery that were not obvious
when individually viewing the results of each component. For example, the lack of effective
communication experienced by clients was not identified by CQI but was important in client
78
interviews. Yet the lack of access to diagnostic results and other clinical issues were identified
by CQI processes but not client interviews.
Limitations
There were weaknesses in the study’s design and execution. The small scale of the CQI study
and the small number of interviews limited its generalisability. The lead researcher conducted
both parts of the study and recognises the bias inherent in being a practitioner in the service
being investigated. An independent researcher with an Indigenous background may have more
effectively explored issues such as racism. More robust findings may have been produced with a
larger sample of service users as well as clients who chose not to use the service.
Recommendations
Primary health care literature promotes local Indigenous community participation in a
collaborative approach.14 However, disability and paediatric literature highlight the complex
needs of clients with physical disability and those caring for them,16-18 suggesting that seeking
general community representation alone might not be adequate to improve services to this
particularly vulnerable population. The process of including service users into the CQI process
is a challenge given demands placed on community-based services and the busy lives of clients
and their carers. A number of approaches may be considered. The physiotherapy service could:
(i) schedule informal or formal interviews with willing clients using an interview guide at a
designated time of year; (ii) invite current or previous clients and other Indigenous community
members working with these clients as part of a reference group to either come together or act in
an individual capacity as a resource that can be contacted by the service to discuss ideas for new
service developments or changes; (iii) develop or alter the current CQI tools to include items
that examine areas such as interpersonal skills and other client concerns with the assistance of
willing clients.
79
CONCLUSION:
The adapted ABCD CQI audit provided a practical and outcome-oriented approach to improving
services. It reflected improvements in clinical practice indicators and organisational systems
when applied to a community-based physiotherapy service. However, the interviews highlighted
that the CQI process did not address all the concerns of Indigenous clients and underlined the
importance of their inclusion in the CQI process.
Acknowledgements
Funding from the Nursing and Allied Health Scholarship and Support Scheme assisted with
student tuition of the lead author during the last year of completion of this study. We are deeply
grateful to all those who participated in this project.
80
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CHAPTER 7:
FINAL DISCUSSION
82
CHAPTER 7: FINAL DISCUSSION
7.1 Overview
Disability is a complex phenomenon104, 106 that involves social, physical and personal aspects of
the experience. People with disability are considered to be amongst the most marginalised and
vulnerable in the global population. Indigenous children with disability are especially vulnerable
as they are not only more likely to experience physical disability than their non-Indigenous peers
but can be considered further disadvantaged through exposure to social determinants and
disability during their critical years of development.
Due to the highly individualised nature of disability, defining and studying disability is a
challenging process that involves research in the medical, social and cultural domains. Research
by physiotherapists or concerning the discipline has been directed at clinical interventions and
quality of life studies for various populations with a variety of different physical disabilities, but
minimal attention has been directed towards Indigenous childhood disability.5 Other research in
the fields of disability as well as Indigenous health research highlights the lack of Indigenous
representation in disability studies, the vulnerability of Indigenous people with disability, and
the multiple barriers faced by this population in accessing appropriate services.107, 108 Research
across a number of fields has also highlighted the complexity of disability experiences43, 106
and
the heterogeneity of Indigenous Australia,109, 110 negating a “one size fits all” approach.
This mixed methods study combined CQI and qualitative components. The first study
component examined the adaptation and application of a CQI process used successfully within
Indigenous primary health care at one community-based physiotherapy service. The second
study component involved interviews with Indigenous children with a physical disability and
83
their carers who currently or previously used the same service. The results of these two
components were then compared and reflected on and similarities and differences in the findings
were analysed.
The CQI process aimed to explore who used the service as well as how the service was accessed
and used. It examined characteristics of the client population such as age, gender, diagnosis;
referral pathways to the service; documented needs of the clients and whether the needs were
met; and documented services provided. Quality of care was investigated through the inclusion
of indicators of engagement and clinical practice from an Audit for Best Practice CQI tool, best
practice guidelines and physiotherapy literature. The study also examined whether
improvements in quality of services could be made through this process. The CQI process
demonstrated that a structured method could provide information about how a community-based
physiotherapy team was accessed by its Indigenous clients, what services were provided and
which services were most in demand. This process also led to improvements in service delivery.
Within the study, some changes resultant from the CQI process have already occurred such as
improved, medical record access, reorganisation of files and use of summary cover sheets in the
records of clients with complex needs. Other changes incorporating recommendations by
interview participants such as making the office a more welcoming space are still ongoing.
The qualitative component of the study explored the personal experiences of previous or current
clients with a physical disability and their carers with their physiotherapy service. The findings
of these semi-structured interviews presented a different picture of the physiotherapy service,
offered insight into being or raising an Indigenous child with a disability and provided an
84
additional dimension to the clinical documentation in the physiotherapy records highlighting
both richer as well as different perspectives.
The findings from both components were then compared and explored for similarities and
differences. The two elements of the study complemented each other in many ways. The CQI
audit offered glimpses into what services were provided from a clinical perspective and how the
organisation either supported or hindered service delivery. The interview findings offered rich,
more personal information about clients’ experiences within and outside of their physiotherapy
involvement.
The findings of both studies brought to light several strengths and weaknesses of the
physiotherapy service. The service’s flexibility in offering appointments at different locations
and accommodating the requests of the service users was highlighted as a strength; the lack of
information or low profile of the physiotherapy service within the greater community, absence
of referrals from Indigenous identified positions within the health and education services and
lack of a comfortable facility to receive children and families were highlighted as weaknesses.
There may be various reasons that this physiotherapy service has escaped the attention within
the greater community of Indigenous providers of health and education services. This may
include a lack of awareness of the community-based physiotherapy service, a lack of
understanding about what this service can provide or difficulty in recognising conditions or
physical issues that would benefit from the services of this community-based team.
Physiotherapy may also be a lower priority if other significant medical or social issues are more
pressing.
85
The two studies’ findings also differed from one another by either covering completely different
aspects of care or providing different representations of a given experience or procedure. The
clinical and organisational focus assessing quality of care in the CQI process diverged from the
clients’ focus on interpersonal practice skills. Qualities of service delivery such as providing
consistency of care and communication skills which were valued by clients and supported in
literature on Indigenous engagement111 were missing from the CQI indicators. Whilst the carers’
experience of multiple and complex demands in their lives is reflected in the number and variety
of services provided in the audit records, the degree of complexity and demands placed on the
carers and the impact this may have on service delivery were not captured in the CQI process.
7.2 Implications for physiotherapy practice
A number of recommendations have been identified through this study that have implications
for physiotherapy practice. Recommendations for improving services derived from the findings
of both components of this study included the need to:
1) develop stronger links with community and Indigenous health organisations
2) provide a more culturally comfortable space for children and their families
3) acknowledge the complex and demanding lives of the clients and their carers
4) include and collaborate with clients and their carers in quality improvement activities
5) develop sustainable, ongoing mechanisms for improvement and evaluation related to:
a) quality of communication
b) responsiveness to individual (including cultural) needs
c) consistency of staffing care
d) client satisfaction
e) cultural safety of services
86
Schembri notes that the medical profession has historically focused on technical aspects of
medical services whilst patients focus on their experiences when evaluating the care they
receive, and suggested that evaluating service provision is beyond the realm of quality of care
and satisfaction surveys.112 Successful engagement with Indigenous populations requires
relationships of respect, trust and honesty, ongoing, accessible communication and information;
an appreciation of the diversity within the Indigenous population, cultural skills and knowledge
of community groups and Indigenous people; participatory processes that involve Indigenous
aspirations and priorities, agency, decision making; clear, desired outcomes, indicators and ways
to achieve them; and joint monitoring and evaluation to meet the rights and needs of each
party.110
The results of this study strongly support a person/family-centred approach that enables
physiotherapists to develop a better understanding of each client’s unique situation in order to
provide relevant and responsive care. This approach is supported in the ICF framework,104
Indigenous Wellbeing Framework113 and physiotherapy literature.114 Whilst practice knowledge,
defined here as ‘the quality of care provided which incorporates tailored communication and
respect for clients’ is discussed in the APA standards,115 this study highlights its importance and
the need for physiotherapists to actively seek an understanding of the client’s context when
delivering services.
Currently there are no available communication guidelines or indicators to evaluate
physiotherapy practice in Indigenous health care. The disparity between the CQI and
interviewees’ focus related to quality of care highlights the need for client perspective to be
87
included in the development of CQI tools. However, there is evidence that clinical indicators can
only assess the presence of processes that might lead to an improved result and not a better
result in and of itself116 and that other tools incorporating Indigenous perspectives may be more
fruitful113 which suggests a different avenue of research.
7.3 Limitations
This study had a number of limitations. First, the small scale of the study across both
components of the project limited its generalisability. The CQI study was conducted by one
researcher at one physiotherapy service comprised of a small group of physiotherapists with a
small, diverse group of clients. There was little infrastructure or support for CQI within the
allied health team’s department beyond what was available in this study. While this made the
process more realistic as many rural and remote services lack resources, it also separated it from
the larger scale ABCD studies in primary health care that have led to significant improvements
in the quality of care. The clinical audit tool was used as a research tool to examine client
characteristics, access patterns and usage as well as quality of care received. This made the
current audit form large and unwieldy for such a small service with limited resources. The
Systems Assessment Tool also needed further modification to make it more pertinent to the
service as participating physiotherapists felt that some of the items were either irrelevant or
given more attention than required. Importantly, the clinical audit tool reflects processes of care
and the services that are documented rather than actual outcomes for clients of the service.
Second, the qualitative study was restricted to the same physiotherapy service, involved mostly
females, and only included clients and their carers that used the service and were willing to
participate. The interview format required verbal communication, therefore, children with
88
language and communication difficulties, although getting their points across, were difficult to
quote directly in the study. The interview guides, although containing questions from a survey
for Indigenous consumers, were developed by the researcher. It is possible that some important
areas for clients and carers were not explored. However, the guide covered many broad areas.
Third, the position of being a physiotherapist at the study site exposed the research to significant
potential bias. Although efforts were made to reduce bias throughout the process, the lead
researcher was responsible for calculating and tabulating audit and workshop results,
highlighting strengths and weaknesses during the results presentation and facilitating the
workshop and goal setting discussion. The presence of the researcher within the team may have
influenced implementation of CQI strategies inadvertently through being an ongoing presence
within the department or being a ‘go to’ person when implementation issues arose.
Fourth, the enculturated viewpoint of a non-Indigenous researcher steeped in the culture of
physiotherapy may have influenced the interpretation and analysis of data. The inherent power
imbalance within interviews conducted by a researcher/service provider with
participants/service users might have influenced the selection of participants and the content of
the interviews as well as prevented participants from sharing how they truly felt.
7.4 Future research
Research pertaining to physiotherapy practice in the field of Indigenous Australian childhood
physical disability is a largely unexplored area and there are many areas that require attention.
This was a very small study but the findings suggest potential areas for further development and
research on many fronts. Further local research could: 1) explore the development of a CQI
89
process in collaboration with clients that better reflects service practices meeting client values
and needs; 2) develop and evaluate other tools in collaboration with clients that better reflect
service practices meeting clients values or needs; 3) investigate why Indigenous children with
physical disability do not appear to be referred from Indigenous medical and community
organisations or from Indigenous-identified positions within the school and health departments;
4) investigate why the target area of goal setting was not met given its importance in the
available therapy literature and how this can be improved; 5) identify and interview the children
with physical disability and carers who choose not to use the physiotherapy service; 6) evaluate
efforts to develop linkages with external health services, Indigenous medical services and other
Indigenous organisations; 7) expand the small sampling of Indigenous clients with physical
disability to include younger children and those outside the service and examine a broader range
of experiences within their community; and 8) develop and evaluate efforts to video-conference
with Indigenous children with physical disability and their interstate providers when these
children are receiving services interstate.
More general research might: 1) develop a basic adaptable tool in conjunction with interested
clients and other Indigenous personnel that could be used to assess physiotherapy practices with
Indigenous children with physical disability and their carers in a range of contexts (acute care,
community, early intervention, disability care) and a method for clients to feedback on the
services they receive; 2) adapt and evaluate practical applications of principles to support locally
defined, culturally safe services suggested within Indigenous primary health care literature,113
such as allocating appropriate caseloads and time when scheduling appointments to allow for the
development of adequate relationships between clients and health care providers; 3) explore in-
depth interviews with Indigenous physiotherapy clients with physical disability of all ages
90
throughout Australia to develop more insight into their lived experiences; 4) explore in-depth
interviews of the same clients from an Indigenous perspective or using a particular framework
such as the ICF; 5) develop other methods for Indigenous children with physical disability and
their families to share their experiences such as through photographs and videos using cameras,
smart phones and tablets; 6) develop and evaluate efforts to provide services to Indigenous
children with physical disability through video-conferencing and similar applications found on
smartphones, tablets and computers; and 7) seek how to better incorporate Indigenous
perspectives into CQI and other clinical and evaluative tools.
7.5 Final conclusions
The results from this research suggest that physiotherapists develop skills that enable them to
relate to their clients, see the children wholistically and respond in a timely and appropriate
manner. The research also points to the need for departments to provide an organisation
enabling flexibility in the service, consistency in personnel offering care, providing ongoing
cultural competence training for physiotherapy staff and developing linkages with Indigenous
health and community organisations as well as other health and community service providers.
The research also clearly reflects the need for more dialogue between physiotherapists and
Indigenous people both nationally and within the community in which this research was
conducted.
Community based physiotherapy offers a tremendous opportunity to contribute to the health of
diverse populations and “the possibility to practice in a wide range of locations and contexts, but
also scope to integrate broad conceptualisations of health, health promotion and rehabilitation
...”. 114(p139) Physiotherapists who work with Indigenous children with a disability and their
91
carers should understand the privilege afforded to them as guests in the very busy and often
vulnerable lives of their clients and treat every contact as an opportunity to learn from as well as
teach clients and carers.
Improving community-based physiotherapy services for Indigenous children with physical
disability requires a multi-faceted approach. This includes the development not only of excellent
clinical knowledge, but the ability to provide responsive care relevant to the clients’ expressed
needs, communication skills and cultural appreciation. Most importantly it requires the integrity,
commitment and reciprocity enshrined in Indigenous research values and principles that are
equally relevant in the context of service provision.
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APPENDICES
APPENDIX 1:
ETHICS APPROVAL
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APPENDIX 1: ETHICS APPROVAL
105
106
APPENDIX 2:
SEARCH HISTORY
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APPENDIX 2: SEARCH HISTORY
Objectives
The aim of the literature review was to examine the best evidence available from published
literature on: physiotherapy interventions and practices for Indigenous children with physical
disability and gross motor delay.
Search methods
A literature search was conducted using online databases, the local Government Intranet
website, professional association databases and health libraries between February 2012 and
September 2013.
Databases searched are listed below. The databases with the strongest clinical evidence were
searched first. This was followed by databases recommended for physiotherapy and allied health
(Campbell 2012). Databases concerning Indigenous and social issues were then searched. Grey
literature was then searched through the local Government Intranet website, professional
association databases and disability websites between February 2012 and September 2013.
The grey literature was searched using terms such as physiotherapy, allied health, disability and
Indigenous though the NT government website, the Charles Darwin University library, the NT
Health Library and other government and non-government websites identified through
bibliographic references in Australian HealthInfonet and Google searchers. Additional literature
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was sourced through the NT Government Aged and Disability Darwin Urban services, Cerebral
Palsy Alliance, conference papers and personal correspondence.
Databases included:
The Cochrane Library
Physiotherapy Evidence Database (PEDro)
Medline
PubMed
Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Academic Search Premier (EBSCO host)
Education Resource Information Centre (EBSCO host)
PsycInfo (EBSCO host)
Psych and Behavioral Sciences Collection (EBSCO host)
Soc INDEX (EBSCO host)
Rural and Remote Health Database (Informit)
Science Direct Health and Society (Informit)
Health Collection (Informit), Humanities and Social Sciences Collection (Informit)
Indigenous Australia – ATSIC Library (Informit)
Web of Science
Wiley Online Library
Australian Indigenous Health Infonet
OT Seeker
Trove
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Websites searched included:
Australian Bureau of Statistics
Aboriginal Institute of Health and Welfare
Australian HealthInfoNet
Australian Physiotherapy Association
CanChild
Cerebral Palsy Alliance
Council of Australian Governments, Australian Government Department of Families, Housing,
Community Services and Aboriginal Affairs
One21Seventy
Menzies School of Public Health Research
World Health Organization
Selection criteria
Literature using research of any design published from 1970 onwards and written in English or
an Indigenous language was included. Initial searches involved participants who were
Indigenous Australians aged 0-18 years. Interventions included physiotherapy. Any outcome
was included. Literature was included if it pertained to 1) Indigenous people receiving
physiotherapy 2) Indigenous children with a physical disability
Exclusions included articles that were not relevant to physiotherapy or Indigenous children with
physical disability. For instance, articles on chiropractic practice for an Indigenous community
and physiotherapy for children with chronic lung disease were excluded.
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Search Terms
Search terms were initially obtained from the National Health Service Medical Subject Headings
(MeSH) keywords and expanded to include keywords found in references found. They included
1 Physiotherap*
2 Physical Ther*
3 1 or 2
4 Indigen*
5 Oceanic Ancestry Group
6 Aborigin*
7 Torres Strait Islander*
8 Maori
9 First Nations
10 Native Americ*
11 Inuit
12 Metis*
13 Child*
14 Ped*
15 4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12
16 (1 or 2) AND (4 or 5 or 6 or 7 or 8 or 9 or 10 or 11 or 12)
17 16 AND (13 OR 14)
Example 1
MEDLINE Search
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SEARCH Articles
3 82,786
15 83
17 23
Included Articles: 3
Example 2:
CINAHL Search using MeSH terms
1(MH "Indigenous Peoples+") OR (MH "Health Services, Indigenous") OR (MH "Indigenous
Health")
2 (MH "Therapeutics+") OR (MH "Physical Therapy+") OR (MH "Rehabilitation, Pediatric")
3 (MH "Disability Evaluation+") OR (MH "Developmental Disabilities") OR (MH
"International Classification of Functioning, Disability, and Health")
4 (MH "Child, Disabled")
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SEARCH Articles
1 15,276
1 AND 2 2882
1 AND 2 AND 3 7
1 AND 2 AND 3 AND 4 4
Included articles: 4
APPENDIX 3:
CONTINUOUS QUALITY IMPROVEMENT STUDY
SUPPLEMENT
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3.1 CONSENT FORM FOR STAFF PARTICIPANTS
A research project about physiotherapy services for children with gross motor delay of
physical disability
This means you can say NO.
Before you sign this from please make sure that you understand what it means to participate in
this research project. Please read the Information Sheet. Please contact me to answer any
questions you might have.
It is important that you understand:
You do not have to take part in this research. You can stop at any time.
Meetings involving system assessment tool, clinical audit tool feedback and goal setting will be
audio-recorded so I get your words straight. Your information will only be used for this research
project. It will be stored in a secure place; only my research supervisor and I will have access.
After five years the record will be destroyed. Your name and details will not be made public.
Nothing written in the report will link you to the project.
Do you have a copy of the Project Information Sheet? ☐Yes
☐No
Do you agree to participate in the research? ☐Yes
☐No
Do you agree to the meetings being audio-recorded? ☐Yes
☐No
Do you agree that some of your words (but not your name) be used in reports
and publications? ☐Yes
☐No
Participant’s name: ____________________________________________________________
Signed: _____________________________________Date:_____________________________
I understand that the ownership of Aboriginal knowledge and cultural history is retained by the
informant and this will be acknowledged in research findings and in the dissemination of the
research.
I have explained the nature and purpose of the research to the above participant and have
answered their questions.
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Researcher’s name:____________________________________________________________
Signed: ________________________________________________ Date: ________________
Contact Details: For more information about the research project: Caroline Greenstein- Ph: 08 xxxxxxxx or xxxxxxxxxx
Email: caroline.greenstein@xxxxxxxx
For more information about ethical conduct of the research project: The Secretary, Human Research Ethics Committee of NT Department of Health
and Menzies School of Health Research, phone 08 89227922
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3.2 INFORMATION SHEET FOR STAFF PARTICIPANTS
Research Project Information for Physiotherapists
(This is for you to keep)
You are invited to participate in a research project about physiotherapy services to children with
gross motor delay or physical disability
What is this project about?
Children are commonly referred to physiotherapy services for movement disorders or gross motor delay.
There is much research about paediatric physiotherapy services for the non-Indigenous population but
little research on physiotherapy services involving Indigenous children.
The study involves auditing the physiotherapy records of Indigenous clients who have used the
physiotherapy service, sessions asking therapists to examine organisational aspects of the service and
interviews with Indigenous children and their carers or young adults that currently use the service or have
previously used the service.
I want to understand how Indigenous children with movement difficulties utilize physiotherapy services
and what facilitators and barriers assist or deter physiotherapy service use.
I would also like to understand if the services offered to Indigenous children with a movement disorder
are provided with services in line with best practice for their condition.
What does it involve? I will conduct a clinical audit of children who have been referred to your services for gross motor delay or
physical disability.
The audit will cover the year previous to the start date. The audit covers how the client was referred, what
assessments were done, services offered and provided and outcomes measured. In particular, assessment
and follow up of children with Cerebral Palsy will be audited.
Participating physiotherapists will be asked to attend a session in which a system assessment tool will be
used for the physiotherapists to comment on the system in which they operate.
Participating physiotherapists will be asked to attend a feedback session in which results of the clinical
audit will be shared. They will then be asked to participate in goal prioritizing and setting at the same or a
separate session.
One year later the physiotherapists will be asked to complete the system assessment tool again and attend
a feedback session in which results of a second audit will be shared.
Some Frequently asked questions
What happens from all the information you have collected from Physiotherapists?
Information collected directly from physiotherapists will only be used by me on this project.
How long does it take?
The Systems Assessment Tool will take 1-2 hours and will occur once a year.
The feedback from the clinical audit tool will take up to 1 hour and will occur once a year for 2 years.
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The goals and priority setting tool following the clinical audit feedback will take up to 1-2 hours and will
occur once for the purpose of this study.
An option to prioritise and set additional goals is offered.
What do I need to do?
Young people interested in participating will need to sign a consent form to take part. If under 18 years
old, their parents/guardians also need to sign the consent form before they can take part.
How will the information be collected?
Information will be audiotaped to ensure I get the information straight if therapists consent. Notes will be
taken at the meeting and a Systems Assessment Tool will be collated.
Is my information confidential?
All the information given by physiotherapists will be kept confidential.
The information relating to the clinical audit and systems assessment will be protected in locked files in
my office or in my locked home. It is only available to me and my research supervisors overseeing the
project.
This information will only be shared if participants gave their permission to do so beforehand. However,
if participants tell us about something against the law (like robbing a bank), there is no law that protects
this information if it is
requested by the Police or court.
I will use the information to make a report to tell other researchers, physiotherapists and program planners
what I have found. No names will be used and any information that could identify people contributing will
be removed.
Are there benefits?
There is no money involved; gourmet coffees and snacks will be provided as a thank you for your time. In
the long term, I hope the information collected will make physiotherapy more fun and better for more
Indigenous youth who come to see physiotherapists.
Are there any risks?
There is little risk from taking part. I do not think any questions I ask will cause distress. But if you do get
upset or talk to me about something that is upsetting you, I can organize extra help and support for you.
Where can I find out more information?
You can call me on xxxxxxxxxx or email Caroline Greenstein on: caroline.greenstein@xxxxxxxx
Or my supervisor David Thomas on 8922 7610 or email: [email protected]
If you have any concerns about the conduct of this study, or would like to make a complaint, please
contact:
HREC Ethics Administration
Human Research Ethics Committee of the NT Department of Health, and
Menzies School of Health Research
Phone: 08 89227922
Email: [email protected]
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3.3 PHYSIOTHERAPYCLINICAL AUDIT TOOL Physiotherapy Clinical Audit Tool
Version 1.8
1.1 Client ID ____________________1.2 Date of birth ______________ 1.3 Age at date of Audit ______________1.4 Sex Male 1 Female 2
1.5 Indigenous Status Aboriginal 1 Torres Strait Islander 2 Both 3 Not Stated 4
1.6 Family Background Indigenous Carer 1 Non-Indigenous Carers 2 Indigenous Foster Carer 3 Non-Indigenous Foster Carers 4
1.7 Language Spoken at Home English 1 Indigenous Language 2 Other 3 Not Stated 4
1.8 Date of Referral to Physiotherapy ______________ 1.9 Source of Referral: Aboriginal &/or Torres Strait Islander Health Worker 1 Aboriginal &/or Torres Strait Liaison Officer 2 Allied Health-Other 3 Educator 4 General practitioner 5
Orthopaedist 6 Paediatrician 7 Parent/Carer 8 Physiotherapist 9
Neurologist 10 Nurse 11 Other 12 1.10 Location of Referral Source: Early Intervention Disability Service 1
Town Public Hospital 2 Town Private Hospital 3 Interstate Hospital 4 Private Practice 5 Indigenous Medical Centre 6 Community Care Clinic 7 Dept of Ed/ Independent Education Office 8 Other 9 Not Stated 10
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1.11 Reason for Referral ______________________________________
1.12 Auditor _____________________
Section Two: Attendance
2.1 Date last attended ___________ TC 2.2 If the client has NOT attended within 12 months is there any record of an
unsuccessful follow up attempt since last attendance? 1-Yes 0-No 9-N/A 2.3 If yes, how many follow up attempts were made over the last 12 months? ________________ 2.4 Was there an attempt to contact the primary carer before the first appointment? 1-Yes 0-No 9- N/A 2.5 Was there a successful contact with primary carer before the first appointment? 1-Yes 0-No 9-N/A 2.6 Did the primary carer attend the physiotherapy appointment? 1-Yes 0-No 2.7 If the primary carer did not attend is there any record of follow up attempt
with the primary carer (either for appointment that was not attended or with appointment attended with another person such as teacher)?
1-Yes 0-No 2.8 Location of family consultation: Home 1 School 2 Office 3 Hospital 4 Telephone 5 Email 6 Other 7 Not recorded 8 2.9 If English is not the home language was an interpreter used?
1-Yes 0-No
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Physiotherapy Clinical Audit Tool
Version 1.8
If the child has been seen for first time in the last 12 months please complete section A
Section A: Background Is the following recorded anywhere in the client file or computer records?
Section Three: Key Information from Department Client Files and Computer Records
3.1 Birth History 1-Yes 0-No 3-Unknown 3.2 General medical history 1-Yes 0-No 3-Unknown 3.3 Developmental history 1-Yes 0-No 3-Unknown 3.4 Family History 1-Yes 0-No 3-Unknown 3.5 Social History 1-Yes 0-No 3-Unknown 3.6 Education history 1-Yes 0-No 3-Unknown 3.7 Diagnosis 1-Yes 0-No 3-Unknown 3.8 Risk Factors 1-Yes 0-No 3-Unknown
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Physiotherapy Clinical Audit Tool
Version 1.8
Is there a record of each of the following having been provided at least once inthe last 12 months? NOTE: If a service is not recommended than circle 9-N/A forthose items. NOTE: If child has diagnosis of cerebral palsy skip to section 5.
Measurements
Subjective:
Observation
Gross motor function
4.10 General Appearance 1-Yes 0-No 9-N/A 4.11 Behaviour 1-Yes 0-No 9-N/A 4.12 Child interaction with environment 1-Yes 0-No 9-N/A 4.13 Primary Carer/child interaction 1-Yes 0-No 9-N/A
4.14 ASQ (if >= 5 years) 1-Yes 0-No 8-Incomplete 9-N/A 4.15 AIMS (if non-ambulant ages 0-2) 1-Yes 0-No 8-Incomplete 9-N/A 4.16 NSMDA (age 0-6 and suspected cerebral palsy)1-Yes 0-No 8-Incomplete 9-N/A 4.17 Movement ABC (age 3-16 and no diagnosis) 1-Yes 0-No 8-Incomplete 9-N/A 4.18 Neurological 1-Yes 0-No 8-Incomplete 9-N/A 4.19 Musculoskeletal 1-Yes 0-No 8-Incomplete 9-N/A 4.20 Mobility 1-Yes 0-No 8-Incomplete 9-N/A 4.21 Gait (if applicable) 1-Yes 0-No 8-Incomplete 9-N/A
4.1 Pain 1-Yes 0-No 3-Unknown 9-N/A 4.2 Primary Carer’s Needs 1-Yes 0-No 3-Unknown 9-N/A 4.3 Child’s Needs 1-Yes 0-No 3-Unknown 9-N/A 4.4 Primary Carer’s Goals 1-Yes 0-No 3-Unknown 9-N/A 4.5 Child’s Goals 1-Yes 0-No 3-Unknown 9-N/A 4.6 Strengths 1-Yes 0-No 3-Unknown 9-N/A 4.7 Weaknesses 1-Yes 0-No 3-Unknown 9-N/A 4.8 Primary Carer’s Priorities 1-Yes 0-No 3-Unknown 9-N/A 4.9 Child’s Priorities 1-Yes 0-No 3-Unknown 9-N/A
Section Four: Clinical Services for Gross Motor Delay
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Environment
4.22 Home 1-Yes 0-No 3-Unknown 9-N/A 4.23 Preschool/School (if applicable) 1-Yes 0-No 3-Unknown 9-N/A 4.24 Childcare (if applicable) 1-Yes 0-No 3-Unknown 9-N/A 4.25 Equipment Needs 1-Yes 0-No 3-Unknown 9-N/A
4.26 Physical activity and rest 1-Yes 0-No 3-Unknown 9-N/A
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Physiotherapy Clinical Audit Tool
Version 1.8
NOTE: If child DOES NOT have a diagnosis of cerebral palsy skip to section 6
Clinical details
Measurements (In the last 12 months) Subjective:
Section Five: Clinical Services for Clients with Cerebral Palsy
5.1 CP Classification at diagnosis 1-Yes 0-No 3-Unknown Specify________________________________________________________
5.2 How old when diagnosed 1-Yes 0-No 3-Unknown 5.3 CP Type and Typography (recent) 1-Yes 0-No 3-Unknown
Specify________________________________________________________ 5.4 MACS 1-Yes 0-No 3-Unknown 5.5 Birth defects present 1-Yes 0-No 3-Unknown 5.6 Known syndromes 1-Yes 0-No 3-Unknown 5.7 Presence of Epilepsy 1-Yes 0-No 3-Unknown 5.8 Intellectual impairment 1-Yes 0-No 3-Unknown 5.9 Visual impairment 1-Yes 0-No 3-Unknown 5.10 Hearing impairment 1-Yes 0-No 3-Unknown 5.11 Communications impairment 1-Yes 0-No 3-Unknown 5.12 Sleep issues 1-Yes 0-No 3-Unknown 5.13 Respiratory Issues 1-Yes 0-No 3-Unknown 5.14 Pain issues 1-Yes 0-No 3-Unknown 5.15 Skin Integrity/health 1-Yes 0-No 3-Unknown 5.16 Surgical interventions 1-Yes 0-No 3-Unknown 5.17 Medical interventions (BoNT A, Baclofin) 1-Yes 0-No 3-Unknown 5.18 Details of hip x-ray in last 12 months 1-Yes 0-No 3-Unknown 9-N/A
5.19 Results of hip x-ray in last 12 months 1-Yes 0-No 3-Unknown 9-N/A
5.20 Pain 1-Yes 0-No 3-Unknown 9-N/A 5.21 Primary Carer’s Needs 1-Yes 0-No 3-Unknown 9-N/A 5.22 Child’s Needs 1-Yes 0-No 3-Unknown 9-N/A 5.23 Primary Carer’s Goals 1-Yes 0-No 3-Unknown 9-N/A 5.24 Child’s Goals 1-Yes 0-No 3-Unknown 9-N/A 5,25 Teacher/Goals 1-Yes 0-No 3-Unknown 9-N/A 5.26 Strengths 1-Yes 0-No 3-Unknown 9-N/A 5.27 Weaknesses 1-Yes 0-No 3-Unknown 9-N/A 5.28 Primary Carer’s Priorities 1-Yes 0-No 3-Unknown 9-N/A 5.29 Child’s Priorities 1-Yes 0-No 3-Unknown 9-N/A
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Observation
Environment
Mobility Functional Mobility
Gait
5.39 GMFCS (age <=18) 1-Yes 0-No 3-Unknown 9-N/A 5.40 FMS (age 4-18) 1-Yes 0-No 3-Unknown 9-N/A 5.41 GMFM 88 for GMFCS IV-V 1-Yes 0-No 8-Incomplete 9-N/A 5.42 GMFM 66 for GMFCS I-III 1-Yes 0-No 8-Incomplete 9-N/A 5.43 Sitting position 1-Yes 0-No 8-Incomplete 9-N/A 5.44 Transitional movements 1-Yes 0-No 8-Incomplete 9-N/A 5.45 Standing 1-Yes 0-No 8-Incomplete 9-N/A 5.46 Independence level 1-Yes 0-No 8-Incomplete 9-N/A 5.47 Self Care-Functional Level 1-Yes 0-No 8-Incomplete 9-N/A
Specify Assessment Used (e.g. PEDI) ____________________________
5.48 OGS or PRS 1-Yes 0-No 8-Incomplete 9-N/A 5.49 Assistance required 1-Yes 0-No 8-Incomplete 9-N/A 5.50 Equipment required 1-Yes 0-No 8-Incomplete 9-N/A 5.51 Orthotics used 1-Yes 0-No 8-Incomplete 9-N/A
5.52 2D VGA 1-Yes 0-No 8-Incomplete 9-N/A
5.30 General Appearance 1-Yes 0-No 9-N/A
5.31 Behaviour 1-Yes 0-No 9-N/A
5.32 Child interaction with environment 1-Yes 0-No 9-N/A
5.33 Primary carer / child interaction 1-Yes 0-No 9-N/A
5.34 Home 1-Yes 0-No 3-Unknown 9-N/A
5.35 Preschool/School (if applicable) 1-Yes 0-No 3-Unknown 9-N/A
5.36 Childcare (if applicable) 1-Yes 0-No 3-Unknown 9-N/A
5.37 Equipment Needs 1-Yes 0-No 3-Unknown 9-N/A
5.38 Physical activity and rest 1-Yes 0-No 3-Unknown 9-N/A
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Lower Limb Musculoskeletal Measurements (with goniometer)
Hips
Knees
Ankles
Feet: non-weight bearing
5.53 Supine Abduction (hips 0) R1 1-Yes 0-No 7-VE 9-N/A 5.54 Supine Abduction (hips 0) R2 1-Yes 0-No 7-VE 9-N/A 5.55 Supine Abduction (hips 90) R1 1-Yes 0-No 7-VE 9-N/A 5.56 Supine Abduction (hips 90) R2 1-Yes 0-No 7-VE 9-N/A 5.57 Supine Flexion R2 1-Yes 0-No 7-VE 9-N/A 5.58 Supine Hip Extension R1 1-Yes 0-No 7-VE 9-N/A 5.59 Staheli test or Thomas test 1-Yes 0-No 7-VE 9-N/A 5.60 Prone ER R2 1-Yes 0-No 7-VE 9-N/A 5.61 Prone IR R2 1-Yes 0-No 7-VE 9-N/A 5.62 Duncan Ely R1 1-Yes 0-No 7-VE 9-N/A
5.63 Duncan Ely R2 1-Yes 0-No 7-VE 9-N/A
5.64 Knee Extension 1-Yes 0-No 7-VE 9-N/A 5.65 Popliteal Angle R1 1-Yes 0-No 7-VE 9-N/A 5.66 Popliteal Angle R2 1-Yes 0-No 7-VE 9-N/A
5.67 Ankle dorsiflexion (knee 90) R1 1-Yes 0-No 7-VE 9-N/A 5.68 Ankle dorsiflexion (knee 90) R2 1-Yes 0-No 7-VE 9-N/A 5.69 Ankle dorsiflexion(knee 0) R1 1-Yes 0-No 7-VE 9-N/A 5.70 Ankle dorsiflexion(knee 0) R2 1-Yes 0-No 7-VE 9-N/A
5.71 Position noted R1 1-Yes 0-No 7-VE 9-N/A
5.72 Hindfoot (varus or valgus) 1-Yes 0-No 7-VE 9-N/A 5.73 Midfoot supination/pronation (knee 90) 1-Yes 0-No 7-VE 9-N/A 5.74 Hindfoot to forefoot alignment 1-Yes 0-No 7-VE 9-N/A 5.75 Toes alignment 1-Yes 0-No 7-VE 9-N/A5.76 Great toe 1-Yes 0-No 7-VE 9-N/A
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Spine
Pelvis /Leg length
Standing posture/alignment
5.77 Standing position 1-Yes 0-No 9-N/A 5.78 Sitting position 1-Yes 0-No 9-N/A
5.79 Prone attempt spinal correction 1-Yes 0-No 9-N/A
5.80 Standing position 1-Yes 0-No 9-N/A 5.81 Sitting position 1-Yes 0-No 9-N/A 5.82 Passive correction 1-Yes 0-No 9-N/A 5.83 Hip dysplasia/dissociation/subluxation 1-Yes 0-No 9-N/A 5.84 Leg length difference 1-Yes 0-No 7-V/E 9-N/A
5.85 Toes-frontal (Abd/add) 1-Yes 0-No 3-Unknown 9-N/A 5.86 Toes- sagittal (ext/flex) 1-Yes 0-No 3-Unknown 9-N/A 5.87 Forefoot-frontal (abd/add) 1-Yes 0-No 3-Unknown 9-N/A 5.88 Forefoot/midfoot-sagittal (cavus/planus) 1-Yes 0-No 3-Unknown 9-N/A 5.89 Forefoot/midfoot-transverse (supination/pronation)1-Yes 0-No 3-Unknown 9-N/A 5.90 Hindfoot-frontal (varus/valgus) 1-Yes 0-No 3-Unknown 9-N/A 5.91 Ankle/Hindfoot-sagittal (DF/PF) 1-Yes 0-No 3-Unknown 9-N/A 5.92 Ankles (inv/ev) 1-Yes 0-No 3-Unknown 9-N/A 5.93 Knee –frontal view (valgus/varus) 1-Yes 0-No 3-Unknown 9-N/A 5.94 Knee –sagittal view(crouch/recurvatum) 1-Yes 0-No 3-Unknown 9-N/A 5.95 Hip-frontal (abd/add) 1-Yes 0-No 3-Unknown 9-N/A 5.96 Hip-sagittal (flex/ext) 1-Yes 0-No 3-Unknown 9-N/A 5.97 Pelvis-frontal (obliquity) 1-Yes 0-No 3-Unknown 9-N/A 5.98 Pelvis-sagittal (tilt) 1-Yes 0-No 3-Unknown 9-N/A 5.99 Pelvis- transverse (rotation) 1-Yes 0-No 3-Unknown 9-N/A 5.100 Lumbar–spine frontal (scoliosis) 1-Yes 0-No 3-Unknown 9-N/A 5.101 Lumbar-spine sagittal (lordosis/kyphosis) 1-Yes 0-No 3-Unknown 9-N/A 5.102 Thoracic spine-frontal (scoliosis) 1-Yes 0-No 3-Unknown 9-N/A 5.103 Thoracic spine-sagittal(lordosis/kyphosis) 1-Yes 0-No 3-Unknown 9-N/A 5.104 Shoulder girdle-frontal (obliquity) 1-Yes 0-No 3-Unknown 9-N/A 5.105 Shoulder girdle-sagittal (IR) 1-Yes 0-No 3-Unknown 9-N/A 5.106 Cervical spine-frontal (sideflexion) 1-Yes 0-No 3-Unknown 9-N/A
5.107 Cervical spine – sagittal (flex/ext) 1-Yes 0-No 3-Unknown 9-N/A
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Motor function Lower Limbs - Strength
Selective Motor Control
Lower Limbs – Spasticity (MAS or ASA)
CP Type and Typography in the past 12 months
5.122 Physiotherapy assessed type and typography 1-Yes 0-No 3-Unknown 9-N/A
5.108 Hip Flexors 1-Yes 0-No 3-Unknown 9-N/A 5.109 Hip Abductors 1-Yes 0-No 3-Unknown 9-N/A 5.110 Hip Extensors 1-Yes 0-No 3-Unknown 9-N/A 5.111 Quadriceps 1-Yes 0-No 3-Unknown 9-N/A 5.112 Hamstrings 1-Yes 0-No 3-Unknown 9-N/A 5.113 Ankle Dorsiflexors 1-Yes 0-No 3-Unknown 9-N/A 5.114 Calves 1-Yes 0-No 3-Unknown 9-N/A
5.116 Hip Flexors 1-Yes 0-No 3-Unknown 9-N/A 5.117 Hip Adductors 1-Yes 0-No 3-Unknown 9-N/A 5.118 Quadriceps 1-Yes 0-No 3-Unknown 9-N/A 5.119 Hamstrings 1-Yes 0-No 3-Unknown 9-N/A 5.120 Gastrocnemii 1-Yes 0-No 3-Unknown 9-N/A 5.121 Solei 1-Yes 0-No 3-Unknown 9-N/A
5.115 Ankle Dorsiflexion 1-Yes 0-No 3-Unknown 9-N/A
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Physiotherapy Clinical Audit Tool
Version 1.8
Standing Frames
Wheeled mobility
Assisted Seating
Mobility Equipment (gait aides)
Physiotherapy Clinical Audit Tool
Version 1.8
Section Six: Equipment
6.1 Standing Frame description 1-Yes 0-No 8-Incomplete 9-N/A 6.2 Assistance required for transfers/use 1-Yes 0-No 8-Incomplete 9-N/A 6.3 Where item issued from 1-Yes 0-No 8-Incomplete 9-N/A 6.4 When item issued 1-Yes 0-No 8-Incomplete 9-N/A 6.5 Schedule of use (frequency/session time) 1-Yes 0-No 8-Incomplete 9-N/A 6.6 Issues with use 1-Yes 0-No 8-Incomplete 9-N/A 6.7 Issues with condition 1-Yes 0-No 8-Incomplete 9-N/A
6.8 Wheeled mobility description 1-Yes 0-No 8-Incomplete 9-N/A 6.9 Wheeled seating description 1-Yes 0-No 8-Incomplete 9-N/A 6.10 Assistance required for transfers 1-Yes 0-No 8-Incomplete 9-N/A 6.11 Where item issued from 1-Yes 0-No 8-Incomplete 9-N/A 6.12 When item issued 1-Yes 0-No 8-Incomplete 9-N/A 6.13 Issues with use 1-Yes 0-No 8-Incomplete 9-N/A 6.14 Issues with condition 1-Yes 0-No 8-Incomplete 9-N/A
6.15 Seating device description 1-Yes 0-No 8-Incomplete 9-N/A 6.16 Assistance required 1-Yes 0-No 8-Incomplete 9-N/A 6.17 Where item issued from 1-Yes 0-No 8-Incomplete 9-N/A 6.18 When item issued 1-Yes 0-No 8-Incomplete 9-N/A 6.19 Issues with use 1-Yes 0-No 8-Incomplete 9-N/A 6.20 Issues with condition 1-Yes 0-No 8-Incomplete 9-N/A
6.21 Equipment description 1-Yes 0-No 8-Incomplete 9-N/A 6.22 Assistance required 1-Yes 0-No 8-Incomplete 9-N/A 6.23 Where item issued from 1-Yes 0-No 8-Incomplete 9-N/A 6.24 When item issued 1-Yes 0-No 8-Incomplete 9-N/A 6.25 Issues with use 1-Yes 0-No 8-Incomplete 9-N/A 6.26 Issues with condition 1-Yes 0-No 8-Incomplete 9-N/A
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Lower Limb Orthotics
Is there a record of the following?
6.27 Lower limb orthotics been reviewed 1-Yes 0-No 8-Incomplete 9-N/A 6.28 Type prescribed 1-Yes 0-No 8-Incomplete 9-N/A 6.29 Type the child is using 1-Yes 0-No 8-Incomplete 9-N/A 6.30 Aim of orthotic 1-Yes 0-No 8-Incomplete 9-N/A 6.31 Time worn (hours/day) 1-Yes 0-No 8-Incomplete 9-N/A 6.32 Duration worn (months) 1-Yes 0-No 8-Incomplete 9-N/A
6.33 Issues (skin ulceration, compliance) 1-Yes 0-No 8-Incomplete 9-N/A
7.1Discussion with primary carer of results 1-Yes 0-No 9-N/A
7.2Action/support plan made with primary carer 1-Yes 0-No 9-N/A
7.3Action/support plan made with other provider (e.g. teacher) 1-Yes 0-No 9-N/A
7.4Referral to other agencies (e.g. paediatrician, audiology) 1-Yes 0-No 9-N/A
7.5Referral if X-Ray required at time of assessment 1-Yes 0-No 9-N/A
Section Seven: Results
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Physiotherapy Clinical Audit Tool
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Is there a record of the following provided in the past 12 months?
Goals Setting and Outcomes
Intervention Type
Mode of delivery
Comments Box
8.1 Short written assessment report 1-Yes 0-No 9-N/A 8.2 Goals set 1-Yes 0-No 9-N/A 8.3 COPM goals 1-Yes 0-No 9-N/A 8.4 GAS goals 1-Yes 0-No 9-N/A 8.5 Review plan developed to direct the measurement
of progress towards achievement of goals 1-Yes 0-No 9-N/A 8.6 Outcomes recorded 1-Yes 0-No 8-Incomplete 9-N/A
8.7 Outcomes obtained 1-Yes 0-No 8-Incomplete 9-N/A
8.8 Adaptive/therapeutic aids/equipment 1 8.9 Functional mobility training 2 8.10 Fitness 3 8.11 Casting 4 8.12 Referral to external source 5 8.13 Other 6
8.9 Focus on: 1-Yes 0-No9-N/A
participation in physical sports and activities 1body structures and functions, posture ,quality of movement andtransitional movement, mobility 2contextual factors (environmental and personal) 3
hip surveillance, adaptive/therapeutic aids and equipmenttraining, function, PRST, Gait fitness, casting
8.13 Individual session delivery 1 8.14 Group session delivery 2 8.15 Integrated into everyday activities 3 8.16 School Program 4 8.17 Home Program 5 8.18 Other 6
Specify_________________________________________________
Section Eight: Outcomes and Interventions
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3.4 PHYSIOTHERAPY CLINICAL AUDIT TOOL PROTOCOL
Physiotherapy Clinical Audit Protocol Tool Version 1.8
_______________________________________________________________________
Physiotherapy Clinical Audit Protocol Tool for Gross Motor Delay and Physical Disability
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Introduction
Eligibility of clients
To be eligible for inclusion in the Department audit, a child must:
be a client of Department
have been referred to physiotherapy with gross motor difficulties orphysical disability
Sample size A sample size of at least 30 records is recommended for this audit as referred to in other ABCD literature (McDonald and Ross Bailie, 2010). Due to the small number of clients with these needs accessing Department, all clients fitting thestated criteria will be audited. Due to the small service population, should there be less than 30, all reported data will be treated cautiously when using andcomparing reported data.
Content and Usage This audit is designed to be used in a few different ways. These include looking at how a service is initially accessed (e.g. referral source and reason forreferral); how a service is used (what service is requested and received);whether there have been barriers or facilitators to service use; whether thestandard of service is in line with best practice particularly in the changingsphere of cerebral palsy assessment and treatment; and whether outcomes areachieved.
The transient nature of allied health staff is recognized and additionalinformation and references have been provided on various items such asassessments for educational purposes of staff entering the field of community paediatric physiotherapy.
This audit tool can be used to audit service delivery to two broad groupcategories:
Clients with gross motor delay (can include diagnoses with physicaldisabilities other than cerebral palsy)
Clients with a diagnosis of cerebral palsy
A separate section to audit services to clients with cerebral palsy reflects thelarge proportion of Australian clients with physical disability who have cerebral palsy (Access Economics, 2008) and the dynamic nature of research andassessment for this clientele. The audit items will assist in examining whetherthe Department clinical records and assessment are in line with recommended standards from the national cerebral palsy register and CP Alliance, a nationalresearch and clinical organisation that promotes best practice (Cerebral PalsyAlliance, 2012, Cerebral Palsy Register, 2012).
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The structure of this protocol is based on the Child Health Clinical Audit Protocol (One21Seventy National Centre for Quality Improvement in Indigenous Primary Health Care and Menzies School of Health Research, 2011) and heavily references the following sources: AUSTRALIAN PHYSIOTHERAPY COUNCIL 2006. Australian Standards for Physiotherapy. In: COUNCIL, A. P. (ed.) CAMPBELL, S. K., PALISANO, R. & ORLIN, M. N. 2012. Physical therapy for
children, Saint Louis, Elsevier. CEREBRAL PALSY ALLIANCE. 2012. Cerebral Palsy Alliance [Online].
Available: http://www.cerebralpalsy.org.au [Accessed 31 October 2012]. WORLD CONFEDERATION FOR PHYSICAL THERAPY. WCPT guideline for
standards of physical therapy practice [Online]. London: WCPT Secretariat. Available: http://www.wcpt.org/sites/wcpt.org/files/files/Guideline_standards_practice_complete.pdf http://www.wcpt.org/guidelines/standards [Accessed 9 September 2012].
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1.1 Client ID The auditor will prepare a master list of clients included in the audit that contains the name of the client, date of birth and client id. 1.2 Date of birth Record the client’s date of birth as dd/mm/yyyy. 1.3 Age at date of audit Record the client’s age at the starting date record of the audit. Record the client’s age as months for clients <1 year old Record the client’s age as years and months for clients >1 year old. 1.4 Sex Indicate sex of client. 1.5 Indigenous status Record the client’s Indigenous status as stated in Department file referral, general information form or Computer system information. Circle 1-Aboriginal, 2-Torres Strait Islander, 3-Both. 1.6 Family background Record the carer’s background including parenting arrangements. Circle 1-living with Indigenous relatives, 2- living with non-Indigenous relatives, 3-living with Indigenous foster carers, 4-living with non-Indigenous foster carers, 5-not stated. If relatives are designated foster carers, Circle 1-living with Indigenous relatives. 1.7 Language Spoken at Home Record the language spoken at home. Circle 1-English, 2-Indigenous Language, 3-Other, 4-Not Stated 1.8 Date of Referral to Department Physiotherapy: Record the date of referral to Department Physiotherapy. This can be found in the Department file under referral section or within medical letter of referral placed under correspondence or referral section. 1.9 Source of Referral: Record the source of referral such as doctor, parent or physiotherapist. This can be found in the Department file in the Department referral in the referral
This section describes the characteristics of the clients in the sample, including age, sex and Indigenous status.
Section 1 General Information
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section or within medical letter of referral placed under correspondence orreferral section.
1.10 Location of Referral Source: Record the location of the source. For instance if the referral was from a doctor, record whether from private practice, RDH or interstate hospital. This can befound in the Department file in the Department referral in the referral section orwithin medical letter of referral placed under correspondence or referral section.
1.11 Reason for Referral Record the reason for referral to Physiotherapy.
1.12 Auditor Record the person’s name doing the audit. You may want to use a stamp if youregularly audit files.
1.13 Audit Date Record the date audited as dd/mm/yyyy. The audit date should be the same forall clients being audited in this cycle. Even if all auditing cannot be completed onthis date, continue to use the same audit date for all clients and audit therecords retrospectively from this date.
2.1 Date last attended Record the date last attended by physiotherapy as dd/mm/yyyy. Note: If service provided by telephone contact only in the past year record thedate as dd/mm/yyyy and circle TC.
2.2 Any record of unsuccessful follow-up attempt since lastattendance? If the client has not attended physiotherapy in the past 12 months is there anyrecord of an unsuccessful follow-up attempt since last attendance? Circle 1-Yes or 0-No.
2.3 Number of follow up attempts made
Section 2 Attendance
Time since last attendance is a useful measure of the level of client engagement with the health service (One21Seventy National Centre for Quality Improvement in Indigenous Primary Health Care and Menzies School of Health Research, 2011). The type and success of contact attempts by Department can shed light on client and physiotherapy service engagementand the ongoing management of the Department Physiotherapy services.
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If there was unsuccessful follow-up attempts to contact client made over the past 12 month, record the number of attempts made. 2.4 Was there an attempt to contact the primary carer before the first appointment? Record if an attempt to contact the primary carer before the appointment was documented. Circle 1-Yes or 0-No. 2.5 Was there a successful contact with primary carer before the first appointment? Record if documentation of successful contact with the primary carer before the first physiotherapy appointment and how the contact was made. Circle 1-Yes or 0-No. 2.6 Did the primary carer attend the physiotherapy appointment? Record if any documentation of primary carer attendance at a physiotherapy appt. Circle 1-Yes or 0-No. 2.7 Follow up attempt with primary carer Is there any record of a follow-up attempt with the primary carer (either for an appointment that was not attended by primary carer and child or an appointment attended by child with another person such as a teacher). Record any documentation of follow up attempt. Circle 1-Yes or 0-No. 2.8 Location of family consultation Record the location of the family consultation from the computer records, Physiotherapy report or Intake Summary Report. Record as 1-Home, 2-School (if met at child’s school), 3-Office (if met with family in the Department or Satellite Community Health (Burns and Mac Donald, 1996)made), 6-email if email contact made, 7-other (if , for instance, met at a park or other area), 8-not recorded. 2.9 Interpreter Use If English is not the home language has an interpreter been used? Circle 1-Yes or 2-No.
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An item (such as documentation of a diagnosis) may be found in more than one part of the file. To assist with locating a record of the item, several locations are listed where the item may be found within the record. The item location is listed in order from the most common to the least common. Once the item has been cited, circle yes and go to the next question. Complete if client has been seen for the first time in the last 12 months. Otherwise, skip to Section B. 3.1 Is there a record of the child’s birth history in the Department file or Computer records? The birth history can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department referrals (which many include Department Referral Form, Green RDH referral form or medical letters)
medical reports filed under Reports section.
The birth history may be found in the computer records under the Department Case History in:
Computer event notes
Any Department Reports placed under documents section Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 3.2 Is there a record of the child’s general medical history in the Department file or Computer records? The general medical history can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Birth history, general medical history, developmental history, family history , social history, education history, diagnosis and risk factors are all important background factors influencing the assessment and interventions provided by physiotherapy (Burns and Mac Donald, 1996). This information is in line with standards listed in World Confederation for Physical Therapy guideline for standards of physical therapy practice (World Confederation for Physical Therapy).
Section 3 Key information in Department files and computer records
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Department referrals (which many include Department Referral Form,Green RDH referral form or medical letters) medical reports filed underReports section.
The general medical history may be found in the computer records under theDepartment Case History in:
Computer event notes
Any Department Reports placed under documents section
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available.
3.3 Is there a record of the child’s developmental history in theDepartment file or Computer records? The developmental history can be found in the following areas of theDepartment File:
Department Intake Information Form filed in the Miscellaneous section
Department referrals (which many include Department Referral Form,Green RDH referral form or medical letters), medical reports filed underReportssection.
The developmental history may be found in the computer records under theDepartment Case History in:
Computer event notes
Any Department Reports placed under documents section
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available.
3.4 Is there a record of the child’s family history in the Department file or computer records? The family history can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department referrals (which many include Department Referral Form,Green RDH referral form or medical letters), medical reports filed underReportssection.
The family history may be found in the computer records under the Department Case History in:
Computer event notes
Any Department Reports placed under documents section
Circle 1-Yes or 0-No
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Circle 3-Unknown if there is documentation the information has been soughtbut is not available.
3.5 Is there a record of the child’s social history in the Department file orComputer records?
The social history can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department referrals (which many include Department Referral Form,Green RDH referral form or medical letters),
Department Assessment reports medical reports filed under Reportssection.
Medical reports filed under Reports section.
The social history may be found in the computer records under the Department Case History in:
Computer event notes
Any Department Reports placed under documents section
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available.
3.6 Is there a record of the parent’s or child’s educational history in theDepartment file or Computer records?
The parental education history can be found in the following areas of theDepartment File:
Department Intake Information Form filed in the Miscellaneous section
Department referrals (which many include Department Referral Form,Green RDH referral form or medical letters), medical reports filed underReports section.
The parental education history may be found in the computer records under theDepartment Case History in:
Computer event notes
Any Department Reports placed under documents section
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available.
3.7 Is there a record of a child’s diagnosis in the Department file orComputer records?
The diagnosis can be found in the following areas of the Department File:
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Department referrals (which many include Department Referral Form, Green RDH referral form or medical letters) under Referrals section.
medical reports filed under Reports section.
Department Intake Information Form filed in the Miscellaneous section The diagnosis may be found in the computer records under Department Case History under:
Computer Issues under Department Case
Computer event notes
Department reports under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 3.8 Is there a record of risk factors in the Department file or Computer records? Check Department information form Risk factors include parental factors such as smoking, drinking during pregnancy or depression as well as child factors such as premature birth and extra low birthweight. The risk factors can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department referrals (which many include Department Referral Form, Hospital referral form or medical letters), medical reports filed under Reports section.
The risk factors may be found in the computer records under the Department Case History in:
Computer event notes
Any Department Reports placed under documents section Circle 1-Yes or 0-No if located anywhere in file or computer. Circle 3-Unknown
if there is documentation the information has been sought but is not available. If client diagnosed with Cerebral Palsy skip to Section 5.
Section 4 Clinical assessment and services for gross motor delay or physical disability
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Sujective 4.1 Pain Is there a record of a question or an observation regarding the child’s experience of pain documented at least once in the last 12 months? This may include a question put to the carer of a baby or child with a severe communication or cognitive disorder or directly to the child. Pain questions can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Medical reports filed under Reports section.
Department Report filed under the reports section Pain questions may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 4.2 Primary Carer Needs Is there a record of discussion of primary carer needs with the primary carer in the last 12 months? This may include a question put to the carer about concerns or issues that they have. Primary carer needs can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department Intake Summary Report under Reports section.
Medical reports filed under Reports section.
Department Physiotherapy Report filed under the Reports section.
Greater attention has been directed at the personal, physical and social environment of the child as reflected in the International Classification of Functioning, Disability and Health (ICF) framework (Wahlgren and Palombaro, 2012). Collaboration in seeking and sharing information and providing a physiotherapy service is emphasized within client and family-centred practice (Campbell, 2006). Information regarding environment is sought through the subjective and observation sections of a clinical assessment.
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Primary carer needs may be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary Report placed under documents.
Department Physiotherapy Report placed under documents.
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available. Circle 9-N/A if the question is not applicable.
4.3 Child’s Needs Is there a record of discussion of child’s needs with the child with or without thefamily/carer input in the last 12 months? This may include a question put to thechild about things that he or she has troubles with.
Child’s needs may be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department Intake Summary Report under the Reports section.
Medical reports filed under Reports section.
Department Physiotherapy Report filed under the Reports section.
Child’s needs may be found in the computer records under Department CaseHistory under:
Computer event notes
Department Intake Summary Report placed under documents.
Department Physiotherapy Reports placed under documents.
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available. Circle 9-N/A if the question is not applicable.
4.4 Primary Carer’s Goals Is there a record of discussion of primary carer goals with the primary carer in the last 12 months?
Primary carer goals can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
Department Intake Summary Report filed under the Reports section.
Department COPM forms under the Miscellaneous section
Primary carer goals may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents.
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Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 4.5 Child’s Goals (for those 8 years and over) Is there a record of discussion of child’s goals with or without the primary carer in the last 12 months? Child’s goals can be found in the following areas of the Department File:
Department Report filed under the reports section
Department COPM forms under the Miscellaneous section Child’s goals may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable (child under age 8 or severely intellectually impaired). 4.6 Strengths Is there a record of a comment regarding the child’s strengths provided at least once in the last 12 months? This may be a comment found within a Department Physiotherapy report or as a question put to the carer or teacher or directly to the child. Strengths comments can be found in the following areas of the Department File:
Department Report filed under the reports section
Child’s School Educational Assessment Plan or Learning Profile filed in Reports section or miscellaneous.
Physiotherapy notes filed in the Miscellaneous section Strengths may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable.
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In the computer notes, a comment regarding strengths may be listed in Department Case History Event Notes or under Department Physiotherapy report under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 4.7 Weaknesses Is there a record of a comment regarding the child’s weaknesses provided at least once in the last 12 months? This may be a comment regarding “concerns or issues to work on” found within a Department Physiotherapy report or as a question put to the carer or teacher or directly to the child. Weaknesses comments can be found in the following areas of the Department File:
Department Report filed under the reports section
Child’s School Educational Assessment Plan (EAP) or Learning Profile filed in Reports section or miscellaneous.
Physiotherapy notes filed in the Miscellaneous section Weaknesses comments may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 4.8 Primary Carer’s Priorities Is there a record primary carer priorities regarding physiotherapy provided at least once in the last 12 months? This may be a question put to the carer or teacher or directly to the child or within an assessment such as the COPM. Family/Carer Priorities s can be found in the following areas of the Department File:
Department Report filed under the Reports section
COPM form under Miscellaneous section.
Physiotherapy notes filed in the Miscellaneous section Primary carer priorities may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents.
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Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 4.9 Child’s Priorities (for age 8 years and over) Is there a record of child’s priorities regarding physiotherapy provided at least once in the last 12 months? This may be a question put to the child with or without the carer and or with the carer. Child’s Priorities can be found in the following areas of the Department File:
Department Report filed under the Reports section
COPM form under Miscellaneous section.
Physiotherapy notes filed in the Miscellaneous section Child’s priorities may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable (child under age 8 or severely intellectually impaired).
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Clinical Measurements Observation 4.10 General Appearance Is there a comment on the child’s general appearance recorded at least once in the last 12 months? This may include but not be limited to a comment regarding weight, posture, biomechanical alignment, skin health. General appearance comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. General appearance comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents. Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable. 4.11 Behaviour Is there a record of a comment regarding the child’s behavior provided at least once in the last 12 months? This may be observations during Intake assessment, Department Physiotherapy assessment or during physiotherapy interventions. Behaviour comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. Behaviour comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable. 4.12 Child interaction with environment Is there a record of a comment regarding the child’s behavior provided at least once in the last 12 months? This may be observations during Department
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Intake assessment, Department Physiotherapy assessment or during physiotherapy interventions. Behaviour comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. Behaviour comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable.
4.13 Primary carer/child interaction Is there a comment regarding the primary carer/child interaction provided at least once in the last 12 months? This may be observations during Intake assessment, Department Physiotherapy assessment or during physiotherapy interventions. Parent or carer/child comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. Parent or carer/child comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable.
Gross Motor Function
4.14 Is there a record of completion of the Ages and Stages Questionnaire (ASQ) at least once in the last 12 months? If the child is less than one month or over 66 months, skip to next question. If the child has scored above cut off in
Physiotherapists are known as specialists in movement disorders and are involved in the assessment and improvement in gross motor development of children. Often gross motor delay in infants and young children is the first indication that there may be delay in other areas. Subsequently, screening and monitoring is recommended in other areas of development as well.
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gross motor skills (but still requires physiotherapy) and is seeing either a Department OT or SLP, skip to next question. The ASQ results can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department ASQ forms filed under Miscellaneous section. The ASQ can be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary report or Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable.
4.15 AIMS Is there a record of completion of the Alberta Infant Motor Scale (AIMS) at least once in the last 12 months? If the infant/toddler is less than 4 months or ambulant, skip to next question. The AIMS results can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department AIMS form filed under Miscellaneous section. The AIMS can be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary report or
Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable
Department has chosen to use the Ages and Stages Questionnaire (ASQ-3) as a developmental screening tool in combination with physiotherapy assessment (Squires, 2012) The ASQ-3 is a valid and reliable parent questionnaire and screening tool assisting in monitoring a child’s
development.
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4.16 NSMDA Gross motor assessment Is there a record of completion of the Neuro-Sensory and Motor DevelopmentalAssessment for Infants and Young Children (NSMDA) at least once in the last12 months? If the child is 7 years or older, skip to next question.
The NSMDA results can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
Department NSMDA form filed under Miscellaneous section.
The NSMDA can be found in the computer records under Department CaseHistory under:
Computer event notes
Department Intake Summary report or Department Physiotherapyreports placed under documents
Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable
4.17 Movement Assessment Battery (Movement ABC) Is there a record of completion of the Movement ABC? If the child is under age3 years old, older than age 16 years, or has a diagnosed condition, skip to nextquestion.
The Movement ABC results can be found in the following areas of the File:
Department Physiotherapy Report filed under the Reports section
Department Movement ABC form filed under Miscellaneous section.
The Movement ABC can be found in the computer records under Department Case History under:
The Alberta Infant Motor Scale is a valid and reliable screening tool used toidentify infants at risk of motor dysfunction (Piper and Darrah, 1994). It is used in combination with other motor assessments that look at posturalcontrol, motor control, strength and other factors contributing to movementdelay or disorders (Piper and Darrah, 1994) .
The NSMDA assesses gross and fine motor skills, neurological status, infantile reflexes, posture and balance reactions and response to sensoryinput. It is a valid and reliable assessment that has been used to identifyinfants with CP and other motor dysfunctions (Burns, 1992, Burns and MacDonald, 1996).
• Computer event notes• Department Intake Summary report or Department Physiotherapy
reports placed under documents
Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable
4.18 Neurological assessment Is there a record of a neurological assessment of the client in the past 12 months? Neurological tests include but are not limited to muscle tone, deep tendon reflexes, clonus, sensation, Babinski reflex and infantile reflexes. If at least 2 tests are performed circle yes. If not, circle no.
Neurological records can be found in the following areas of the Department File:
• Department Physiotherapy Report filed under the Reports section• NSMDA form or physiotherapy notes filed under Miscellaneous
section.
Neurological records can be found in the computer records under Department Case History under:
• Computer event notes• Department Intake Summary report or Department Physiotherapy
reports placed under documents
Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable
4.19 Musculoskeletal assessment Is there a record of a musculoskeletal assessment of the client in the past 12 months? Musculoskeletal tests include but are not limited to joint range of motion, muscle length, muscle strength, biomechanical alignment. If at least 2 tests are performed circle yes. If not, circle no.
Musculoskeletal records can be found in the following areas of the Department File:
• Department Physiotherapy Report filed under the Reports section
The Movement Assessment Battery 3rd edition identifies motor impairment in children age 3- 16 years (Henderson et al., 2007). It is considered the gold standard for assessing Developmental Coordination Disorder (Campbell et al., 2012).
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Department NSMDA form or physiotherapy notes filed under Miscellaneous section.
Musculoskeletal records can be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary report or Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable 4.20 Mobility Is there a record of a mobility assessment of the client in the past 12 months? Mobility records include observation on movement quality and independence in transitional movements (changing position in lying, lying to sitting, floor sitting to standing, sitting to standing from chair, sitting in chair from standing), gait, ascending/descending steps and running. Mobility records can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
Department ASQ, AIMS, NSMDA and Movement ABC forms or physiotherapy notes filed under Miscellaneous section.
Mobility records can be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary report or Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable. 4.21 Gait Is there a record of a general gait observation/assessment of the client in the past 12 months? Gait records include observation on movement quality and gait parameters (such as speed, cadence, heel strike, step width and step length, symmetry). Gait records can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
Department ASQ, NSMDA and Movement ABC forms or physiotherapy notes filed under Miscellaneous section.
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Gait records can be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary report or Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 8-Incomplete if records or assessment incomplete. Circle 9-N/A if the question is not applicable.
Environment 4.22 Home environment Is there a record regarding home environment? Issues discussed might include access, safety issues, and assistance required. Home environment records can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
ASQ form, Paediatric Evaluation of Disability Inventory form or physiotherapy notes filed under Miscellaneous section.
Musculoskeletal records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 4.23 School environment Is there a record regarding preschool/school environment? Issues discussed might include access, safety issues, and assistance required to participate in school activities. School environment records can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
physiotherapy notes filed under Miscellaneous section. School environment records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
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Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 4.24 Is there a record of discussion regarding childcare? Issues discussed might include access, safety issues, and assistance required. Records can be found in the following areas of the Department File:
Department Physiotherapy Report or Department Intake Summary Report filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 4.25 Is there a record of discussion regarding equipment needs? Issues discussed might include access, safety issues, and assistance required. Records can be found in the following areas of the Department File:
Department Physiotherapy Report or Department Intake Summary Report filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 4.26 Is there a record of discussion regarding physical activity and rest? Issues discussed might include type of play, amount of time involved in physical activity each day, endurance level and rest required. Records can be found in the following areas of the Department File:
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Department Physiotherapy Report or Department Intake Summary Report filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable
Physiotherapists as clinicians who work with children with movement disorders, have a responsibility to understand and promote physical activity and fitness (Campbell et al., 2012). This is particularly important with the increasing prevalence of obesity and diabetes within Australian Indigenous Populations (Pink and Allbon, 2008).
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If client does not have a diagnosis of cerebral palsy skip to Section 6.
Clinical details 5.1 CP Classification at diagnosis There are several systems to classify cerebral palsy. Systems include: type and distribution (e.g. spastic hemiplegia), mild, moderate, severe CP and bilateral vs unilateral CP. Is there a recording of the CP classification? Write in the classification used. Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports filed under the Reports section or correspondence
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.2 Age at diagnosis Record the age of diagnosis. This information may provide an idea of how early identified and level of engagement with medical system as well as any changes to diagnosis after age 5. Records can be found in the following areas of the Department file:
Department Physiotherapy Report, Medical or Specialist reports filed under the Reports section or correspondence
physiotherapy notes filed under Miscellaneous section.
Section 5 Clinical assessment and services for clients with cerebral palsy
Cerebral Palsy is the most common physical disability affecting children with increased frequency of multiple coexisting impairments (Access Economics, 2008). The field of research is growing and a dynamic, frequently changing standard of practice is required in line with the emerging evidence . Clinical details for sections 5.1 through to 5.123 are in line with CP Alliance (Cerebral Palsy Alliance, 2012) and information required by the Cerebral Palsy Register (Cerebral Palsy Register, 2012). Information regarding specific assessments or interventions are listed in the boxes under that item.
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Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available.
5.3 Current Classification of Type and Typography Is there a record of type and typography classification performed by medical specialists in the previous 12 months? Write in the classification used.
Circle 1-Yes 0-No 3-Unknown Circle 3-Unknown if there is documentation the information has been soughtbut is not available. Circle 9-N/A if not applicable.
5.4 Manual Ability Classification System (MACS) Is there a MACS score recorded? If the child is less than age 4 or over age 18,skip to next question.
Records can be found in the following areas of the Department File:
Department Physiotherapy, Occupational Therapy or Medical Reportfiled under the Reports section
physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case Historyunder:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available.
5.5 Birth Defects Is there a record of the presence of birth defects?
Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports filedunder the Reports section
physiotherapy notes filed under Miscellaneous section.
Please see attachment entitled DESCRIPTION OF CEREBRAL PALSY fordetails.
The MACS describes the ability to handle objects in daily life for children withcerebral palsy use their hands to handle objects in daily life (Eliasson et al., 2006).
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Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available.
5.6 Known Syndromes Is the presence of any known syndrome recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.7 Presence of epilepsy Is the presence of epilepsy recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.8 Presence of intellectual impairment Is the presence of intellectual impairment recorded?
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Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist, Psychology, School Guidance Officer, Early Childhood Intervention reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.9 Visual impairment Is the presence of visual impairment recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist or Early Childhood Intervention reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.10 Presence of hearing impairment Is the presence of a hearing impairment recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist, Early Childhood Intervention or NT Hearing reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
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Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable
5.11 Communications impairment Is the presence of a communications impairment recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Department Speech Pathology Report, Medical or Specialist, or Early Childhood Intervention filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.12 Presence of sleep issues Is the presence of any sleep issues recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Department Occupational Therapy Report, Medical or Specialist, or Early Childhood Intervention filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.13 Respiratory issues Is the presence of respiratory issues recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report,, Medical or Specialist, or Department Speech Pathology reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section.
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Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available.
5.14 Pain Is the presence of pain recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.15 Skin Integrity/health Is the skin integrity/health recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports, Wheelchair Clinic General Information form filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. 5.16 Surgical Intervention Is there a record of surgical interventions? These include any surgical procedures. Records can be found in the following areas of the Department File:
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Department Physiotherapy Report, Medical or Specialist reports,Wheelchair Clinic General Information form filed under the Reportssection
physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available.
5.17 Medical Interventions Are medical interventions recorded? These include prescription of medications for pain, epilepsy, spasticity and injections of BoNT-A. Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports, SEATGeneral Information form filed under the Reports section
physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available.
5.18 Has a hip x-ray been performed within the recommended time frame? Refer to sheet attached for guidelines Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A for not applicable
5.19 Are the results reported? Are the migration indices (MP) reported for most recent hip x-ray? Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A for not applicable.
Hip dislocation is a severe and serious secondary complication affecting many children with Cerebral Palsy. Hip surveillance programs are required to track insidious hip displacement and prevent unnecessary disability. Every child should be referred for hip surveillance at the time of diagnosis of cerebral palsy (Wynter et al., 2011).
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Subjective 5.20 Pain Is there a record of a question or an observation regarding the child’s experience of pain documented at least once in the last 12 months? This may include a question put to the carer of a baby or child with a severe communication or cognitive disorder or directly to the child. Pain questions can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Medical reports filed under Reports section.
Department Report filed under the reports section Pain questions may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 5.21 Primary Carer Needs Is there a record of discussion of primary carer needs with the primary carer in the last 12 months? This may include a question put to the carer about concerns or issues that they might have. Primary carer needs can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department Intake Summary Report under Reports section.
Medical reports filed under Reports section.
Department Physiotherapy Report filed under the Reports section Primary carer needs may be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary Report placed under documents.
Department Physiotherapy Report placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable.
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5.22 Child’s Needs Is there a record of discussion of child’s needs with the child with or without the family/carer input in the last 12 months? This may include a question put to the child about things that he or she has troubles with. Child’s needs can be found in the following areas of the Department File:
Department Intake Information Form filed in the Miscellaneous section
Department Intake Summary Report under the Reports section.
Medical reports filed under Reports section.
Department Physiotherapy Report filed under the Reports section. Child’s needs may be found in the computer records under Department Case History under:
Computer event notes
Department Intake Summary Report placed under documents.
Department Physiotherapy Reports placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 5.23 Primary Carer Goals Is there a record of discussion of primary carer goals with the primary carer in the last 12 months? Primary carer goals can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
Department Intake Summary Report filed under the Reports section.
Department COPM forms under the Miscellaneous section Primary carer goals may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 5.24 Child’s Goals (for those 8 years and over) Is there a record of discussion of child’s goals with or without the primary carer in the last 12 months? Child’s goals can be found in the following areas of the Department File:
Department Report filed under the reports section
Department COPM forms under the Miscellaneous section
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Child’s goals may be found in the computer records under Department CaseHistory under:
Computer event notes
Department reports under placed under documents.
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available. Circle 9-N/A if the question is not applicable.
5.25 Teacher’s Goals If the concerns were raised by the teacher who then attended the meeting, is there a record of discussion of teacher’s goals in the last 12 months? Teacher’s goals can be found in the following areas of the Department File:
Department Report filed under the reports section
Department COPM forms under the Miscellaneous section
Teacher’s goals may be found in the computer records under Department CaseHistory under:
Computer event notes
Department reports under placed under documents.
Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been soughtbut is not available. Circle 9-N/A if the question is not applicable.
5.26 Strengths Is there a record of a comment regarding the child’s strengths provided at least once in the last 12 months? This may be a comment found within a Department Physiotherapy report or as a question put to the carer or teacher or directly tothe child.
Strengths comments can be found in the following areas of the Department File:
Department Report filed under the reports section
Child’s School Educational Assessment Plan or Learning Profile filed inReports section or miscellaneous.
Physiotherapy notes filed in the Miscellaneous section
Strengths may be found in the computer records under Department CaseHistory under:
Computer event notes
Department reports under placed under documents.
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Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. In the computer notes, a comment regarding strengths may be listed in Department Case History Event Notes or under Department Physiotherapy report under documents. Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable. 5.27 Weaknesses Is there a record of a comment regarding the child’s weaknesses provided at least once in the last 12 months? This may be a comment regarding “concerns or issues to work on” found within a Department Physiotherapy report or as a question put to the carer or teacher or directly to the child. Weaknesses comments can be found in the following areas of the Department File:
Department Report filed under the reports section
Child’s School Educational Assessment Plan or Learning Profile filed in Reports section or miscellaneous.
Physiotherapy notes filed in the Miscellaneous section Weaknesses comments may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 5.28 Primary Carer’s Priorities Is there a record primary carer priorities regarding physiotherapy provided at least once in the last 12 months? This may be a question put to the carer or teacher or directly to the child or within an assessment such as the COPM. Primary Carer Priorities can be found in the following areas of the Department File:
Department Report filed under the Reports section
COPM form under Miscellaneous section.
Physiotherapy notes filed in the Miscellaneous section Family/carer priorities may be found in the computer records under Department Case History under:
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Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable. 5.29 Child’s Priorities (for age 8 years and over) Is there a record of child’s priorities regarding physiotherapy provided at least once in the last 12 months? This may be a question put to the child with or without the carer and or with the carer. Child’s Priorities s can be found in the following areas of the Department File:
Department Report filed under the Reports section
COPM form under Miscellaneous section.
Physiotherapy notes filed in the Miscellaneous section Child’s priorities may be found in the computer records under Department Case History under:
Computer event notes
Department reports under placed under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable (child under age 8 or severely intellectually impaired)
Observation 5.30 General Appearance Is there a comment on the child’s general appearance recorded at least once in the last 12 months? This may include but not be limited to a comment regarding weight, posture, biomechanical alignment, skin health. General appearance comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. General appearance comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents. Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable.
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5.31 Behaviour Is there a record of a comment regarding the child’s behavior provided at least once in the last 12 months? This may be observations during Intake assessment, Department Physiotherapy assessment or during physiotherapy interventions. Behaviour comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. Behaviour comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable. 5.32 Child interaction with environment Is there a record of a comment regarding the child’s behavior provided at least once in the last 12 months? This may be observations during Intake assessment, Department Physiotherapy assessment or during physiotherapy interventions. Behaviour comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. Behaviour comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable.
5.33 Primary carer/child interaction Is there a comment regarding the primary carer/child interaction provided at least once in the last 12 months? This may be observations during Intake assessment, Department Physiotherapy assessment or during physiotherapy interventions.
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Primary carer/child comments can be found in the following areas of the Department File:
Department Intake Summary Report or Department Physiotherapy Report filed under the Reports section
Department physiotherapy notes filed under Miscellaneous section. Primary carer/child comments can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 9-N/A if the question is not applicable.
Environment 5.34 Home environment Is there a record regarding home environment? Issues discussed might include access, safety issues, and assistance required. Home environment records can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
ASQ form, Paediatric Evaluation of Disability Inventory form or physiotherapy notes filed under Miscellaneous section.
Musculoskeletal records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 5.35 School environment Is there a record regarding preschool/school environment? Issues discussed might include access, safety issues, and assistance required to participate in school activities. School environment records can be found in the following areas of the Department File:
Department Physiotherapy Report filed under the Reports section
physiotherapy notes filed under Miscellaneous section.
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School environment records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 5.36 Is there a record of discussion regarding childcare? Issues discussed might include access, safety issues, and assistance required. Records can be found in the following areas of the Department File:
Department Physiotherapy Report or Department Intake Summary Report filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable 5.37 Is there a record of discussion regarding equipment needs? Issues discussed might include access, safety issues, and assistance required. Records can be found in the following areas of the Department File:
Department Physiotherapy Report or Department Intake Summary Report filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable
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5.38 Is there a record of discussion regarding physical activity and rest? Issues discussed might include type of play, amount of time involved in physical activity each day, endurance level and rest required. Records can be found in the following areas of the Department File:
Department Physiotherapy Report or Department Intake Summary Report filed under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable
5.39 Gross Motor Functional Classification Score (GMFCS) Is there a Gross Motor Functional Classification Score (GMFCS) recorded? Records can be found in the following areas of the Department File:
Department Physiotherapy Report, Medical or Specialist reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section.
Physiotherapists in the school and community often prescribe, organise, fit and train children and staff in the used of community to assist children to access their environment. Equipment is part of a total therapeutic management program for a client that should augment home, school, therapy home programs and lifestyle. (Burns and Mac Donald, 1996).
Physiotherapists as clinicians who work with children with movement disorders have a responsibility to understand and promote physical activity (Campbell et al., 2012). This is particularly important with evidence reflecting the difficulties children with cerebral palsy encounter accessing physical activity (Palisano et al., 2012), the increasing prevalence of obesity and diabetes within Australian Indigenous populations (Love et al., 2010, Pink and Allbon, 2008). Certain conditions such as juvenile rheumatoid arthritis also require information on rest and energy conservation (Campbell et al., 2012)
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Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable
Motor Function 5.40 Functional Motor Scale (FMS) If the child is between the ages 4-12 years is there a record of the FMS at least once within the past 12 months? In the Department file this information will be found in physiotherapy and medical reports found in the Reports section, Department Physiotherapy CP worksheet notes found in the Miscellaneous section. In the Computer records this information will be recorded in the Department Case History Computer notes and in the Department Physiotherapy Reports under documents. Circle 1-Yes or 0-No Circle 3-Unknown if there is documentation the information has been sought but is not available. Circle 9-N/A if the question is not applicable
5.41 Gross Motor Functional Measure-66 (GMFM-66) If the child is classified as GMFCS I-III is there a record of the GMFM-66 performed at least once in the last 12 months? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under Reports section
The FMS is a mobility scale is a valid and reliable tool used to describe the child’s need for assistive mobility aides during functional (versus therapeutic) mobility at distances of 5, 50 and 50 metres (Graham et al., 2004).
GMFCS is a classification system that describes gross motor function of children aged 0-18 years with cerebral palsy (Palisano et al., 1997). It provides a reliable classification of the severity of CP on motor function and is widely used in research and practice. (Campbell et al., 2012).
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physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case Historyunder:
Computer event notes(Nelson, 2007)
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No or 8-Incomplete if not completed 9-N/A if notapplicable
5.42 Gross Motor Functional Measure-88 (GMFM-88) If the child is classified as GMFCS IV-V is there a record of the GMFM-88performed at least once in the last 12 months?
Records can be found in the following areas of the Department File:
Department Physiotherapy Report or other physiotherapy reports filedunder the Reports section
physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case Historyunder:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No or 8-Incomplete if not completed 9-N/A if notapplicable
5.43 Sitting position If child is over 6 months corrected age is a comment on type of sitting position(e.g. w-sitting, tailor sitting, ring sitting) and amount of assistance requiredrecorded in the past 12 months?
Records can be found in the following areas of the Department File:
Department Physiotherapy Report or other physiotherapy reports filedunder the Reports section
The GMFM, is one of the most widely used tools to assess the gross motor ability of children with CP. It is valid and reliable and used clinically and forresearch (Gemus et al., 2001). GMFM-66 has been validated for use withGMFCS 1 –III (Campbell et al., 2012).
The GMFM, is one of the most widely used tools to assess children with CP. It isvalid and reliable and used clinically and for research . GMFM-88 has beenvalidated for use with GMFCS 1 –V (Gemus et al., 2001).
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physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable
5.44 Transitional Positions Is a comment recorded on the quality of transitional movements and assistance required demonstrated in the last 12 months? Examples include rolling, lying to sitting, sitting to standing, moving floor to chair, floor to walker with one person assisting for balance or to help initiate movement. Records can be found in the following areas of the Department File:
Department Physiotherapy Report or other physiotherapy reports filed under the Reports section
physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable 5.45 Standing Is a comment recorded on the quality of standing and assistance required demonstrated in the last 12 months Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable 5.46 Independence Level Is the level of independence required for transfers and transitional movements recorded? This should include mobility assistance as well as aides. Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable 5.47 Self Care- Functional Level Is there a record of a child’s self-care ability in the previous 12 months? This may be contained as a referral to an Occupational Therapy report or within an assessment such as the Pediatric Evaluation of Disability Inventory. Please specify assessment used.
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Records can be found in the following areas of the Department File:
Department Physiotherapy Report or other occupational therapy or physiotherapy reports filed under the Reports section
Physiotherapy/Occupational Therapy notes filed under Miscellaneous section.
Education Assessment Plan records filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable
Gait 5.48 Observational Gait Scale (OGS) or Physician’s Rating Scale (PRS) If child is walking is there a record of an OGS or PRS to assess the gait in the past 12 months? Records can be found in the following areas of the Department File:
Department Physiotherapy Report or other physiotherapy reports filed under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable
5.49 Gait assistance required If child is walking is there a record of assistance required at least once in the past 12 months? Records can be found in the following areas of the Department File:
Department Physiotherapy Report or other physiotherapy reports filed under the Reports section (GMFCS, FMS, OGS)
physiotherapy notes filed under Miscellaneous section.
Observational gait analysis is a standard for physiotherapy practice for children with cerebral palsy. Several gait assessment tools exist. A standardized gait tool such as the Observational Gait Scale or PRS is recommended (Love et al., 2010).
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Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable or 9-N/A if not applicable
5.50 Mobility equipment required If child is walking is there a record of gait aides required at least once in the past 12 months?
Records can be found in the following areas of the Department File:
Department Physiotherapy Report or other physiotherapy reports filedunder the Reports section
physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable
5.51 Orthotics If child is walking and uses orthotics is there a record of any orthotics used and the type of orthotic at least once in the past 12 months?
Circle 1-Yes or 0-No 8-Incomplete if not completed or 9-N/A if not applicable
5.52 Two Dimensional (Standard) Gait Video If the child is walking, is there a record of a 2 dimensional gait video recorded in the last year with front, back and side views?
Records can be found in the Department File:
A labeled CD/DVD at the front of the chart
Department Physiotherapy reports placed under documents
Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documentsCircle 1-Yes or 0-No 8-Incomplete if not complete or 9-N/A if not applicable
Two dimensional (standard) video of gait is valuable in classifying gait patterns which lead to more informed orthotic prescription and longitudinal monitoring, spasticity management and of quality of gait over time within the community (Harvey et al., 2009, Love et al., 2010). Community therapists are often asked to video gait to be sent to the interstate medical,
surgical and physiotherapy specialists.
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Measurements In the following items records can be found in the following areas of the Department File:
Department Physiotherapy Report or other physiotherapy reports filedunder the Reports section
physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Lower Limb Musculoskeletal Measurements with goniometer IF there is only a visual estimate: indicate VE next to measurement
Hip 5.53 Supine Abduction (hips 0) R1 Is there a record of an R1 (catch) measurement of supine hip abduction with hips at neutral at least once within the past 12 months?
Circle 1-Yes or 0-No, 7-VE if visual estimate only or 9-N/A if not applicable
5.54 Supine Abduction (hips 0) R2 Is there a record of an R2 (Full passive range of motion) of supine hip abduction at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.55 Supine Abduction (hips 90) R1 Is there a record of an R1 (catch) measurement of supine hip abduction with hips flexed at 90 degrees at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.56 Supine Abduction (hips 90) R2 Is there a record of an R2 (Full passive range of motion) of supine hip abduction at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.57 Supine Flexion Is there a record of supine hip flexion at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
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5.58 Supine Hip Extension Is there a record of supine hip extension at least once within the past 12 months? Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable 5.59 Staheli test or Thomas test Is there a record of the Staheli test or Thomas test at least once within the past 12 months? Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable 5.60 Prone Hip External Rotation (ER) Is there a record of prone hip external rotation at least once within the past 12 months? Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable 5.61 Prone Hip Internal Rotation (IR) Is there a record of supine hip internal rotation at least once within the past 12 months? Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable 5.62 Duncan Ely R1 Is there a record of Duncan Ely R1 measurement (point at which a catch is felt upon quick passive movement) at least once within the past 12 months? Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable 5.63 Duncan Ely R2 Is there a record of Duncan Ely R2 measurement (full passive range of motion) at least once within the past 12 months? Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable 5.64 Knee Extension Is there a record of knee extension at least once within the past 12 months? Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable 5.65 Popliteal Angle R1 Is there a record of popliteal angle R1 measurement at least once within the past 12 months?
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Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.66 Popliteal Angle R2 Is there a record of popliteal angle R2 measurement at least once within thepast 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.67 Ankle dorsiflexion (knee 90) R1 Is there a record of ankle dorsiflexion with knees flexed 90 degrees R1 measurement at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.68 Ankle dorsiflexion (knee 90) R2 Is there a record of an ankle dorsiflexion with knees flexed 90 degrees R2measurement at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.69 Ankle dorsiflexion (knee 0) R1 Is there a record of an ankle dorsiflexion with knees extended to 0 degrees R1measurement at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.70 Ankle dorsiflexion (knee 0) R2 Is there a record of an ankle dorsiflexion with knees extended to 0 degrees R2measurement at least once within the past 12 months?
Circle 1-Yes or 0-No, -VE if visual estimate only or 9-N/A if not applicable
5.71 Position noted (prone or supine) Is there a record of the position in which measurement taken of calves?
Circle 1-Yes or 0-No, 7-VE if visual estimate only or 9-N/A if not applicable
Foot Is there a record of the following measurements taken in the past 12 months? Circle 1-Yes or 0-No, 7-VE if visual estimate only or 9-N/A if not applicable
5.72 Hindfoot varus or valgus 1-Yes 0-No 7-VE 9-N/A 5.73 Midfoot supination/pronation (knee 90) 1-Yes 0-No 7-VE 9-N/A 5.74 Hindfoot to forefoot alignment 1-Yes 0-No 7-VE 9-N/A 5.75 Toes alignment 1-Yes 0-No 7-VE 9-N/A5.76 Great toe 1-Yes 0-No 7-VE 9-N/A
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Spine 5.77 Spinal position - standing Is there a record of an evaluation of the spinal position in standing? Circle 1-Yes or 0-No or 9-N/A if not applicable 5.78 Spinal position - sitting or lying Is there a record of an evaluation of the spinal position in sitting or lying down in contracture? Circle 1-Yes or 0-No or 9-N/A if not applicable 5.79 Prone attempt spinal correction Is there a record of an assessment of passive spinal in prone (or sitting or supine if prone not tolerated)? Circle 1-Yes or 0-No or 9-N/A if not applicable
Is there a record taken of the following measurements in the past 12 months? Circle 1-Yes or 0-No or 9-N/A if not applicable
Pelvis/Leg length Circle 3-Unknown when there is documentation that the assessment has been attempted but unable to proceed (e.g. due to cooperation or pain).
5.80 Standing position 1-Yes 0-No 9-N/A 5.81 Sitting position 1-Yes 0-No 9-N/A 5.82 Passive correction 1-Yes 0-No 9-N/A 5.83 Hip dysplasia/dissociation/subluxation 1-Yes 0-No 9-N/A 5.84 Leg/Length difference 1-Yes 0-No 7-VE 9-N/A
Postural Alignment in standing: Circle 3-Unknown when there is documentation that the assessment has been attempted but unable to proceed (e.g. due to cooperation or pain).
5.85 Toes-frontal (Abd/add) 1-Yes 0-No 3-Unknown 9-N/A 5.86 Toes- sagittal (ext/flex) 1-Yes 0-No 3-Unknown 9-N/A 5.87 Forefoot-frontal (abd/add) 1-Yes 0-No 3-Unknown 9-N/A 5.88 Forefoot/midfoot-sagittal (cavus/planus) 1-Yes 0-No 3-Unknown 9-N/A 5.89 Forefoot/midfoot-transverse (supination/pronation) 1-Yes 0-No 3-Unknown 9-N/A 5.90 Hindfoot-frontal (varus/valgus) 1-Yes 0-No 3-Unknown 9-N/A 5.91 Ankle/Hindfoot-sagittal (DF/PF) 1-Yes 0-No 3-Unknown 9-N/A 5.92 Ankles-frontal(inversion/eversion) 1-Yes 0-No 3-Unknown 9-N/A 5.93 Knee –frontal view (valgus/varus) 1-Yes 0-No 3-Unknown 9-N/A 5.94 Knee –sagittal view(crouch/recurvatum) 1-Yes 0-No 3-Unknown 9-N/A 5.95 Hip-frontal (abd/add) 1-Yes 0-No 3-Unknown 9-N/A 5.96 Hip-sagittal (flexion/extension) 1-Yes 0-No 3-Unknown 9-N/A 5.97 Pelvis-frontal (obliquity) 1-Yes 0-No 3-Unknown 9-N/A 5.98 Pelvis-sagittal (tilt) 1-Yes 0-No 3-Unknown 9-N/A
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5.99 Pelvis- transverse (rotation) 1-Yes 0-No 3-Unknown 9-N/A 5.100 Lumbar–spine frontal (scoliosis) 1-Yes 0-No 3-Unknown 9-N/A 5.101 Lumbar-spine sagittal (lordosis/kyphosis)1-Yes 0-No 3-Unknown 9-N/A 5.102 Thoracic spine-frontal (scoliosis) 1-Yes 0-No 3-Unknown 9-N/A 5.103 Thoracic spine-sagittal (lordosis/kyphosis)1-Yes0-No 3-Unknown 9-N/A 5.104 Shoulder girdle-frontal (obliquity) 1-Yes 0-No 3-Unknown 9-N/A 5.105 Shoulder girdle-sagittal (Retraction/Protraction/IR)1-Yes0-No3-Unknown 9-N/A
5.106 Cervical spine-frontal (sideflexion)1-Yes 0-No 3-Unknown 9-N/A 5.107 Cervical spine – sagittal (flex/ext) 1-Yes 0-No 3-Unknown 9-N/A
Motor Function Lower Limb Strength Muscle strength grades should be indicated in a 0/5-5/5 scale. Circle 3-Unknown when there isdocumentation that the assessment has been attempted but unable to proceed (e.g. due tocooperation or pain).
5.108 Hip Flexors 1-Yes 0-No 3-Unknown 9-N/A 5.109 Hip Abductors 1-Yes 0-No 3-Unknown 9-N/A 5.110 Hip Extensors 1-Yes 0-No 3-Unknown 9-N/A 5.111 Quadriceps 1-Yes 0-No 3-Unknown 9-N/A 5.112 Hamstrings 1-Yes 0-No 3-Unknown 9-N/A 5.113 Ankle Dorsiflexors 1-Yes 0-No 3-Unknown 9-N/A 5.114 Calves 1-Yes 0-No 3-Unknown 9-N/A
Motor ControlCircle 3-Unknown when there is documentation that the assessment has been attempted butunable to proceed (e.g. due to cooperation or pain).
5.115 Selective Motor Control for dorsiflexion Circle 1-Yes 0-No 3-Unknown or 9-N/A for not applicable.
Lower Limb Spasticity Is there a record of the Modified Ashworth Scale (MAS) or the AustralianSpasticity Assessment Scale (ASAS) present for each of the following items inthe past 12 months? 5.116 Hip Flexors 1-Yes 0-No 3-Unknown 9-N/A 5.117 Hip Adductors 1-Yes 0-No 3-Unknown 9-N/A 5.118 Quadriceps 1-Yes 0-No 3-Unknown 9-N/A 5.119 Hamstrings 1-Yes 0-No 3-Unknown 9-N/A 5.120 Gastrocnemii 1-Yes 0-No 3-Unknown 9-N/A5.121 Solei 1-Yes 0-No 3-Unknown 9-N/A
5.122 Physiotherapy Assessed Type and Typography If there is no record of type and typography classification performed by medical
The selective motor control test examines the child’s ability to dorsiflex and the balance of muscle activity used (Boyd, Rodda and Graham, 1996).
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specialists in the previous 12 months, is there a physiotherapy assessed type and typography? Circle 1-Yes 0-No 3-Unknown 9-N/A
Please see attachment entitled DESCRIPTION OF CEREBRAL PALSY for details.
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If client does not need equipment, circle N/A.
6.1 Standing Frame description If a standing frame is used, is there a record of the type and model? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.2 Assistance required for transfers/use If a standing frame is used, is there a record of assistance required for transfer in and out of the standing frame and while the child is using it? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.3 Source of Issue If a standing frame is used and has been issued in the past year or the client has entered Department services in the past year, is there a record of where the item was issued from? This may be from Territory Independent Mobility Equipment Scheme, the family, Variety Club funding and so on. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.4 Date of Issue If a standing frame is used and has been issued in the past year or the client has entered Department services in the past year, is there a record of where the item was issued from? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.5 Schedule of Use If a standing frame is used, is the use of the standing frame including frequency of sessions and time spent in the standing frame recorded? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.6 Issues with use If a standing frame is used, are any issues with use of standing frame recorded? This may include compliance, disrepair, fit, or difficulties with transfers and fit of standing frame. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.7 Issues with condition
Section 6 Equipment
Equipment is part of a total therapeutic management program for a child. The equipment recommended should augment home, school, therapy home programs and lifestyle. Equipment prescription and provision is a dynamic, labour and financially intensive, complex and constantly changing process. Equipment provision requires regular monitoring to ensure optimal use and success for the children and carers involved (Burns and Mac Donald, 1996).
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If standing frame is used, are any issues with the condition and maintenance of the item recorded? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.8 Wheeled mobility description If wheeled mobility is used, is there a record of the type (s) used and model(s)? For instance, a child may use items such as a pram, manual wheelchair, power wheelchair or a combination of such devices. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.9 Wheeled seating description If wheeled mobility is used, is there a record of the type (s) of seating used and the seating model(s)? The type of seating and its features should be recorded. For instance, a child may use a customized seat cushion with a variety of features such as pummel, thigh guides and anti-thrust design and/or a modular system made by a Invacare, Medifab and so on with similar features. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.10 Assistance required for transfers If wheeled mobility is used, is the amount and type of assistance recorded for transfers. For example, a child may need one person to assist with a standing transfer, or may need two people to assist with a hoist transfer. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.11 Source of Issue If wheeled mobility is used, is there a record of where the item was issued from? This may be from Territory Independent Mobility Equipment Scheme, the family, Interstate equipment schemes and so on. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.12 Date of Issue If wheeled mobility is used, is there a record of when the item was issued? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.13 Issues with use If wheeled mobility is used, are any issues with use of the item recorded? This may include compliance, disrepair, fit, or difficulties with transfers. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.14 Issues with condition If wheeled mobility is used, are any issues with the condition and maintenance of the item recorded? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.15 Seating device description If specialized seating is used, is there a record of the type and model? For
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example, a Kelly Chair with attachments such as pelvic strap and a mobilebase, size 3. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.16 Assistance required If specialized seating is used, is the amount and type of assistance recorded fortransfers. For example, a child may need one person to assist with a standingtransfer, or may need two people to assist with a hoist transfer. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.17 Source of issue specialized seating If specialized seating is used, is there a record of where the item was issued from? This may be from Territory Independent Mobility Equipment Scheme, thefamily, Interstate equipment schemes and so on. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.18 Date of IssueIf specialized is used, is there a record of when the item was issued? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.19 Issues with use If specialized seating is used, are any issues with use of the item recorded?This may include compliance, disrepair, fit, or difficulties with transfers. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.20 Issues with condition If specialized seating is used, are any issues with the condition and maintenance of the item recorded? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.21 Mobility Equipment Description If mobility equipment is used, is there a record of the type and model of theequipment. Examples of mobility equipment include: posterior walkers, elbowcrutches and gait trainers. Models might include Invacare Crocodile Walker orKaye walker. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.22 Assistance required If mobility equipment is used, is the amount and type of assistance recorded for transfers. For example, a child may be independent using a walker or requireone person to assist with standing up into the walker and securing theattachments. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
6.23 Source of Issue
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If mobility equipment is used, is there a record of where the item was issued from? This may be from Territory Independent Mobility Equipment Scheme, the family, Interstate equipment schemes and so on Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.24 Date of Issue If mobility equipment is used, is there a record of when the item was issued? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.25 Issues with use If mobility equipment is used, are any issues with use of the item recorded? This may include compliance, disrepair, fit, or difficulties with transfers Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.26 Issues with condition If mobility equipment is used, are any issues with the condition and maintenance of the item recorded? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.27 Orthotic review If orthotics are used, is there a record of orthotic review in the past 12 months? This includes fit and use. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.28 Type of Orthotic Prescribed If orthotics are used, is there a record of the type of orthotic prescribed the past 12 months (for example, articulated ankle foot orthotic, supramalleolar ankle foot orthotic)? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.29 Type of Orthotic Used If orthotics are used, is there a record of the type of orthotic being used in the past 12 months? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.30 Aim of orthotic If orthotics are used, is there a record of the aim of the orthotic prescribed in the past 12 months? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.31 Time worn (hours/day) If orthotics are used, is there a record of the amount of time the orthotic is worn (for example, hours per day, all day, half day in the past 12 months? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.32 Duration worn (months) If orthotics are used, is there a record of the number of months the present
186
orthotic type has been worn in the past 12 months? If issued within the past year, the date of issue is acceptable. Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable 6.33 Issues If orthotics are used, is there any record of issues such as skin ulceration, pressure sores, fit, compliance within the past 12 months? Circle 1-Yes 0-No 8-Incomplete or 9-N/A for not applicable
Results of Assessments and Reviews 7.1 Discussion with Primary Carer If a review or assessment was conducted in the last 12 months, is there a record of discussion of results with primary carer? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No or 9-N/A if not applicable 7.2 Action Plan If a review or assessment was conducted in the last 12 months, is there a record of an action plan made with the primary carer? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No or 9-N/A if not applicable 7.3 Action plan with other provider
Section 7 Results
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If a review or assessment was conducted in the last 12 months and there has been no action plan made with the family/carer, is there a record of an action plan made with the another provider (for example, a teacher or case manager)? Circle 1-Yes 0-No or 9-N/A if not applicable 7.4 Referral to other agencies If there is evidence of concern, is there a record of referral made to other agencies (for example, pediatrician or audiology services)? Records can be found in the following areas of the Department File:
Department Intake Report of Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No or 9-N/A if not applicable 7.5 Radiology referral If child is identified at risk of hip dislocation, is there a record of referral made to medical practitioner for hip surveillance x-ray? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No or 9-N/A if not applicable
If client does not require intervention, circle N/A and skip to Item 8.7.
Section 8 Goal Setting, Outcomes and Intervention
Goal setting is a standard requirement within physiotherapy practice (World Confederation for Physical Therapy, Australian Physiotherapy Council). Goal directed therapy has gained increased prominence within cerebral palsy and a number of tools are available to assist with prioritization and achievement of goals.
188
8.1 Written Report If intervention is required, is there a short written report with goals provided in the past 12 months? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section Records can be found in the computer records under Department Case History under:
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No or 9-N/A if not applicable 8.2 Goals stated If intervention is required, is the establishment of measurable goals recorded in the past 12 months? These can be any form of goal. Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No or 9-N/A if not applicable 8.3 Canadian Occupational Performance Measure (COPM) If intervention is required, is the establishment of COPM measures recorded in the past 12 months? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes or COPM form filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No or 9-N/A if not applicable
The COPM is a tool that measure client identified problems with daily function and includes the areas of self-care, productivity and leisure. It can be used to measure client outcome and goal achievement (Law et al., 1990, Sakzewski et al., 2007).
189
8.4 Goal Attainment Scaling (GAS)If intervention is required, is the establishment of GAS measures recorded in thepast 12 months?
Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case Historyunder:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No or 9-N/A if not applicable
8.5 Review Plan If intervention is required, is the establishment of a review plan to direct themeasurement of progress towards goal achievement recorded in the past 12months? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case Historyunder:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No or 9-N/A if not applicable
8.6 Outcomes If goals have been established, have outcomes been recorded in the past 12months?
Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section.
Records can be found in the computer records under Department Case History under:
The GAS is an individualized outcome measure, widely used to assess progress ofa client in attaining their individual goals that can measure client identified goals and can be used independently or with other tools such as the COPM orframeworks such as the ICF (MacDougall and Wright, 2009, Sakzewski et al.,2007).
190
Computer event notes
Department Physiotherapy reports placed under documents Circle 1-Yes or 0-No 8-Incomplete or 9-N/A if not applicable 8.7 Goal Attainment If goals have been established, is there a record of goals being met in the past 12 months? Records can be found in the following areas of the Department File:
Department Physiotherapy Report under the Reports section
Physiotherapy notes filed under Miscellaneous section. Records can be found in the computer records under Department Case History under:
Computer event notes
Department Physiotherapy reports placed under documents
Circle 1-Yes or 0-No 8-Incomplete or 9-N/A if not applicable 8.8 Focus of Intervention If a child has received intervention in the past 12 months, please circle all of the applicable areas recorded. Intervention focus may be on a variety of issues that influence an outcome. Circle all that may apply. 8.8 Circle 1 if on adaptive or therapeutic aides or equipment 8.9 Circle 2 if involving functional mobility training 8.10 Circle 3 if involving fitness training 8.11 Circle 4 if involving serial casting or splinting of a limb 8.12 Circle 5 if referring to external source 8.13 Circle 6 if other (Please specify interventions in space provided). 8.9 Mode of Delivery If a child has received intervention in the past 12 months, please circle all of the applicable areas recorded. 8.14 Circle 1 if individual session delivery provided at home, Department office, Satellite Community
Clinic/ACCHO Clinic/childcare or school. 8.15 Circle 2 if group session delivery is provided. This may be done at Department office,
Satellite Community Clinic, ACCHO, childcare or school. 8.16 Circle 3 if integrated if activities integrated into every day. 8.17 Circle 4 if a school program is provided in a consultation model. 8.18 Circle 5 if home program offered is provided in a consultation model. 8.19 Circle 6 if another mode of delivery is offered Write in all additional modes of delivery.
191
Comments Box Please include additional comments as seen fit in the box provided. Examplesmay include observations regarding appointment contacts and follow up,percentage of time involved in a particular activity or use of additional servicesto organise appointments and so forth.
Other comments may address the focus of interventions on: participation in physical sports and activities; intervention focuses on body structures and functions (such as posture, quality of movement, fitness, motor skills andmusculoskeletal interventions) or contextual factors (such as changing theenvironment or working on individual attitudes, health literacy or other personalfactors).
REFERENCES
ACCESS ECONOMICS 2008. The economic impact of cerebral palsy in Australia 2007. Access
Economics.
AUSTRALIAN PHYSIOTHERAPY COUNCIL. Australian Standards for Physiotherapy:Safe
and effective physiotherapy July 2006 [Online]. Available:
http://www.physiocouncil.com.au/files/the-australian-standards-for-physiotherapy
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BURNS, Y. 1992. N.S.M.D.A. Physiotherapy Assessment for Infants and Young Children,
Brisbane, CopyRight Publishing.
BURNS, Y. & MAC DONALD, J. (eds.) 1996. Physiotherapy and the growing child, London:
WB Saunders Ltd.
CAMPBELL, S. 2006. Physical therapy for children, St. Louis, Missouri, Saunders Elsevier.
CAMPBELL, S. K., PALISANO, R. & ORLIN, M. N. 2012. Physical therapy for children,
Saint Louis, Elsevier.
CEREBRAL PALSY ALLIANCE. 2012. Cerebral Palsy Alliance [Online]. Available:
www.cerebralpalsy.org.au [Accessed 31 October 2012].
CEREBRAL PALSY REGISTER. 2012. CP Register [Online]. Available:
http://www.cpregister.com [Accessed 2 November 2012].
ELIASSON, A., KRUMLINDE, S. L., ROSBLAD, B., BECKUNG, E., ARENER, M.,
OHRVALL, A. & ROSENBAUM, P. 2006. The Manual Ability Classification System
(MACS) for children with cerebral palsy: scale development and evidence of validity
and reliability. Developmental Medicine & Child Neurology, 48, 549-554.
GEMUS, M., PALISANO, R., RUSSELL, D., ROSENBAUM, P., WALTER, S. D., GALUPPI,
B. & LANE, M. 2001. Using the gross motor function measure to evaluate motor
development in children with Down syndrome. Phys Occup Ther Pediatr, 21, 69-79.
Items on focus and mode of delivery are relevant to looking at service deliveryfrom International Classification of Function (ICF) framework to determine if various components of health and functioning have been addressed and to whichdomains physiotherapy resources are most frequently directed (Wahlgren andPalombaro, 2012).
GRAHAM, H. K., RODDA, J., NATTRASS, G. R. & PIRPIRIS, M. 2004. The functional mobility scale (FMS). JPO, 24, 514-520.
HARVEY, A., ROSENBAUM, P., GRAHAM, H. K. & PALISANO, R. J. 2009. 'Current and future uses of the Gross Motor Function Classification System'. Dev Med Child Neurol, 51, 328-9.
HENDERSON, S.E., SUGDEN, D.A., & BARNETT, A.L. 2007. Movement Assessment Battery for Children-2 examiners manual, Second edn, London, Harcourt.
LAW, M., BAPTISTE, S., MCCOLL, M., OPZOOMER, A., POLATAJKO, H. & POLLOCK, N. 1990. The Canadian Occupational Performance Measure: an outcome measure for occupational therapy. Canadian Journal of Occupational Therapy, 57, 82-87.
LOVE, S., NOVAK, I., KENTISH, M., DESLOOVERE, K., HEINEN, F., MOLENAERS, G., O' FLAHERTY, S. & GRAHAM, H. K. 2010. Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement. European Journal of Neurology 17, 9-37.
MACDOUGALL, J. & WRIGHT, V. 2009. The ICF-CY and Goal Attainment Scaling: benefits of their combined use for pediatric practice. Disabil Rehabil, 31, 1362-1372.
MCDONALD, E. & ROSS BAILIE, R. 2010. Hygiene improvement: essential to improving child health in remote Aboriginal communities. Journal of Paediatrics and Child Health 46 (2010) 491–496, 46, 491-496.
NELSON, A. 2007. Seeing white: a critical exploration of occupational therapy with Indigenous Australian people. Occup Ther Int, 14, 237-55.
ONE21SEVENTY NATIONAL CENTRE FOR QUALITY IMPROVEMENT IN INDIGENOUS PRIMARY HEALTH CARE & MENZIES SCHOOL OF HEALTH RESEARCH 2011. Child health clinical audit tool 3 months to <15 years version 3.1. Darwin: Menzies School of Health Reasearch.
PALISANO, R., ROSENBAUM, P., WALTER, S., RUSSELL, D., WOOD, E. & GALUPPI, B. 1997. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol, 39, 214-23.
PALISANO, R. J., CHIARELLO, L. A., KING, G. A., NOVAK, I., STONER, T. & FISS, A. 2012. Participation-based therapy for children with physical disabilities. Disabil Rehabil, 34, 1041-52.
PINK, B. & ALLBON, P. 2008. The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples
Canberra: Australian Institue of Health and Welfare. PIPER, M. C. & DARRAH, J. 1994. Motor assessment of the developing infant, Philadelphia,
W.B. Saunders. SAKZEWSKI, L., BOYD, R. & ZIVIANI, J. 2007. Clinimetric properties of participation
measures for 5- to 13-year-old children with cerebral palsy: a systematic review. Dev Med Child Neurol, 49, 232-240.
SQUIRES, J. 2012. Ages and Stages Questionnaire-version 3, . WAHLGREN, A. & PALOMBARO, K. 2012. Evidence-based physical therapy for BPPV
using the International Classification of Functioning, Disability and Health model: a case report. Journal of Geriatric Physical Therapy.
WORLD CONFEDERATION FOR PHYSICAL THERAPY. 2011. WCPT guideline for standards of physical therapy practice [Online]. London: WCPT Secretariat. Available: http://www.wcpt.org/sites/wcpt.org/files/files/Guideline_standards_practice_complete.pdf
http://www.wcpt.org/guidelines/standards [Accessed 9 September 2012 2012].
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ay o
r p
hys
ical
dis
abili
ty s
imila
rly
incl
ud
e:
a)
C
linic
al c
are
serv
ices
fo
r th
ose
wit
h a
dia
gno
sis
wit
h r
efer
red
wit
h a
gro
ss m
oto
r d
elay
or
dia
gno
sed
dis
ease
or
con
dit
ion
imp
acti
ng
on
p
hys
ical
dev
elo
pm
ent
b)
Clin
ical
ser
vice
s fo
r th
e p
reve
nti
on
an
d e
arly
det
ect
ion
of
dis
ease
(in
clu
din
g sc
reen
ing,
gro
wth
mo
nit
ori
ng,
cas
e fi
nd
ing,
bri
ef
inte
rven
tio
ns/
cou
nse
ling-
gen
eral
ly h
ealt
h c
en
tre
bas
ed
, on
e-t
o-o
ne
act
ivit
ies
bu
t m
ay a
lso
incl
ud
e gr
ou
p a
ctiv
itie
s c)
P
op
ula
tio
n p
rogr
ams
and
act
ivit
ies
(e.g
. to
pro
mo
te p
hys
ical
act
ivit
y)-
gen
eral
ly c
om
mu
nit
y b
ased
. Ea
ch o
f th
ese
th
ree
typ
es o
f se
rvic
es is
imp
ort
ant
in e
ffec
tive
ph
ysio
ther
apy
man
agem
ent
and
car
e o
f ch
ildre
n w
ith
gro
ss m
oto
r d
elay
or
ph
ysic
al
dis
abili
ty. T
he
qu
alit
y o
f sy
stem
s in
pla
ce t
o s
up
po
rt t
he
m m
ay d
iffe
r w
ith
in a
nd
bet
wee
n c
lien
t gr
ou
ps
acce
ssin
g th
e sa
me
serv
ice
.
19
6
The
pro
mp
ts p
rovi
de
in t
his
to
ol a
re in
ten
ded
on
ly a
s a
guid
e to
so
me
of
the
sort
s o
f sy
stem
issu
es t
hat
on
e m
igh
t co
nsi
der
fo
r sc
ori
ng
each
item
of
the
too
l. Th
ere
pro
mp
ts m
ay n
ot
cove
r al
l th
e re
leva
nt
issu
es f
or
a p
hys
ioth
era
py
serv
ice.
The
use
of
this
to
ol p
rovi
de
s a
sco
re f
or
the
stat
e o
f d
evel
op
men
t o
f d
iffe
ren
t as
pec
ts o
f h
ealt
h c
entr
e sy
stem
s. T
he
sco
res
may
be
use
d a
s a
guid
e fo
r w
her
e im
pro
vem
ents
may
be
mad
e, b
ut
the
mem
be
rs o
f a
ph
ysio
ther
apy
serv
ice
sho
uld
bas
e it
s p
rio
riti
es o
n t
he
full
ran
ge o
fin
form
atio
n a
vaila
ble
to
th
em a
nd
th
e o
pp
ort
un
ity
they
hav
e fo
r im
pro
vem
ent
in d
iffe
ren
t ar
eas.
Ref
ere
nce
s to
res
ou
rces
rel
evan
t to
dif
fere
nt
clie
nt
gro
up
s ar
e p
rovi
ded
at
the
end
of
the
too
l.
The
pre
sen
t to
ol h
as b
een
ad
apte
d f
or
use
in q
ual
ity
imp
rove
men
t ac
tivi
ties
dir
ecte
d a
t p
hys
ioth
erap
y se
rvic
es f
or
child
ren
age
d 0
-18
yea
rs w
ith
gr
oss
mo
tor
del
ay o
r p
hys
ical
dis
abili
ty.
19
7
Syst
ems
Ass
ess
men
t To
ol C
om
po
nen
ts
The
mo
del
co
mp
on
ents
incl
ud
e:
1
. D
eliv
ery
syst
em d
esig
n r
efer
s to
th
e e
xten
t to
wh
ich
th
e d
esig
n o
f th
e h
ealt
h s
erv
ice’
s in
fras
tru
ctu
re, s
taff
ing
and
car
e p
roce
sses
m
axim
ise
th
e p
ote
nti
al e
ffec
tive
nes
s o
f th
e se
rvic
e.
2.
Info
rmat
ion
sys
tem
s an
d d
ecis
ion
su
pp
ort
ref
ers
to in
form
atio
n s
tru
ctu
res
and
pro
cess
es t
o s
up
po
rt t
he
pla
nn
ing
and
del
iver
y o
f ca
re,
incl
ud
ing
dec
isio
n s
up
po
rt.
3.
Self
-man
age
men
t su
pp
ort
ref
ers
to in
form
atio
n s
tru
ctu
res
and
pro
cess
es t
hat
su
pp
ort
clie
nts
an
d f
amili
es t
o p
lay
a m
ajo
r ro
le in
m
ain
tain
ing
thei
r h
ealt
h, m
anag
ing
the
ir h
ealt
h p
rob
lem
s, a
nd
ach
ievi
ng
safe
an
d h
ealt
hy
envi
ron
men
ts.
4.
Lin
ks w
ith
th
e co
mm
un
ity,
oth
er h
ealt
h s
ervi
ces
and
oth
er s
ervi
ces
and
res
ou
rces
ref
ers
to t
he
ext
ent
to w
hic
h t
he
he
alth
ser
vice
use
s ex
tern
al li
nka
ges
to in
form
ser
vice
pla
nn
ing,
lin
ks c
lien
ts t
o o
uts
ide
reso
urc
es, w
ork
s o
ut
in t
he
com
mu
nit
y, a
nd
co
ntr
ibu
tes
to r
egio
nal
p
lan
nin
g an
d r
eso
urc
e d
evel
op
men
t. It
is p
rim
arily
th
rou
gh t
his
co
mp
on
ent
of
the
too
l th
at t
he
qu
alit
y o
f p
op
ula
tio
n p
rogr
ams
and
ac
tivi
ties
is a
sses
sed
. 5
. O
rgan
isat
ion
al in
flu
en
ce a
nd
inte
grat
ion
ref
ers
to t
he
use
of
org
anis
atio
nal
infl
uen
ce t
o c
reat
e a
cult
ure
an
d s
up
po
rt o
rgan
isat
ion
al
stru
ctu
res
and
pro
cess
es t
hat
pro
mo
te s
afe,
hig
h q
ual
ity
care
; an
d h
ow
wel
l all
the
sys
tem
co
mp
on
ents
are
inte
grat
ed
acr
oss
th
e se
rvic
e.
Res
ou
rce
do
cum
ents
an
d g
uid
elin
es r
ele
van
t to
th
e d
evel
op
men
t o
f th
e O
ne2
1se
ven
ty S
yste
ms
Ass
essm
ent
Too
l an
d t
he
mo
dif
icat
ion
s fo
r p
hys
ioth
erap
y se
rvic
e sy
stem
s re
view
are
pla
ced
at
the
bac
k o
f th
is d
ocu
men
t.
19
8
Co
mp
on
en
t 1
: D
eliv
ery
Sys
tem
De
sign
Ef
fect
ive
del
iver
y o
f a
ph
ysio
ther
apy
serv
ice
req
uir
es t
hat
th
e se
rvic
e’s
infr
astr
uct
ure
, sta
ffin
g an
d c
are
pro
cess
es a
re d
esig
ned
to
mee
t th
esp
ecif
ic n
eed
s o
f d
iffe
ren
t cl
ien
t gr
ou
ps
and
th
eir
fam
ilies
. Th
is in
volv
es m
ore
th
an a
dd
ing
inte
rven
tio
ns
or
pro
gram
s to
an
exi
stin
g sy
stem
focu
sed
on
acu
te c
are
. It
oft
en n
eces
sita
tes
sign
ific
ant
chan
ges
to t
he
org
anis
atio
n o
f ca
re.
Ite
m 1
.1: T
eam
str
uct
ure
an
d f
un
ctio
n
Elem
en
ts f
or
dis
cuss
ion
: i
Team
ap
pro
ach
– is
th
ere
secu
rity
an
d o
ngo
ing
avai
lab
ility
of
all t
he
pra
ctit
ion
ers
req
uir
ed?
ii Le
ade
rsh
ip –
is it
def
ine
d a
nd
rec
ogn
ized
? D
oes
th
e le
ader
hav
e a
n a
pp
rop
riat
e le
vel o
f fo
rmal
au
tho
rity
wit
hin
th
e p
ract
ice
team
? Iii
D
efi
nit
ion
of
role
s an
d r
esp
on
sib
iliti
es
and
lin
es
of
rep
ort
ing
– ar
e th
ese
def
ine
d f
or
all t
eam
mem
ber
s? A
re t
hes
e in
tegr
ated
into
d
eliv
ery
syst
em d
esig
n?
iv
Co
mm
un
icat
ion
an
d c
oh
esi
on
– d
oes
th
is e
xist
wit
hin
th
e te
am?
Do
es t
he
team
mee
t re
gula
rly?
Are
th
ere
est
ablis
hed
pro
cess
es f
or
effe
ctiv
e d
ecis
ion
mak
ing?
v.
De
velo
pin
g te
am m
em
be
rs’ s
kills
an
d r
ole
s –
is t
her
e a
stra
tegi
c ap
pro
ach
?
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rtG
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0 1
2
3
4 5
6
78
91
01
1
i N
o t
eam
ap
pro
ach
: p
ract
itio
ner
s n
eed
ed f
or
team
ap
pro
ach
no
t av
aila
ble
Som
e ef
fort
s to
est
ablis
h a
tea
m
app
roac
h; p
ract
itio
ner
s n
eed
ed
for
team
ap
pro
ach
so
met
imes
avai
lab
le, b
ut
no
t se
cure
or
on
goin
g
Team
ap
pro
ach
bec
om
ing
wel
les
tab
lish
ed;
pra
ctit
ion
ers
nee
ded
for
team
ap
pro
ach
usu
ally
av
aila
ble
, bec
om
ing
mo
re s
ecu
re
and
on
goin
g
Fully
est
ablis
hed
tea
m a
pp
roac
h;
secu
re, o
ngo
ing
avai
lab
ility
of
pra
ctit
ion
ers
nee
ded
fo
r te
amap
pro
ach
ii Te
am le
ader
ship
no
t cl
earl
yd
efin
ed
Team
lead
ersh
ip b
eco
min
g d
efin
edan
d r
eco
gniz
ed, l
ead
er a
cqu
irin
gfo
rmal
au
tho
rity
Team
lead
ersh
ip c
lear
ly d
efi
ned
and
re
cogn
ized
, lea
der
has
form
al a
uth
ori
ty
iii
Def
init
ion
of
team
ro
les,
lin
es o
f re
po
rtin
g an
d in
tegr
atio
n in
syst
em d
esig
n a
re f
air
Def
init
ion
of
team
ro
les,
lin
es o
f re
po
rtin
g an
d in
tegr
atio
n in
sys
tem
des
ign
are
fai
r
Def
init
ion
of
team
ro
les,
lin
es o
f re
po
rtin
g an
d in
tegr
atio
n in
syst
em d
esig
n a
re v
ery
goo
d
iv
Fair
co
mm
un
icat
ion
an
d c
oh
esio
nw
ith
in t
he
team
; tea
m m
eet
sir
regu
larl
y; d
ecis
ion
-mak
ing
is f
air
Go
od
co
mm
un
icat
ion
an
d c
oh
esio
nw
ith
in t
he
team
; tea
m m
eet
ings
bec
om
ing
regu
lar;
de
cisi
on
-mak
ing
is g
oo
d
Ver
y go
od
co
mm
un
icat
ion
an
dco
hes
ion
wit
hin
th
e te
am; t
eam
m
eeti
ngs
re
gula
r; d
eci
sio
n-
mak
ing
is v
ery
goo
d
19
9
Ite
m 1
.2 C
linic
al le
ade
rsh
ip
Elem
en
ts f
or
dis
cuss
ion
: i.
Clin
ical
lead
ers
hip
–is
it f
ully
est
ablis
he
d a
nd
rec
ogn
ized
in t
his
are
a?
ii.
Co
ntr
ibu
tio
n –
do
es c
linic
al le
ader
ship
co
ntr
ibu
te t
o t
he
serv
ice’
s vi
sio
n f
or
hig
h q
ual
ity
care
fo
r th
e cl
ien
t gr
ou
p?
iii.
Kn
ow
led
ge a
bo
ut
rese
arch
evi
de
nce
- d
oes
clin
ical
lead
ersh
ip h
elp
to
en
sure
th
at t
he
serv
ice
rem
ain
s kn
ow
led
geab
le a
bo
ut
rese
arch
ev
iden
ce?
Is t
he
evid
ence
inte
rpre
ted
an
d a
pp
rop
riat
ely
app
lied
to
th
e s
ervi
ce’s
clin
ical
ser
vice
s an
d p
rogr
ams?
v
Dev
elo
pm
ent
of
team
me
mb
ers’
sk
ills
and
ro
les
is f
air
Dev
elo
pm
ent
of
team
me
mb
ers’
sk
ills
and
ro
les
is g
oo
d
Dev
elo
pm
ent
of
team
me
mb
ers’
sk
ills
and
ro
les
is v
ery
goo
d
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al c
linic
al
lead
ersh
ip
Clin
ical
lead
ers
hip
em
ergi
ng
Clin
ical
lead
ers
hip
be
com
ing
esta
blis
hed
an
d r
eco
gnis
ed
C
linic
al le
ade
rsh
ip f
ully
es
tab
lish
ed a
nd
rec
ogn
ise
d
ii
Co
ntr
ibu
tio
n o
f cl
inic
al le
ader
ship
to
cen
tre’
s vi
sio
n f
or
hig
h q
ual
ity
care
is f
air
Co
ntr
ibu
tio
n o
f cl
inic
al le
ader
ship
to
cen
tre’
s vi
sio
n f
or
hig
h q
ual
ity
care
is g
oo
d
Co
ntr
ibu
tio
n o
f cl
inic
al
lead
ersh
ip t
o c
entr
e’s
visi
on
fo
r h
igh
qu
alit
y ca
re is
ver
y go
od
iii
C
on
trib
uti
on
of
clin
ical
lead
ersh
ip
to k
no
wle
dge
an
d a
pp
licat
ion
is
fair
Co
ntr
ibu
tio
n o
f cl
inic
al le
ader
ship
to
kn
ow
led
ge a
nd
ap
plic
atio
n is
go
od
Co
ntr
ibu
tio
n o
f cl
inic
al
lead
ersh
ip t
o k
no
wle
dge
an
d
app
licat
ion
is v
ery
goo
d
20
0
Ite
m 1
.3: A
pp
oin
tme
nts
an
d s
che
du
ling
Elem
en
ts f
or
dis
cuss
ion
: i.
app
oin
tmen
t sy
stem
– is
th
ere
an e
stab
lish
ed a
pp
oin
tmen
t sy
stem
fo
r th
is a
rea?
Do
es it
hav
e th
e fl
exib
ility
to
sys
tem
atic
ally
acco
mm
od
ate
the
nee
ds
of
the
clie
nt
gro
up
incl
ud
ing
a) d
rop
–in
un
anti
cip
ate
d u
rgen
t re
ferr
als/
issu
es b
) lo
ng
or
un
exp
ecte
dly
com
ple
x co
nsu
ltat
ion
s; a
nd
c)
clie
nts
se
ein
g m
ult
iple
pro
vid
ers
in a
sin
gle
visi
t as
req
uir
ed
?ii.
Spec
ific
clin
ics
and
/or
sess
ion
s -
are
th
ere
clin
ics/
sess
ion
s w
ith
sp
eci
alis
t su
pp
ort
ava
ilab
le (
as a
pp
rop
riat
e)?
Are
th
ey p
art
of
rou
tin
ep
ract
ice
for
this
are
a?iii
.P
lan
nin
g an
d s
ched
ulin
g- is
it r
ou
tin
e p
ract
ice
for
the
ser
vice
’s c
om
mu
nit
y b
ased
act
ivit
ies
and
pro
gram
s in
th
is a
rea
to b
ep
lan
ned
/sch
ed
ule
d a
hea
d o
f ti
me?
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rt
Go
od
su
pp
ort
Fu
lly d
evel
op
ed s
up
po
rt
0 1
2
3
4 5
6
78
91
01
1
i N
o a
pp
oin
tmen
t sy
ste
m
Som
e ap
po
intm
ents
mad
e;
flex
ibili
ty is
ad
ho
c A
pp
oin
tmen
t sy
stem
bec
om
ing
esta
blis
hed
; fle
xib
ility
bec
om
ing
syst
emat
ic
Ap
po
intm
ent
syst
em f
ully
esta
blis
hed
; fl
exib
ility
issy
stem
atic
ii Sp
ecif
ic c
linic
s an
d/o
r se
ssio
ns
no
t u
sed
Sp
ecif
ic c
linic
s an
d/o
r se
ssio
ns
use
d in
ad
ho
c w
ay
Spec
ific
clin
ics
and
/or
sess
ion
s b
eco
min
g p
art
of
rou
tin
e p
ract
ice
Sp
ecif
ic c
linic
s an
d/o
r se
ssio
ns
par
t o
f ro
uti
ne
pra
ctic
e
iii
No
or
few
co
mm
un
ity
bas
edac
tivi
ties
Sc
hed
ulin
g o
f ac
tivi
ties
/pro
gram
sis
ad
ho
c P
lan
nin
g/sc
hed
ulin
g o
f ac
tivi
ties
/pro
gram
s b
eco
min
gro
uti
ne
pra
ctic
e
Pla
nn
ing/
sch
edu
ling
of
acti
viti
es/p
rogr
ams
is r
ou
tin
ep
ract
ice
20
1
Ite
m 1
.4:
Car
e P
lan
nin
g El
eme
nts
fo
r d
iscu
ssio
n:
i. R
ou
tin
e p
ract
ice
– is
car
e p
lan
nin
g fo
r cl
ien
ts p
art
of
rou
tin
e p
ract
ice?
ii.
El
eme
nts
of
care
pla
nn
ing
– is
it c
on
sist
ent
wit
h b
est
pra
ctic
e gu
idel
ines
? Is
it d
on
e jo
intl
y b
y p
rovi
der
s an
d c
lien
ts/f
amili
es?
Incl
ud
e
goal
set
tin
g? In
corp
ora
tes
self
-man
age
men
t go
als
and
str
ateg
ies?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al c
are
pla
nn
ing
Car
e p
lan
nin
g is
ad
ho
c C
are
pla
nn
ing
be
com
ing
par
t o
f ro
uti
ne
pra
ctic
e
Car
e p
lan
nin
g p
art
of
rou
tin
e p
ract
ice
ii
Som
e el
emen
ts in
clu
de
d
Mo
st e
lem
ents
incl
ud
ed
A
ll el
em
ents
incl
ud
ed
20
2
Ite
m 1
.5:
Syst
em
atic
ap
pro
ach
to
fo
llow
-up
Elem
en
ts f
or
dis
cuss
ion
: i.
Elec
tro
nic
re
min
der
s –
are
they
use
d t
o s
up
po
rt c
lien
t ca
re in
th
is a
rea?
Is t
hei
r u
se c
on
sist
en
t ac
ross
th
e cl
inic
al a
rea?
ii.R
egu
lar
serv
ices
an
d r
evie
ws
– ar
e cl
ien
ts f
ollo
wed
-up
in a
cco
rdan
ce w
ith
bes
t p
ract
ice?
Is t
his
par
t o
f ro
uti
ne
pra
ctic
e?iii
.A
bn
orm
al a
sses
smen
t fi
nd
ings
– is
fo
llow
up
a s
yste
mat
ic p
art
of
rou
tin
e p
ract
ice?
iv.
Hea
lth
ser
vice
sta
ff a
nd
co
mm
un
ity
kno
wle
dge
an
d r
eso
urc
es a
re u
sed
to
en
han
ce f
ollo
w-u
p?
Do
es it
bal
ance
du
ty o
f ca
re w
ith
clie
nt
self
-man
agem
en
t?
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rt
Go
od
su
pp
ort
Fu
lly d
evel
op
ed s
up
po
rt
0 1
2
3
4 5
6
78
91
01
1
i N
o e
lect
ron
ic r
emin
der
s R
emin
der
s so
met
imes
use
d t
o
sup
po
rt c
lien
t ca
re
Rem
ind
ers
usu
ally
use
d t
o s
up
po
rtcl
ien
t ca
re
Rem
ind
ers
con
sist
entl
y u
sed
to
su
pp
ort
clie
nt
care
ii N
o o
r m
inim
al f
ollo
w-u
p o
f cl
ien
ts
Follo
w-u
p o
f cl
ien
ts f
or
regu
lar
revi
ews
is a
d h
oc
Follo
w-u
p o
f cl
ien
ts f
or
regu
lar
revi
ews
is b
eco
min
g p
art
of
rou
tin
ep
ract
ice
Follo
w-u
p o
f cl
ien
ts f
or
regu
lar
revi
ews
is r
ou
tin
e p
ract
ice
iii
No
or
min
imal
pro
cess
es f
or
follo
win
g u
p a
bn
orm
al r
esu
lts
Follo
w-u
p o
f ab
no
rmal
tes
tre
sult
s is
ad
ho
c Fo
llow
-up
of
abn
orm
al a
sses
smen
tre
sult
s is
bec
om
ing
par
t o
f ro
uti
ne
p
ract
ice
Follo
w-u
p o
f ab
no
rmal
asse
ssm
ent
resu
lts
is r
ou
tin
ep
ract
ice
iv
No
or
min
imal
use
of
avai
lab
lere
sou
rces
to
en
han
ce f
ollo
w-
up
Use
of
avai
lab
le r
eso
urc
es t
oen
han
ce f
ollo
w-u
p is
fai
r U
se o
f av
aila
ble
res
ou
rces
to
enh
ance
fo
llow
-up
is g
oo
d
Use
of
avai
lab
le r
eso
urc
es t
oen
han
ce f
ollo
w-u
p is
ver
y go
od
Co
nsi
der
rem
ind
ers
in r
elat
ion
to
ap
po
intm
ent
revi
ews,
eq
uip
men
t re
view
s, m
usc
ulo
skel
etal
mo
nit
ori
ng
(hip
, sp
ine,
fo
ot)
20
3
Ite
m 1
.6:
Co
nti
nu
ity
of
care
El
eme
nts
fo
r d
iscu
ssio
n:
i. D
eliv
ery
syst
em is
des
ign
ed
to
en
han
ce c
on
tin
uit
y o
f ca
re –
in t
his
are
a b
y h
avin
g th
e fo
llow
ing
ele
men
ts:
a.
Wel
l-o
rgan
ised
ele
ctro
nic
clin
ical
re
cord
s an
d c
lear
do
cum
en
tati
on
b
. Sc
hed
ule
d f
ollo
w-u
p v
isit
s c.
C
on
tin
uit
y o
f p
rovi
der
(s)
d.
Team
car
e
e.
Cas
e m
anag
em
ent
f.
Shar
ed c
lien
t re
cord
s g.
O
rien
tati
on
of
hea
lth
ser
vice
sta
ff t
o p
roce
sses
to
en
han
ce c
on
tin
uit
y o
f ca
re
ii.
C
om
mu
nic
atio
n b
etw
een
ho
spit
al (
s) a
nd
th
e h
ealt
h s
ervi
ce –
is t
he
syst
em e
ffec
tive
to
fo
llow
dis
char
ge o
f cl
ien
ts in
th
is a
rea?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i D
eliv
ery
syst
em is
no
t d
esig
ned
to
en
han
ce
con
tin
uit
y o
f ca
re
Del
iver
y sy
stem
beg
inn
ing
to b
e d
esig
ned
to
en
han
ce c
on
tin
uit
y o
f ca
re (
som
e el
emen
ts in
pla
ce)
Del
iver
y sy
stem
qu
ite
wel
l d
esig
ned
to
en
han
ce c
on
tin
uit
y o
f ca
re (
mo
st e
lem
ents
in p
lace
)
Del
iver
y sy
stem
ver
y w
ell
des
ign
ed t
o e
nh
ance
co
nti
nu
ity
of
care
(al
l or
alm
ost
all
elem
ents
in p
lace
)
ii N
o o
r m
inim
al c
om
mu
nic
atio
n
bet
wee
n h
osp
ital
an
d t
he
hea
lth
ser
vice
po
st-d
isch
arge
Po
st-d
isch
arge
co
mm
un
icat
ion
b
etw
een
ho
spit
al a
nd
th
e h
ealt
h
serv
ice
is o
n a
n a
d h
oc
bas
is o
nly
Syst
em f
or
rou
tin
e p
ost
-dis
char
ge
com
mu
nic
atio
n b
etw
een
ho
spit
al
and
th
e h
ealt
h s
ervi
ce b
eco
min
g es
tab
lish
ed
Syst
em f
or
rou
tin
e p
ost
-d
isch
arge
co
mm
un
icat
ion
h
osp
ital
an
d t
he
hea
lth
ser
vice
fu
lly e
stab
lish
ed
20
4
Ite
m 1
.7: C
lien
t ac
cess
/ c
ult
ura
l co
mp
ete
nce
El
eme
nts
fo
r d
iscu
ssio
n:
i. P
hys
ical
, co
mm
un
icat
ion
an
d t
ran
spo
rt b
arri
ers
to a
cces
s –
do
hea
lth
ser
vice
de
sign
an
d p
roce
sses
ad
dre
ss c
lien
t p
riva
cy a
nd
co
nfi
den
tial
ity,
th
e u
se o
f tr
ansl
ato
rs (
as r
equ
ire
d)
and
tra
nsp
ort
su
pp
ort
fo
r re
ferr
als?
ii.
St
affi
ng
– is
th
ere
a sy
stem
atic
ap
pro
ach
to
en
suri
ng
that
all
hea
lth
ser
vice
sta
ff p
rovi
din
g ca
re a
re c
ult
ura
lly c
om
pet
ent
thro
ugh
sta
ff
ori
enta
tio
n a
nd
tra
inin
g?
iii.
Gen
der
-rel
ated
issu
es –
is t
her
e a
pro
cess
in p
lace
to
en
sure
res
pe
ct is
ap
plie
d f
or
gen
der
rel
ated
issu
es?
iv.
Ind
ige
no
us
kno
wle
dge
an
d A
HW
exp
erie
nce
– a
re In
dig
eno
us
kno
wle
dge
an
d A
HW
exp
erie
nce
res
pec
ted
? D
oes
it in
form
clin
ical
p
ract
ice
and
co
mm
un
ity
bas
ed a
ctiv
itie
s?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al a
tte
nti
on
giv
en
to b
arri
ers
Bar
rier
s b
egin
nin
g to
be
add
ress
ed b
ut
man
y re
mai
n
Bar
rier
s ad
dre
ssed
qu
ite
wel
l bu
t so
me
rem
ain
B
arri
ers
add
ress
ed v
ery
wel
l an
d
few
or
no
ne
rem
ain
ii N
o o
r m
inim
al a
tte
nti
on
giv
en
to c
ult
ura
l co
mp
eten
ce; n
ot
incl
ud
ed in
ori
enta
tio
n a
nd
tr
ain
ing
Leve
l of
atte
nti
on
to
cu
ltu
ral
com
pe
ten
ce is
fai
r; s
om
etim
es
incl
ud
ed in
ori
enta
tio
n a
nd
tr
ain
ing
Leve
l of
atte
nti
on
to
cu
ltu
ral
com
pe
ten
ce is
go
od
; usu
ally
in
clu
ded
in o
rien
tati
on
an
d t
rain
ing
Leve
l of
atte
nti
on
to
cu
ltu
ral
com
pe
ten
ce is
ver
y go
od
; alw
ays
incl
ud
ed in
ori
enta
tio
n a
nd
tr
ain
ing
iii
No
or
min
imal
res
pec
t fo
r ge
nd
er r
elat
ed is
sues
R
esp
ect
fo
r ge
nd
er-r
elat
ed is
sues
is
fai
r R
esp
ect
fo
r ge
nd
er-r
elat
ed is
sues
is
go
od
R
esp
ect
fo
r ge
nd
er-r
elat
ed
issu
es is
ver
y go
od
iv
No
or
min
imal
res
pec
t fo
r In
dig
en
ou
s kn
ow
led
ge o
r A
HW
ex
per
ien
ce
Res
pe
ct f
or
Ind
igen
ou
s kn
ow
led
ge a
nd
AH
W e
xpe
rien
ce
is f
air
Res
pe
ct f
or
Ind
igen
ou
s kn
ow
led
ge
and
AH
W e
xper
ien
ce is
go
od
R
esp
ect
fo
r In
dig
eno
us
kno
wle
dge
an
d A
HW
exp
eri
ence
is
ver
y go
od
20
5
Ite
m 1
.8:
Ph
ysic
al in
fras
tru
ctu
re, s
up
plie
s an
d e
qu
ipm
en
t El
eme
nts
fo
r d
iscu
ssio
n:
i. P
hys
ical
infr
astr
uct
ure
– is
it s
uit
able
fo
r p
rovi
sio
n o
f ca
re?
ii.
Sup
plie
s o
f co
nsu
mab
les
– ar
e th
ey a
pp
rop
riat
e an
d a
vaila
ble
? iii
. Eq
uip
me
nt
– is
it a
pp
rop
riat
e an
d a
vaila
ble
? Is
it o
f go
od
qu
alit
y an
d v
ery
wel
l mai
nta
ined
(e.
g. d
oes
no
t n
eed
to
be
shar
ed b
etw
een
o
r b
orr
ow
ed f
rom
oth
er c
on
sult
ing
are
as d
ue
to li
mit
ed a
vaila
bili
ty o
r p
oo
r m
ain
ten
ance
)?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i P
hys
ical
infr
astr
uct
ure
u
nsu
itab
le
Ph
ysic
al in
fras
tru
ctu
re s
om
ewh
at
suit
able
P
hys
ical
infr
astr
uct
ure
qu
ite
suit
able
P
hys
ical
infr
astr
uct
ure
hig
hly
su
itab
le
ii A
pp
rop
riat
enes
s an
d
avai
lab
ility
of
con
sum
able
s is
p
oo
r
Ap
pro
pri
aten
ess
and
ava
ilab
ility
o
f co
nsu
mab
les
are
fair
A
pp
rop
riat
enes
s an
d a
vaila
bili
ty o
f co
nsu
mab
les
are
goo
d
Ap
pro
pri
aten
ess
and
ava
ilab
ility
o
f co
nsu
mab
les
are
very
go
od
iii
Equ
ipm
en
t ap
pro
pri
aten
ess
, q
ual
ity
and
mai
nte
nan
ce is
p
oo
r
Equ
ipm
en
t ap
pro
pri
aten
ess
, q
ual
ity
and
mai
nte
nan
ce a
re f
air
Equ
ipm
en
t ap
pro
pri
aten
ess
, q
ual
ity
and
mai
nte
nan
ce a
re g
oo
d
Equ
ipm
en
t ap
pro
pri
aten
ess
, q
ual
ity
and
mai
nte
nan
ce a
re
very
go
od
.
20
6
Co
mp
on
en
t 2
: In
form
atio
n S
yste
ms
and
De
cisi
on
Su
pp
ort
Ef
fect
ive
hea
lth
ser
vice
s en
sure
th
at e
lect
ron
ic in
form
atio
n s
yste
ms
con
tain
up
-to
-dat
e cl
ien
t in
form
atio
n t
hat
is u
sed
to
su
pp
ort
th
e p
lan
nin
g an
d d
eliv
ery
of
care
, in
clu
din
g d
ecis
ion
su
pp
ort
. Evi
den
ce b
ased
gu
idel
ines
an
d o
ther
res
ou
rces
sh
ou
ld b
e av
aila
ble
th
rou
gh t
he
syst
ems
in
form
ats
that
are
ap
pro
pri
ate
and
acc
essi
ble
fo
r al
l me
mb
ers
of
the
hea
lth
tea
m. I
n a
dd
itio
n, a
dvi
ce m
ay b
e av
aila
ble
th
rou
gh s
pec
ialis
t co
llab
ora
tio
ns
and
oth
er m
ech
anis
ms.
It
em
2.1
: Mai
nte
nan
ce a
nd
use
of
ele
ctro
nic
clie
nt
list
(Th
ink
abo
ut
dif
fere
nt
con
dit
ion
s an
d t
hei
r ca
re)
Elem
en
ts f
or
dis
cuss
ion
i.
Elec
tro
nic
list
of
clie
nts
- Is
on
e av
aila
ble
? is
it r
egu
larl
y re
view
ed a
cco
rdin
g to
an
est
ablis
hed
pro
toco
l? Is
it u
p t
o d
ate,
incl
ud
ing
reco
rd o
f p
lace
of
resi
den
ce, p
ost
al a
dd
ress
an
d c
on
tact
det
ails
? ii.
R
egu
lar
clie
nts
– is
ele
ctro
nic
list
ro
uti
nel
y u
sed
to
iden
tify
su
pp
ort
ser
vice
pla
nn
ing
and
del
iver
y? F
or
exam
ple
, id
enti
fyin
g cl
ien
ts f
or
mo
nit
ori
ng
(sea
tin
g, o
rth
oti
cs, s
pas
tici
ty a
nd
co
ntr
actu
re m
anag
emen
t, h
ip s
urv
eilla
nce
, sp
inal
su
rvei
llan
ce)
iii.
Reg
ula
r cl
ien
ts w
ith
sp
ecif
ic c
on
dit
ion
s –
elec
tro
nic
list
is u
sed
to
iden
tify
su
pp
ort
ser
vice
pla
nn
ing
and
del
iver
y? F
or
exam
ple
, to
gen
erat
e lis
ts o
f cl
ien
ts f
or
follo
w-u
p o
r re
gula
rly
sch
edu
led
ser
vice
s.
iv.
Rea
chin
g cl
ien
t gr
ou
ps
– ar
e st
rate
gies
imp
lem
ente
d a
s p
art
of
rou
tin
e p
ract
ice?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o e
lect
ron
ic li
st
List
ava
ilab
le b
ut
no
t re
vie
wed
an
d
ou
t o
f d
ate
(co
vers
less
th
an 8
0%
o
f cl
ien
ts, u
p-t
o-d
ate
resi
den
ce a
nd
fa
mily
mem
ber
an
d c
on
tact
in
form
atio
n s
om
etim
es r
eco
rded
)
List
ava
ilab
le, i
rreg
ula
rly
revi
ewed
an
d r
easo
nab
ly u
p-t
o-d
ate
(co
vers
8
0%
or
mo
re o
f cl
ien
ts, u
p-t
o-d
ate
resi
den
ce a
nd
fam
ily m
em
ber
an
d
con
tact
info
rmat
ion
re
cord
ed)
List
ava
ilab
le, r
egu
larl
y re
view
ed
and
up
-to
-dat
e (c
ove
rs a
ll cl
ien
ts,
up
-to
-dat
e re
sid
ence
an
d f
amily
m
emb
er a
nd
co
nta
ct in
form
atio
n
alw
ays
reco
rded
)
ii
Use
of
the
list
to id
enti
fy r
egu
lar
clie
nts
fo
r p
lan
nin
g an
d d
eliv
ery
is
ad h
oc
Use
of
the
list
to id
enti
fy r
egu
lar
clie
nts
fo
r p
lan
nin
g an
d d
eliv
ery
bec
om
ing
rou
tin
e
Use
of
the
list
to id
enti
fy r
egu
lar
clie
nts
fo
r p
lan
nin
g an
d d
eliv
ery
is r
ou
tin
e
iii
U
se o
f th
e lis
t to
iden
tify
reg
ula
r cl
ien
ts w
ith
sp
ecif
ic c
on
dit
ion
s fo
r p
lan
nin
g an
d s
ervi
ce d
eliv
ery
is a
d
ho
c
Use
of
the
list
to id
enti
fy r
egu
lar
clie
nts
wit
h s
pec
ific
co
nd
itio
ns
for
pla
nn
ing
and
ser
vice
del
ive
ry
bec
om
ing
rou
tin
e
Use
of
the
list
to id
enti
fy r
egu
lar
clie
nts
wit
h s
pec
ific
co
nd
itio
ns
for
pla
nn
ing
and
ser
vice
del
iver
y is
ro
uti
ne
iv
Im
ple
men
tati
on
of
stra
tegi
es t
o
reac
h c
lien
t gr
ou
ps
is a
d h
oc
Imp
lem
enta
tio
n o
f st
rate
gies
to
re
ach
clie
nt
gro
up
s b
eco
min
g ro
uti
ne
pra
ctic
e
Imp
lem
enta
tio
n o
f st
rate
gies
to
re
ach
clie
nt
gro
up
s is
ro
uti
ne
pra
ctic
e
20
7
Ite
m 2
.2. E
vid
en
ce b
ase
d g
uid
elin
es
Elem
en
ts f
or
dis
cuss
ion
: i.
Spec
ialis
t –
gen
eral
ist
colla
bo
rati
on
– is
th
ere
a st
rate
gic
app
roac
h t
o t
hat
res
ult
s in
:a.
enh
ance
d d
eci
sio
n s
up
po
rt f
or
clin
ical
car
eb
.ef
fect
ive
ge
ner
alis
t-sp
ecia
list
com
mu
nic
atio
n a
bo
ut
clie
nt
nee
ds
and
car
e?c.
cult
ura
lly a
pp
rop
riat
e ca
re a
cro
ss t
he
spec
tru
m o
f ge
ner
alis
t-sp
ecia
list
care
?d
.sp
ecia
list
enga
gem
ent
in t
he
dev
elo
pm
ent
of
com
mu
nit
y-b
ased
pro
gram
s th
at p
rom
ote
hea
lth
y so
cial
an
d p
hys
ical
envi
ron
men
ts?
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rt
Go
od
su
pp
ort
Fu
lly d
evel
op
ed s
up
po
rt
0 1
2
3
4 5
6
78
91
01
1
i N
o o
r m
inim
al s
pec
ialis
t-ge
ner
alis
t co
llab
ora
tio
n –
i.e.
trad
itio
nal
re
ferr
al o
nly
Spec
ialis
t-ge
ner
alis
t co
llab
ora
tio
nis
fai
r Sp
ecia
list-
gen
eral
ist
colla
bo
rati
on
is g
oo
d
Spec
ialis
t-ge
ner
alis
tco
llab
ora
tio
n is
ver
y go
od
Rel
evan
t co
llab
ora
tio
ns
incl
ud
e t
ho
se b
etw
een
th
e h
ealt
h t
eam
an
d s
pe
cial
ists
in a
var
iety
of
asp
ects
of
care
incl
ud
ing
ther
apy,
eq
uip
men
t n
eed
s(s
tan
din
g fr
ames
, wal
kin
g fr
ames
, alt
ern
ativ
e se
atin
g), w
hee
lch
air
seat
ing
asse
ssm
ent
and
th
erap
y.
20
8
Co
mp
on
en
t 3
: Se
lf-m
anag
em
en
t Su
pp
ort
Se
lf-m
anag
em
ent
refe
rs t
o t
he
hea
lth
ser
vice
str
uct
ure
s an
d p
roce
sses
th
at s
up
po
rt c
lien
ts a
nd
th
eir
fam
ilies
to
pla
y a
maj
or
role
in m
ain
tain
ing
thei
r h
ealt
h, m
anag
ing
the
ir h
ealt
h p
rob
lem
s, a
nd
ach
ievi
ng
safe
an
d h
ealt
hy
envi
ron
men
ts. E
ffec
tive
sel
f-m
anag
emen
t su
pp
ort
str
ate
gies
in
clu
de
asse
ssin
g an
d d
ocu
men
tin
g se
lf-m
anag
emen
t n
eed
s an
d a
ctiv
itie
s, p
rovi
din
g ed
uca
tio
n a
nd
su
pp
ort
an
d b
ehav
ior
chan
ge in
terv
enti
on
an
d p
rom
oti
ng
pee
r su
pp
ort
. In
volv
ing
clie
nts
’ fam
ilie
s in
th
ese
acti
viti
es is
imp
ort
ant.
Hea
lth
ser
vice
s ca
n o
rgan
ise
inte
rnal
an
d c
om
mu
nit
y re
sou
rces
to
max
imiz
e p
ote
nti
al f
or
com
mu
nit
y m
em
ber
s to
co
ntr
ibu
te t
o t
he
cre
atio
n a
nd
mai
nte
nan
ce o
f th
eir
ow
n h
ealt
h a
nd
to
hea
lth
y so
cial
an
d p
hys
ical
en
viro
nm
ents
. It
em
3.1
: Ass
ess
me
nt
and
do
cum
en
tati
on
El
eme
nts
fo
r d
iscu
ssio
n:
i. Se
lf-m
anag
em
ent
for
clie
nts
in t
his
are
a is
su
pp
ort
ed
as
a ce
ntr
al, s
trat
egic
par
t o
f h
ealt
h c
are.
ii.
Se
lf-m
anag
em
ent
ne
eds
for
clie
nts
in t
his
are
a ar
e ro
uti
nel
y as
sess
ed a
nd
do
cum
ente
d in
a s
tan
dar
d w
ay.
iii.
Clie
nts
/fam
ilies
in t
his
are
a ar
e ro
uti
nel
y en
gage
d in
th
e as
sess
me
nt
and
do
cum
enta
tio
n p
roce
sses
. iv
. U
se o
f cl
ien
t h
eld
rec
ord
s to
pro
mo
te s
elf-
man
age
men
t is
par
t o
f ro
uti
ne
pra
ctic
e in
th
is a
rea
– i.e
. to
ols
th
at a
re d
esig
ned
to
ass
ist
clie
nts
to
ad
her
e to
sel
f-m
anag
emen
t p
rogr
ams
and
to
set
go
als,
tra
ck t
hei
r p
rogr
ess
and
un
der
stan
d t
he
reas
on
s fo
r h
ealt
h v
isit
s.
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al s
up
po
rt f
or
self
-man
age
men
t Fa
ir s
up
po
rt f
or
self
-man
agem
ent
Go
od
su
pp
ort
fo
r se
lf-m
anag
emen
t V
ery
goo
d s
up
po
rt f
or
self
-m
anag
emen
t
ii Se
lf-m
anag
em
ent
ne
eds
are
rare
ly a
sses
sed
Se
lf-m
anag
em
ent
ne
eds
are
som
etim
es a
sses
sed
on
an
ad
ho
c b
asis
on
ly
Ass
essm
ent
and
do
cum
enta
tio
n o
f se
lf-m
anag
em
ent
ne
eds
bec
om
ing
rou
tin
e p
ract
ice
Ass
essm
ent
and
do
cum
enta
tio
n
of
self
-man
agem
ent
nee
ds
is
rou
tin
e p
ract
ice
iii
No
or
min
imal
en
gage
men
t o
f cl
ien
ts/f
amili
es in
ass
essm
ent
pro
cess
es
Clie
nts
/fam
ilies
en
gage
men
t in
as
sess
men
t an
d d
ocu
men
tati
on
is
ad h
oc
Clie
nts
/fam
ilies
en
gage
men
t in
as
sess
men
t an
d d
ocu
men
tati
on
b
eco
min
g ro
uti
ne
pra
ctic
e
Clie
nts
/fam
ilies
en
gage
men
t in
as
sess
men
t an
d d
ocu
men
tati
on
is
ro
uti
ne
pra
ctic
e
iv
No
or
min
imal
use
of
clie
nt
hel
d r
eco
rds
Use
of
clie
nt
hel
d r
eco
rds
is a
d
ho
c U
se o
f cl
ien
t h
eld
re
cord
s b
eco
min
g p
art
of
rou
tin
e p
ract
ice
U
se o
f cl
ien
t h
eld
re
cord
s is
par
t o
f ro
uti
ne
pra
ctic
e
Ite
m 3
.2: S
elf
-man
age
me
nt
ed
uca
tio
n a
nd
su
pp
ort
, be
hav
iou
ral r
isk
red
uct
ion
an
d p
ee
r su
pp
ort
20
9
Elem
en
ts f
or
dis
cuss
ion
: i.
Self
-man
age
men
t ed
uca
tio
n a
nd
su
pp
ort
– a
re r
ou
tin
ely
pro
vid
ed
by
staf
f w
ith
rec
ogn
ized
tra
inin
g an
d s
kills
in s
elf-
man
agem
en
t su
pp
ort
? ii.
In
volv
emen
t o
f fa
mili
es-
are
fam
ilies
invo
lved
in s
elf-
man
agem
ent
edu
cati
on
an
d s
up
po
rt a
ctiv
itie
s as
par
t o
f ro
uti
ne
pra
ctic
e?
iii.
Beh
avio
ura
l ris
k re
du
ctio
n –
is t
her
e a
syst
emat
ic a
pp
roac
h t
o b
ehav
ior
chan
ge in
terv
enti
on
s? F
or
exam
ple
, bri
ef in
terv
enti
on
fo
r w
eigh
t re
du
ctio
n o
r in
crea
sed
exe
rcis
e?
iv.
Edu
cati
on
res
ou
rces
– a
re g
oo
d q
ual
ity
edu
cati
on
al r
eso
urc
es u
sed
fo
r cl
ien
ts a
nd
fam
ilies
to
su
pp
ort
beh
avio
ura
l ris
k re
du
ctio
n in
se
lf-m
anag
em
ent?
Is t
his
par
t o
f ro
uti
ne
pra
ctic
e?
v.
Co
mm
un
ity
pee
r su
pp
ort
– is
pro
mo
tio
n a
nd
su
pp
ort
fo
r p
rogr
ams
and
act
ivit
ies
a ce
ntr
al s
trat
egic
par
t o
f h
ealt
h c
are?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al s
elf-
man
agem
ent
Edu
cati
on
or
sup
po
rt
Som
e se
lf-m
anag
eme
nt
edu
cati
on
an
d s
up
po
rt b
y st
aff
wit
h li
mit
ed t
rain
ing
and
ski
lls
Go
od
sel
f-m
anag
eme
nt
edu
cati
on
an
d s
up
po
rt b
y st
aff
wit
h r
elev
ant
trai
nin
g an
d s
kills
Ver
y go
od
sel
f-m
anag
eme
nt
edu
cati
on
an
d s
up
po
rt b
y st
aff
wit
h r
elev
ant
trai
nin
g an
d s
kills
ii N
o o
r m
inim
al e
nga
gem
ent
of
fam
ilies
in e
du
cati
on
/su
pp
ort
ac
tivi
ties
Enga
gem
ent
of
fam
ilies
in
edu
cati
on
/su
pp
ort
act
ivit
ies
bu
t o
n a
n a
d h
oc
bas
is o
nly
Enga
gem
ent
of
fam
ilies
in
edu
cati
on
/su
pp
ort
act
ivit
ies
bec
om
ing
rou
tin
e p
ract
ice
Enga
gem
ent
of
fam
ilies
in
edu
cati
on
/su
pp
ort
act
ivit
ies
is
rou
tin
e p
ract
ice
iii
No
or
min
imal
use
of
reso
urc
es t
o s
up
po
rt s
elf-
man
agem
ent
Som
e u
se o
f re
sou
rces
to
su
pp
ort
se
lf-m
anag
em
ent
Use
of
reso
urc
es t
o s
up
po
rt s
elf-
man
agem
ent
bec
om
ing
rou
tin
e p
ract
ice
Use
of
reso
urc
es t
o s
up
po
rt s
elf-
man
agem
ent
is r
ou
tin
e p
ract
ice
iv
No
or
min
imal
pro
visi
on
of
beh
avio
r ch
ange
inte
rve
nti
on
s So
me
beh
avio
ura
l in
terv
en
tio
ns
pro
vid
ed b
ut
by
staf
f w
ith
lim
ite
d
rele
van
t tr
ain
ing
and
ski
lls
Beh
avio
ura
l in
terv
enti
on
s b
y st
aff
wit
h r
elev
ant
trai
nin
g an
d s
kills
b
eco
min
g p
art
of
rou
tin
e p
ract
ice
Beh
avio
ura
l in
terv
enti
on
s b
y st
aff
wit
h r
elev
ant
trai
nin
g an
d
skill
s p
art
of
rou
tin
e p
ract
ice
v N
o o
r m
inim
al p
rom
oti
on
or
sup
po
rt f
or
pee
r su
pp
ort
P
rom
oti
on
an
d s
up
po
rt f
or
pee
r su
pp
ort
ad
ho
c P
rom
oti
on
an
d s
up
po
rt f
or
pee
r su
pp
ort
is b
eco
min
g ce
ntr
al,
stra
tegi
c p
art
of
care
Pro
mo
tio
n a
nd
su
pp
ort
fo
r p
eer
sup
po
rt is
a c
entr
al, s
trat
egi
c p
art
of
care
21
0
Co
mp
on
en
t 4
: Lin
ks w
ith
th
e c
om
mu
nit
y, o
the
r h
eal
th s
erv
ice
s, a
nd
oth
er
serv
ice
s an
d r
eso
urc
es
Go
od
lin
ks a
nd
par
tner
ship
s b
etw
een
th
e h
ealt
h s
ervi
ce a
nd
th
e co
mm
un
ity,
an
d o
ther
co
mm
un
ity
bas
ed o
rgan
isat
ion
s an
d p
rogr
ams
are
imp
ort
ant
in p
rim
ary,
co
mm
un
ity
and
dis
abili
ty c
are
. Th
ey a
llow
th
e h
ealt
h s
ervi
ce t
o h
ave
effe
ctiv
e c
om
mu
nit
y in
pu
t to
pla
nn
ing,
to
lin
k it
scl
ien
ts t
o o
uts
ide
reso
urc
es, t
o w
ork
wit
h p
op
ula
tio
n g
rou
ps
ou
t in
th
e co
mm
un
ity
and
to
co
ntr
ibu
te t
o r
egio
nal
act
ivit
ies
such
as
serv
ice
pla
nn
ing
and
th
e d
evel
op
men
t o
f re
sou
rces
4.1
Co
mm
un
icat
ion
an
d c
oo
pe
rati
on
on
go
vern
ance
an
d o
pe
rati
on
of
the
he
alth
se
rvic
e a
nd
oth
er
com
mu
nit
y b
ase
d o
rgan
isat
ion
s a
nd
pro
gram
s
Elem
en
ts f
or
dis
cuss
ion
: i.
Co
mm
un
ity
inp
ut
to h
ealt
h s
ervi
ce g
ove
rnan
ce –
are
th
ere
wel
l-fu
nct
ion
ing
arra
nge
me
nts
?ii.
Invo
lvem
ent
of
serv
ice
po
pu
lati
on
– is
th
ere
a sy
stem
atic
ap
pro
ach
to
inse
rvic
e p
lan
nin
g an
d f
eed
bac
k? D
oes
it in
clu
de
inp
ut
thro
ugh
an
an
nu
al g
ener
al m
eeti
ng
and
ref
eren
ce g
rou
ps/
com
mit
tees
? D
oes
it h
ave
form
al m
ech
anis
ms
for
dis
sem
inat
ion
of
hea
lth
serv
ice
per
form
ance
info
rmat
ion
?iii
.C
lien
t sa
tisf
acti
on
wit
h t
he
hea
lth
ser
vice
– a
re t
hey
sys
tem
atic
ally
an
d r
ou
tin
ely
asse
ssed
?iv
.Fo
rmal
agr
eem
ents
bet
we
en t
he
hea
lth
ser
vice
an
d m
ain
stre
am p
rim
ary
care
ser
vice
s an
d o
ther
hea
lth
an
d c
om
mu
nit
y se
rvic
esre
leva
nt
to t
his
are
a –
are
agr
eem
ent
in p
lace
? D
o t
hey
invo
lve
goo
d c
om
mu
nic
atio
n a
nd
on
goin
g, s
trat
egi
c ac
tivi
ties
?v.
Par
tner
ship
wit
h r
elev
ant
com
mu
nit
y gr
ou
ps
– ar
e t
her
e w
ell-
fu
nct
ion
ing
arra
nge
men
ts f
or
the
hea
lth
ser
vice
to
wo
rk in
? (f
or
exam
ple
, mu
nic
ipal
co
un
cils
, sch
oo
ls, c
hild
hea
lth
car
e ce
ntr
es, c
hild
care
cen
tre
s, s
po
rt a
nd
rec
reat
ion
gro
up
s, c
ult
ura
l pro
gram
s)?
Do
es t
his
hel
p t
o e
nsu
re c
om
mu
nit
y p
rogr
ams
hav
e a
po
siti
ve h
eal
th im
pac
t?vi
.H
ealt
h o
rie
nta
tio
n –
do
co
mm
un
ity,
so
cial
, ed
uca
tio
n a
nd
oth
er p
rogr
ams
and
org
anis
atio
ns
hav
e a
stro
ng
hea
lth
ori
enta
tio
n?
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rt
Go
od
su
pp
ort
Fu
lly d
evel
op
ed s
up
po
rt
0 1
2
3 4
5
6 7
8
91
01
1
i N
o c
om
mu
nit
y in
pu
t to
go
vern
ance
C
om
mu
nit
y in
pu
t to
go
vern
ance
isfa
ir
Co
mm
un
ity
inp
ut
to g
ove
rnan
ce is
goo
d
Co
mm
un
ity
inp
ut
to g
ove
rnan
ce
is v
ery
goo
d
ii N
o s
ervi
ce p
op
ula
tio
nin
volv
emen
t in
pla
nn
ing
and
feed
bac
k
Serv
ice
po
pu
lati
on
invo
lve
men
t in
p
lan
nin
g an
d f
eed
bac
k is
ad
ho
c Se
rvic
e p
op
ula
tio
n in
volv
em
ent
in
pla
nn
ing
and
fee
db
ack
bec
om
ing
syst
emat
ic
Serv
ice
po
pu
lati
on
invo
lve
men
tin
pla
nn
ing
and
fee
db
ack
issy
stem
atic
an
d r
ou
tin
e
iii
Clie
nt
sati
sfac
tio
n n
ever
or
rare
ly a
sses
sed
A
sses
smen
t o
f cl
ien
t sa
tisf
acti
on
is a
d h
oc
Ass
essm
ent
of
clie
nt
sati
sfac
tio
nb
eco
min
g sy
stem
atic
an
d r
ou
tin
e
Ass
essm
ent
of
clie
nt
sati
sfac
tio
nis
sys
tem
atic
an
d r
ou
tin
e
iv
No
fo
rmal
agr
eem
ents
wit
hFo
rmal
agr
eem
ents
wit
h o
ther
Form
al a
gree
men
ts w
ith
oth
erFo
rmal
agr
eem
ents
wit
h o
ther
21
1
oth
er s
ervi
ces
serv
ices
wit
h f
air
com
mu
nic
atio
n
and
leve
ls o
f ac
tivi
ty
serv
ices
wit
h g
oo
d c
om
mu
nic
atio
n
and
leve
ls o
f ac
tivi
ty
serv
ices
wit
h v
ery
goo
d
com
mu
nic
atio
n a
nd
leve
ls o
f ac
tivi
ty
v N
o o
r p
oo
r p
artn
ersh
ips
wit
h
com
mu
nit
y gr
ou
ps
Par
tner
ship
s w
ith
co
mm
un
ity
gro
up
s ar
e fa
ir
Par
tner
ship
s w
ith
co
mm
un
ity
gro
up
s ar
e go
od
P
artn
ersh
ips
wit
h c
om
mu
nit
y gr
ou
ps
are
very
go
od
vi
Hea
lth
ori
en
tati
on
of
com
mu
nit
y p
rogr
ams
is w
eak
Hea
lth
ori
en
tati
on
of
com
mu
nit
y p
rogr
ams
is f
air
Hea
lth
ori
en
tati
on
of
com
mu
nit
y p
rogr
ams
is g
oo
d
Hea
lth
ori
en
tati
on
of
com
mu
nit
y p
rogr
ams
is v
ery
goo
d
21
2
4.2
Co
mm
un
icat
ion
an
d c
oo
pe
rati
on
on
go
vern
ance
an
d o
pe
rati
on
of
the
he
alth
se
rvic
e a
nd
oth
er
com
mu
nit
y b
ase
d o
rgan
isat
ion
s an
dp
rogr
ams
Elem
en
ts f
or
dis
cuss
ion
:
i.Th
ere
are
sys
tem
atic
arr
ange
men
ts in
pla
ce t
o li
nk
ind
ivid
ual
clie
nts
in t
his
are
a to
ou
tsid
e h
ealt
h a
nd
hea
lth
-rel
ated
re
sou
rces
.ii.
The
reso
urc
e d
irec
tory
th
at s
up
po
rts
thes
e ar
ran
gem
ents
is c
om
pre
hen
sive
, reg
ula
rly
up
dat
ed
, is
easi
ly a
cces
sib
le a
nd
wid
ely
use
d b
y st
aff.
iii.
Lin
kage
arr
ange
men
ts r
elat
ing
to t
hes
e re
sou
rces
are
wel
l in
tegr
ated
into
sta
ff o
rien
tati
on
an
d in
-ser
vice
tra
inin
g p
rogr
ams.
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rt
Go
od
su
pp
ort
Fu
lly d
evel
op
ed s
up
po
rt
0 1
2
3
4
5
6
78
91
01
1
i N
o o
r m
inim
al s
up
po
rt f
or
linki
ng
clie
nts
to
ou
tsid
ere
sou
rces
.
Arr
ange
me
nts
fo
r lin
kin
g cl
ien
ts t
o
ou
tsid
e re
sou
rces
ad
ho
c.
Arr
ange
me
nts
fo
r lin
kin
g cl
ien
ts t
oo
uts
ide
reso
urc
es b
eco
min
gsy
stem
atic
Arr
ange
me
nts
fo
r lin
kin
g cl
ien
tsto
ou
tsid
e r
eso
urc
es a
resy
stem
atic
ii N
o r
eso
urc
e d
irec
tory
R
eso
urc
e d
ire
cto
ry-
com
pre
hen
sive
nes
s, u
pd
atin
gac
cess
ibili
ty a
nd
use
are
fai
r
Res
ou
rce
dir
ect
ory
-co
mp
reh
ensi
ven
ess,
up
dat
ing
acce
ssib
ility
an
d u
se a
re g
oo
d
Res
ou
rce
dir
ect
ory
–
com
pre
hen
sive
nes
s, u
pd
atin
gac
cess
ibili
ty a
nd
use
are
ve
rygo
od
iii
No
or
min
imal
inte
grat
ion
of
linka
ge a
rran
gem
ents
in s
taff
o
rien
tati
on
or
trai
nin
g
Inte
grat
ion
of
linka
gear
ran
gem
ents
in s
taff
ori
en
tati
on
o
r tr
ain
ing
is f
air
Inte
grat
ion
of
linka
gear
ran
gem
ents
in s
taff
ori
en
tati
on
or
trai
nin
g is
go
od
Inte
grat
ion
of
linka
gear
ran
gem
ents
in s
taff
ori
en
tati
on
of
trai
nin
g is
ver
y go
od
21
3
4.3
: Wo
rkin
g o
ut
in t
he
co
mm
un
ity
Elem
en
ts f
or
dis
cuss
ion
: i.
Staf
f en
gage
men
t –
are
sta
ff e
nga
ged
in c
om
mu
nit
y h
ealt
h p
rom
oti
on
/dev
elo
pm
ent
acti
viti
es (
For
exam
ple
, in
pre
-sch
oo
ls a
nd
sch
oo
l; co
mm
un
ity
cen
tres
; yo
uth
gro
up
s, p
lay
gro
up
s)ii.
Des
ign
of
com
mu
nit
y ac
tivi
ties
– a
re c
om
mu
nit
y ac
tivi
ties
we
ll-d
esig
ned
? D
o t
hey
mee
t id
en
tifi
ed n
eed
s o
f d
iffe
ren
t gr
ou
ps?
iii.
Inte
grat
ion
– a
re c
om
mu
nit
y ac
tivi
ties
fu
lly in
tegr
ate
d in
th
e h
ealt
h s
ervi
ce’s
pro
gram
?
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rt
Go
od
su
pp
ort
Fu
lly d
eve
lop
ed s
up
po
rt
0 1
2
3
4 5
6
78
91
01
1
i N
o o
r m
inim
al s
taff
en
gage
men
t in
co
mm
un
ity
hea
lth
p
rom
oti
on
/dev
elo
pm
ent
Leve
l of
staf
f en
gage
men
t in
com
mu
nit
y h
ealt
hp
rom
oti
on
/dev
elo
pm
ent
is f
air
Leve
l of
staf
f en
gage
men
t in
com
mu
nit
y h
ealt
hp
rom
oti
on
/dev
elo
pm
ent
is g
oo
d
Leve
l of
staf
f en
gage
men
t in
com
mu
nit
y h
ealt
hp
rom
oti
on
/dev
elo
pm
ent
is v
ery
goo
d
ii D
esig
n o
f co
mm
un
ity
acti
viti
es is
fa
ir
Des
ign
of
com
mu
nit
y ac
tivi
ties
isgo
od
D
esig
n o
f co
mm
un
ity
acti
viti
es is
very
go
od
iii
Inte
grat
ion
of
com
mu
nit
yac
tivi
ties
into
ser
vice
’s p
rogr
ams
is f
air
Inte
grat
ion
of
com
mu
nit
yac
tivi
ties
into
ser
vice
’s p
rogr
ams
isgo
od
Inte
grat
ion
of
com
mu
nit
yac
tivi
ties
into
ser
vice
’s p
rogr
ams
is v
ery
goo
d
21
4
4.4
Co
mm
un
icat
ion
an
d c
oo
pe
rati
on
on
re
gio
nal
he
alth
pla
nn
ing
and
de
velo
pm
en
t o
f h
eal
th r
eso
urc
es
Elem
en
ts f
or
dis
cuss
ion
: i.
Reg
ion
al p
lan
nin
g- a
re h
ealt
h s
ervi
ce s
taff
act
ivel
y en
gage
d in
an
d p
rom
ote
reg
ion
al p
lan
nin
g?
ii.
Hea
lth
res
ou
rces
– d
o h
ealt
h s
ervi
ce s
taff
act
ivel
y co
ntr
ibu
te t
o t
he
dev
elo
pm
en
t an
d p
rom
oti
on
of
stan
dar
d r
eso
urc
es f
or
hea
lth
se
rvic
es t
hat
hav
e re
gio
n-w
ide
rele
van
ce in
th
is a
rea?
iii
. Lo
cal c
om
mu
nit
y p
lan
s –
are
pla
ns
syst
em
atic
ally
use
d t
o in
form
reg
ion
al p
lan
nin
g p
roce
sses
an
d a
lloca
tio
n o
f re
sou
rces
?
Lim
ite
d o
r n
o s
up
po
rt
Bas
ic s
up
po
rt
Go
od
su
pp
ort
Fu
lly d
evel
op
ed s
up
po
rt
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al e
nga
gem
ent
in
regi
on
al p
lan
nin
g Le
vel o
f en
gage
men
t in
re
gio
nal
p
lan
nin
g is
fai
r Le
vel o
f en
gage
men
t in
re
gio
nal
p
lan
nin
g is
go
od
Le
vel o
f en
gage
men
t in
re
gio
nal
p
lan
nin
g is
ve
ry g
oo
d
ii N
o o
r m
inim
al c
on
trib
uti
on
to
th
e d
evel
op
men
t o
f re
sou
rces
C
on
trib
uti
on
to
th
e d
eve
lop
men
t o
f re
sou
rces
is f
air
Co
ntr
ibu
tio
n t
o t
he
dev
elo
pm
ent
of
reso
urc
es is
go
od
C
on
trib
uti
on
to
th
e d
evel
op
me
nt
of
reso
urc
es is
ve
ry g
oo
d
iii
No
or
min
imal
use
of
com
mu
nit
y p
lan
s U
se o
f co
mm
un
ity
pla
ns
is a
d h
oc
Use
of
com
mu
nit
y p
lan
s is
b
eco
min
g sy
stem
atic
U
se o
f co
mm
un
ity
pla
ns
is
syst
emat
ic
21
5
Co
mp
on
en
t 5
: Org
anis
atio
nal
infl
ue
nce
an
d in
tegr
atio
n
Hea
lth
car
e se
rvic
es w
ill b
e m
ore
eff
ecti
ve if
th
ere
is a
n o
rgan
isat
ion
al c
ult
ure
th
at is
co
mm
itte
d t
o a
dd
ress
ing
the
nee
ds
of
spec
ific
clie
nt
gro
up
s; p
rom
ote
s go
od
rel
atio
nsh
ips
and
co
mm
un
icat
ion
an
d s
afe,
hig
h q
ual
ity
care
an
d q
ual
ity
imp
rove
men
t. In
ad
dit
ion
, eff
ecti
ve h
ealt
h c
are
req
uir
es t
he
inte
grat
ion
of
the
hea
lth
se
rvic
e’s
syst
em c
om
po
nen
ts.
Ite
m 5
.1: O
rgan
isat
ion
al c
om
mit
me
nt
Elem
en
ts f
or
dis
cuss
ion
: i.
Stra
tegi
c an
d b
usi
nes
s p
lan
s –
do
th
ey r
efl
ect
com
mit
men
t to
th
is c
lien
t gr
ou
p (
i.e. v
isio
n s
tate
men
t, p
olic
ies,
fin
anci
ng,
sta
ffin
g an
d
stra
tegi
es)?
ii.
Fu
nd
ing
– is
th
ere
spe
cifi
c fu
nd
ing
for
this
are
a th
at is
at
an a
deq
uat
e le
vel a
nd
lon
g-te
rm?
iii.
Staf
fin
g –
do
sta
ffin
g le
vels
mee
t th
e e
stab
lish
ed n
eed
? A
re a
ll th
e r
elev
ant
role
s d
efin
ed
an
d t
hes
e r
ole
s re
flec
ted
in jo
b
des
crip
tio
ns?
iv
. St
aff
rela
tio
nsh
ips
and
mo
rale
– a
re t
he
re g
oo
d r
elat
ion
ship
s an
d r
egu
lar,
cle
ar c
om
mu
nic
atio
n a
mo
ng
staf
f? W
her
e is
mo
rale
hig
h?
Is t
her
e a
fee
ling
amo
ng
the
line
sta
ff t
hat
sen
ior
staf
f u
nd
erst
and
th
eir
wo
rk a
nd
nee
ds?
v.
Tr
ain
ing
– w
hat
is t
he
ran
ge o
f tr
ain
ing
and
inse
rvic
e o
pp
ort
un
itie
s fo
r st
aff
wo
rkin
g in
th
is a
rea?
vi
. Se
rvic
e d
eliv
ery
str
ateg
ies
– is
th
ere
a ra
nge
of
serv
ice
del
iver
y st
rate
gies
in t
his
are
a ac
ross
ind
ivid
ual
clin
ical
, gro
up
an
d p
op
ula
tio
n
bas
ed a
ctiv
itie
s (a
s ap
pro
pri
ate)
?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
1
0
1
1
i N
o p
lan
s; li
ttle
or
no
inte
rest
in
a p
lan
P
lan
s in
pla
ce; l
evel
of
com
mit
men
t is
fai
r P
lan
s in
pla
ce; l
evel
of
com
mit
men
t is
go
od
P
lan
s in
pla
ce; l
evel
of
com
mit
men
t is
ver
y go
od
ii N
o s
pec
ific
fu
nd
ing
Spec
ific
fu
nd
ing;
leve
l is
fair
an
d/o
r sh
ort
ter
m
Spec
ific
fu
nd
ing;
leve
l is
goo
d
and
/or
med
ium
ter
m
Spec
ific
fu
nd
ing;
leve
l is
very
go
od
an
d/o
r lo
ng
term
iii
Min
imal
sta
ffin
g; n
o s
pec
ific
ro
les
Leve
l of
staf
fin
g is
fai
r; s
om
e ro
les
def
ined
Le
vel o
f st
affi
ng
is g
oo
d; m
ost
ro
les
def
ined
an
d r
efle
cted
in jo
b
des
crip
tio
ns
Leve
l of
staf
fin
g is
ver
y go
od
; all
role
s d
efin
ed a
nd
ref
lect
ed
in
job
des
crip
tio
n
iv
Po
or
rela
tio
nsh
ips
and
litt
le o
r n
o c
om
mu
nic
atio
n
Mo
rale
is lo
w
Rel
atio
nsh
ips
and
co
mm
un
icat
ion
ar
e fa
ir
Mo
rale
is f
air
Rel
atio
nsh
ips
and
co
mm
un
icat
ion
ar
e go
od
M
ora
le is
go
od
Rel
atio
nsh
ips
and
co
mm
un
icat
ion
are
ver
y go
od
M
ora
le is
ver
y go
od
v R
ange
of
trai
nin
g an
d in
serv
ice
op
po
rtu
nit
ies
is p
oo
r R
ange
of
trai
nin
g an
d in
serv
ice
op
po
rtu
nit
ies
is f
air
Ran
ge o
f tr
ain
ing
and
inse
rvic
e o
pp
ort
un
itie
s is
go
od
R
ange
of
trai
nin
g an
d in
serv
ice
op
po
rtu
nit
ies
is v
ery
goo
d
21
6
vi
Ran
ge o
f se
rvic
e d
eliv
ery
stra
tegi
es is
po
or
Ran
ge o
f se
rvic
e d
eliv
ery
stra
tegi
es is
fai
r R
ange
of
serv
ice
del
iver
y st
rate
gies
is
go
od
R
ange
of
serv
ice
del
iver
y st
rate
gies
is v
ery
goo
d
Ite
m 5
.2: Q
ual
ity
imp
rove
me
nt
stra
tegi
es
Elem
en
ts f
or
dis
cuss
ion
: i.
Sen
ior
staf
f su
pp
ort
fo
r q
ual
ity
imp
rove
men
t –
do
se
nio
r st
aff
sup
po
rt q
ual
ity
imp
rove
men
t? Is
it r
eso
urc
ed?
Is s
taff
tra
inin
g p
rovi
ded
? Is
par
tici
pat
ion
en
cou
rage
d?
Do
sta
ff m
emb
ers
hav
e au
tho
rity
to
mak
e im
pro
vem
en
ts?
Is e
ffe
ctiv
enes
s ev
alu
ated
? ii.
Q
ual
ity
imp
rove
men
t p
roce
sses
– a
re t
her
e sy
stem
atic
pro
cess
es in
pla
ce?
Are
th
ey u
sed
co
nsi
sten
tly
(fo
r ex
amp
le, c
yclic
al
pro
cess
es o
f ev
iden
ce-b
ased
ass
essm
ent
of
hea
lth
ser
vice
per
form
ance
usi
ng
goo
d q
ual
ity
dat
a, r
evie
w a
nd
pla
nn
ing
invo
lvin
g th
e w
ho
le t
eam
, an
d s
ervi
ce im
pro
vem
ent)
? iii
. H
ealt
h s
ervi
ce p
erfo
rman
ce r
epo
rtin
g –
is t
he
ele
ctro
nic
clie
nt
info
rmat
ion
sys
tem
ro
uti
nel
y u
sed
in t
his
are
a (f
or
exa
mp
le, i
ncl
ud
ing
pro
file
s an
d n
eed
s o
f cl
ien
t gr
ou
ps,
car
e d
eliv
ery
and
clie
nt
ou
tco
mes
) iv
. P
roce
sses
fo
r d
ealin
g w
ith
err
ors
an
d p
rob
lem
s –
are
sys
tem
atic
pro
cess
es in
pla
ce f
or
dea
ling
wit
h e
rro
rs w
ith
car
e d
eliv
ery?
Do
th
ey in
clu
de
ro
uti
ne
iden
tifi
cati
on
, exa
min
atio
n o
f ro
ot
cau
ses
and
fo
llow
th
rou
gh (
app
rop
riat
e ac
tio
n a
nd
reg
ula
r re
view
)?
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al s
enio
r st
aff
sup
po
rt f
or
qu
alit
y im
pro
vem
ent
Lim
ite
d s
enio
r st
aff
sup
po
rt f
or
qu
alit
y im
pro
vem
ent
Sen
ior
staf
f su
pp
ort
qu
alit
y im
pro
vem
ent
bu
t n
ot
fully
or
con
sist
entl
y
Qu
alit
y im
pro
vem
ent
fully
an
d
con
sist
entl
y su
pp
ort
ed b
y se
nio
r st
aff
ii N
o o
r m
inim
al q
ual
ity
imp
rove
men
t p
roce
sses
A
d h
oc
qu
alit
y im
pro
vem
en
t p
roce
sses
Sy
stem
atic
qu
alit
y im
pro
vem
ent
pro
cess
es b
ut
no
t u
sed
co
nsi
sten
tly
Syst
emat
ic q
ual
ity
imp
rove
men
t p
roce
sses
use
d c
on
sist
entl
y
iii
No
ele
ctro
nic
clie
nt
info
rmat
ion
sys
tem
U
se o
f th
e sy
stem
fo
r re
po
rtin
g o
n s
ervi
ce p
erf
orm
ance
is a
d h
oc
Use
of
the
syst
em f
or
rep
ort
ing
on
se
rvic
e p
erfo
rman
ce b
eco
min
g ro
uti
ne
Use
of
the
syst
em f
or
rep
ort
ing
on
cen
tre
per
form
ance
is
rou
tin
e
iv
No
or
min
imal
pro
cess
es f
or
dea
ling
wit
h e
rro
rs o
r P
roce
sses
fo
r d
ealin
g w
ith
err
ors
o
r p
rob
lem
s ar
e ad
ho
c P
roce
sses
fo
r d
ealin
g w
ith
err
ors
b
eco
min
g sy
stem
atic
P
roce
sses
fo
r d
ealin
g w
ith
err
ors
sy
stem
atic
21
7
pro
ble
ms
Ite
m 5
.3: I
nte
grat
ion
of
he
alth
sys
tem
co
mp
on
en
ts
Elem
en
ts f
or
dis
cuss
ion
: i.
Inte
grat
ion
– t
her
e is
cle
ar r
eco
gnit
ion
of
the
nee
d f
or
and
imp
ort
ance
of
inte
grat
ion
acr
oss
th
e h
ealt
h s
ervi
ce. F
or
exam
ple
:
ho
w w
ell i
nfo
rmat
ion
sys
tem
su
pp
ort
s cl
inic
al d
ecis
ion
mak
ing
(by
mak
ing
guid
elin
es a
cces
sib
le)
or
self
-man
agem
en
t (b
y al
low
ing
reco
rdin
g o
f cl
ien
t go
als)
ho
w w
ell t
he
fun
din
g an
d h
um
an r
eso
urc
es a
rran
gem
ents
su
pp
ort
tea
m c
are
ho
w w
ell w
ork
wit
hin
an
d o
uts
ide
the
hea
lth
cen
ter
com
ple
me
nt
each
oth
er
ho
w w
ell s
taff
tra
inin
g su
pp
ort
s co
nti
nu
ity
of
care
Th
is is
ref
lect
ed in
all
do
cum
ents
/pro
cess
es/a
ctiv
itie
s in
clu
din
g:
bu
sin
ess
pla
n
po
licy
stat
emen
ts
fin
anci
ng
arra
nge
me
nts
info
rmat
ion
sys
tem
regu
lati
on
/le
gisl
atio
n
dep
loym
en
t o
f h
um
an r
eso
urc
es
lead
ersh
ip a
nd
ad
voca
cy r
ole
s
care
pro
cess
es
edu
cati
on
an
d in
serv
ice
pro
gram
s
wo
rk o
uts
ide
th
e h
ealt
h s
erv
ice
par
tner
ship
arr
ange
men
ts
Li
mit
ed
or
no
su
pp
ort
B
asic
su
pp
ort
G
oo
d s
up
po
rt
Fully
dev
elo
ped
su
pp
ort
0
1
2
3
4
5
6
7
8
9
10
11
i N
o o
r m
inim
al in
tegr
atio
n
Fair
leve
l of
inte
grat
ion
G
oo
d le
vel o
f in
tegr
atio
n
Ver
y go
od
leve
l of
inte
grat
ion
21
8
3.6
PH
YS
IOT
HE
RA
PY
GO
AL
SE
TT
ING
TO
OL
Ph
ysi
oth
era
py
Go
al
Set
tin
g T
oo
l (
One2
1se
ven
ty G
oal
Set
tin
g T
emp
late
)
Tab
le 1
: P
rio
riti
es f
or
imp
rov
emen
t id
enti
fied
du
ring p
arti
cipat
ory
in
terp
reta
tio
n.
PR
IOR
ITIE
S
WH
O’S
IN
VO
LV
ED
T
IME
LIN
E
1.
2.
3.
Tab
le 2
: G
oal
s an
d s
trat
egie
s fo
r im
pro
vem
ent
iden
tifi
ed d
uri
ng a
ctio
n p
lannin
g.
Goal
s S
trat
egie
s W
HO
’S I
NV
OL
VE
D
TIM
EL
INE
Fro
m t
he
clin
ical
au
dit
s an
d s
yste
ms
asse
ssm
ent
dat
a, d
ecid
e w
hat
asp
ects
of
you
r h
ealt
h c
entr
e sy
stem
s re
qu
ire
the
mo
std
evel
op
men
t in
ord
er t
o im
pro
ve d
eliv
ery
of
serv
ices
. Tab
les
1 a
nd
2 a
re t
emp
late
s yo
ur
org
anis
atio
n m
ay w
ish
to
use
to
d
ocu
men
t go
als
and
str
ateg
ies
for
imp
rove
men
t
21
9
3.7
DE
VE
LO
PM
EN
T O
F T
HE
TO
OL
CO
NT
EN
T:
SE
LE
CT
ION
OF
IN
DIC
AT
OR
S
US
ED
TO
AS
SE
SS
QU
AL
ITY
OF
PH
YS
IOT
HE
RA
PY
SE
RV
ICE
S
Lit
eratu
re
Cli
nic
al
Ind
icato
rs
On
e21
Sev
enty
Nat
ion
al C
entr
e fo
r Q
ual
ity
Im
pro
vem
ent
in I
nd
igen
ou
s P
rim
ary
Hea
lth
Car
e, M
enzi
es
Sch
oo
l o
f H
ealt
h R
esea
rch.
Chil
d h
ealt
h c
linic
al a
ud
it t
oo
l 3
mo
nth
s to
<1
5 y
ears
ver
sio
n 3
.1.
201
1
On
e21
sev
enty
Nat
ion
al C
entr
e fo
r Q
ual
ity
Im
pro
vem
ent
in I
nd
igen
ou
s P
rim
ary
Hea
lth
Car
e, M
enzi
es
Sch
oo
l o
f H
ealt
h R
esea
rch.
Chil
d h
ealt
h c
linic
al a
ud
it p
roto
col
3 m
on
ths
to <
15
yea
rs v
ersi
on
3.1
.
Dar
win
: M
enzi
es S
chool
of
Hea
lth R
esea
rch
; 2
01
1.
Sec
tion
1 G
ener
al
Info
rma
tio
n
C
lien
t ID
D
ate
of
Bir
th
A
ge
at D
ate
of
Au
dit
S
ex
In
dig
eno
us
Sta
tus
F
amil
y B
ack
gro
un
d
L
ang
uag
e S
po
ken
at
Ho
me
D
ate
of
Ref
erra
l
S
ou
rce
of
Ref
erra
l
L
oca
tio
n o
f R
efer
ral
R
easo
n f
or
Ref
erra
l
A
ud
itor
A
ud
it D
ate
On
e21
Sev
enty
Nat
ion
al C
entr
e fo
r Q
ual
ity
Im
pro
vem
ent
in I
nd
igen
ou
s P
rim
ary
Hea
lth
Car
e, M
enzi
es
Sch
oo
l o
f H
ealt
h R
esea
rch.
Chil
d h
ealt
h c
linic
al a
ud
it t
oo
l 3
mo
nth
s to
<1
5 y
ears
ver
sio
n 3
.1.
201
1
On
e21
sev
enty
Nat
ion
al C
entr
e fo
r Q
ual
ity
Im
pro
vem
ent
in I
nd
igen
ou
s P
rim
ary
Hea
lth
Car
e, M
enzi
es
Sch
oo
l o
f H
ealt
h R
esea
rch.
Chil
d h
ealt
h c
linic
al a
ud
it p
roto
col
3 m
on
ths
to <
15
yea
rs v
ersi
on
3.1
.
Dar
win
: M
enzi
es S
chool
of
Hea
lth R
esea
rch;
20
11
.
Wo
rld C
onfe
der
atio
n f
or
Physi
cal
Th
erap
y.
WC
PT
gu
idel
ine
for
stan
dar
ds
of
ph
ysi
cal
ther
apy
pra
ctic
e
Lon
do
n:
WC
PT
Sec
reta
riat
; 2011 [
updat
ed 1
8 O
cto
ber
20
11
; ci
ted 2
01
2 9
Sep
tem
ber
20
12
]. A
vai
lab
le
fro
m:
htt
p:/
/ww
w.w
cpt.
org
/sit
es/w
cpt.
org
/fil
es/f
iles
/Gu
idel
ine_
stan
dar
ds_
pra
ctic
e_co
mp
lete
.pd
f
htt
p:/
/ww
w.w
cpt.
org
/guid
elin
es/s
tand
ard
s.
Sec
tion
2 A
tten
da
nce
D
ate
last
att
end
ed
F
oll
ow
up
H
ow
man
y a
ttem
pts
to
Fo
llo
w U
p
A
ttem
pt
to c
on
tact
pri
mar
y c
arer
pre
- ap
pt
S
ucc
essf
ul
conta
ct w
ith
pri
mar
y c
arer
pre
app
t
P
rim
ary
car
er a
tten
d t
he
app
oin
tmen
t
F
oll
ow
up
wit
h p
rim
ary
car
er i
f an
oth
er c
arer
atte
nd
ed
L
oca
tio
n o
f fa
mil
y c
on
sult
atio
n
U
se o
f In
terp
rete
r
22
0
Au
stra
lian
Physi
oth
erap
y C
ounci
l. A
ust
rali
an S
tan
dar
ds
for
Ph
ysi
oth
erap
y:
safe
an
d e
ffec
tiv
e
ph
ysi
oth
erap
y J
uly
2006 [
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ble
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hy
sio
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nci
l.co
m.a
u/f
iles
/th
e-
aust
rali
an-s
tan
dar
ds-
for-
physi
oth
erap
y.
Wo
rld C
onfe
der
atio
n f
or
Physi
cal
Th
erap
y.
WC
PT
gu
idel
ine
for
stan
dar
ds
of
ph
ysi
cal
ther
apy
pra
ctic
e
Lon
do
n:
WC
PT
Sec
reta
riat
; 2011 [
updat
ed 1
8 O
cto
ber
20
11
; ci
ted 2
01
2 9
Sep
tem
ber
20
12
]. A
vai
lab
le
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m:
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p:/
/ww
w.w
cpt.
org
/sit
es/w
cpt.
org
/fil
es/f
iles
/Gu
idel
ine_
stan
dar
ds_
pra
ctic
e_co
mp
lete
.pd
f
htt
p:/
/ww
w.w
cpt.
org
/guid
elin
es/s
tand
ard
s.
Sec
tion
3 K
ey I
nfo
rmati
on
in
fil
es a
nd
com
pu
ter
reco
rds
B
irth
His
tory
G
ener
al M
edic
al H
isto
ry
D
evel
op
men
tal
His
tory
F
amil
y H
isto
ry
S
oci
al H
isto
ry
E
du
cati
on
His
tory
D
iagn
osi
s
R
isk
Fac
tors
Bu
rns
Y. N
.S.M
.D.A
. P
hysi
oth
erap
y A
sses
smen
t fo
r In
fan
ts a
nd
Yo
un
g C
hil
dre
n.
Bri
sban
e: C
op
yri
gh
t
Pu
bli
shin
g;
1992.
Cam
pb
ell
S. P
hysi
cal
ther
apy f
or
chil
dre
n.
thir
d e
d. S
t. L
ou
is,
Mis
sou
ri:
Sau
nd
ers
Els
evie
r; 2
00
6.
Cam
pb
ell
SK
, P
alis
ano R
, O
rlin
MN
. P
hysi
cal
ther
apy
fo
r ch
ild
ren
. F
ou
rth e
d. S
ain
t L
ou
is:
Els
evie
r;
20
12
.
Hen
der
son S
E, S
ugden
DA
, B
arn
ett
AL
. M
ovem
ent
Ass
essm
ent
Bat
tery
fo
r C
hil
dre
n-2
ex
amin
ers
man
ual
. S
eco
nd e
d. H
arco
urt
: L
ondon;
20
07
Pip
er M
C, D
arra
h J
. M
oto
r as
sess
men
t o
f th
e d
evel
op
ing
in
fan
t. P
hil
adel
ph
ia:
W.B
. S
aun
der
s; 1
99
4.
Sq
uir
es J
. A
ges
and S
tages
Ques
tionn
aire
-ver
sio
n 3
, 2
01
2.
Wo
rld C
onfe
der
atio
n f
or
Physi
cal
Th
erap
y.
WC
PT
gu
idel
ine
for
stan
dar
ds
of
ph
ysi
cal
ther
apy
pra
ctic
e
Lon
do
n:
WC
PT
Sec
reta
riat
; 2011 [
updat
ed 1
8 O
cto
ber
20
11
; ci
ted 2
01
2 9
Sep
tem
ber
20
12
]. A
vai
lab
le
fro
m:
htt
p:/
/ww
w.w
cpt.
org
/sit
es/w
cpt.
org
/fil
es/f
iles
/Gu
idel
ine_
stan
dar
ds_
pra
ctic
e_co
mp
lete
.pd
f
htt
p:/
/ww
w.w
cpt.
org
/guid
elin
es/s
tand
ard
s.
Wo
rld H
ealt
h O
rgan
izat
ion
. In
tern
atio
nal
cla
ssif
icat
ion
of
fun
ctio
nin
g,
dis
abil
ity a
nd
hea
lth
(IC
F)
20
12
[updat
ed 3
1 O
ctob
er;
cite
d 2
012
3 J
uly
]. A
vai
lab
le f
rom
:
htt
p:/
/ww
w.w
ho.i
nt/
clas
sifi
cati
on
s/ic
f/en
/.
Sec
tion
4 C
lin
ical
Ser
vic
es
for
Gro
ss
Mo
tor
Del
ay
P
ain
P
rim
ary
Car
er’s
Nee
ds
C
hil
d’s
Nee
ds
P
rim
ary
Car
er’s
Go
als
C
hil
d’s
Go
als
S
tren
gth
s
W
eak
nes
ses
P
rim
ary
Car
er’s
Pri
ori
ties
C
hil
d’s
Pri
ori
ties
G
ener
al A
pp
eara
nce
B
ehav
iou
r
C
hil
d i
nte
ract
ion
wit
h e
nv
iro
nm
ent
P
rim
ary
Car
er/c
hil
d i
nte
ract
ion
A
SQ
A
IMS
NSM
DA
M
ov
emen
t-A
BC
N
euro
log
ical
M
usc
ulo
skel
etal
M
ob
ilit
y
G
ait
(if
app
lica
ble
)
22
1
H
om
e
P
resc
ho
ol/
Sch
oo
l (i
f ap
pli
cable
)
C
hil
dca
re (
if a
pp
lica
ble
)
E
qu
ipm
ent
Nee
ds
P
hy
sica
l ac
tiv
ity a
nd
res
t
Cer
ebra
l P
alsy
All
iance
. C
ereb
ral
Pal
sy A
llia
nce
20
12
[ci
ted
20
12
31
Oct
ob
er].
Av
aila
ble
fro
m:
ww
w.c
ereb
ralp
alsy
.org
.au.
Cer
ebra
l P
alsy
Reg
iste
r. C
P
Reg
iste
r [w
ebp
age]
. 2
01
2 [
cite
d 2
012
2 N
ov
emb
er].
Av
aila
ble
fro
m:
htt
p:/
/ww
w.c
pre
gis
ter.
com
.
Eli
asso
n A
, K
rum
lind
e S
L,
Rosb
lad B
, B
eckun
g E
, A
ren
er M
, O
hrv
all
A, et
al.
Th
e M
anu
al A
bil
ity
Cla
ssif
icat
ion
Syst
em (
MA
CS
) fo
r ch
ildre
n w
ith
cer
ebra
l p
alsy
: sc
ale
dev
elo
pm
ent
and
ev
iden
ce o
f
val
idit
y a
nd r
elia
bil
ity.
Dev
elop
men
tal
Med
icin
e &
Ch
ild
Neu
rolo
gy
. 20
06
;48
:54
9-5
4.
Gra
ham
HK
, R
odda
J, N
attr
ass
GR
, P
irpir
is M
. T
he
fun
ctio
nal
mo
bil
ity
sca
le (
FM
S).
JP
O.
20
04
;24
(5):
514
-20.
Hal
ey S
M, C
ost
er W
, L
ud
low
LH
, H
alti
wan
ger
J, A
nd
rell
os
P.
Pae
dia
tric
ev
alu
atio
n o
f d
isab
ilit
y
inv
ento
ry (
PE
DI)
Ver
sion 1
.0 D
evel
op
men
t S
tand
ard
isat
ion
an
d A
dm
inis
trat
ion
Man
ual
. B
ost
on
:
Bo
ston
Un
ives
ity;
1998.
Har
vey
A,
Bak
er R
, ed
itors
. V
ideo
gai
t an
alysi
s (V
GA
) to
su
pp
ort
cli
nic
al d
ecis
ion
mak
ing
in c
ereb
ral
pal
sy.
Inte
rnat
ional
C
ereb
ral
Pal
sy C
onfe
ren
ce;
20
09
; S
ydn
ey.
Lov
e S
C, N
ovak
I,
Ken
tish
M,
Des
loover
e K
, H
ein
en F
, M
ole
nae
rs G
, et
al.
Bo
tuli
nu
m t
ox
in
asse
ssm
ent,
inte
rven
tion a
nd a
fter
-car
e fo
r lo
wer
lim
b s
pas
tici
ty i
n c
hil
dre
n w
ith
cer
ebra
l p
alsy
:
inte
rnat
ional
con
sensu
s st
atem
ent.
Eur
J N
euro
l. 2
01
0;1
7 S
up
pl
2:9
-37
.
Pal
isan
o R
, R
ose
nbau
m P
, W
alte
r S
, R
uss
ell
D, W
oo
d E
, G
alu
pp
i B
. D
evel
op
men
t an
d r
elia
bil
ity o
f a
syst
em t
o c
lass
ify g
ross
moto
r fu
nct
ion i
n c
hil
dre
n w
ith
cer
ebra
l p
alsy
. D
ev M
ed C
hil
d N
euro
l.
19
97
;39
(4):
214
-23.
Sec
tion
5 C
lin
ica
l S
erv
ices
fo
r C
lien
ts w
ith
Cer
ebra
l P
als
y
C
P C
lass
ific
atio
n a
t d
iag
no
sis
H
ow
old
wh
en d
iagn
ose
d
C
P T
yp
e an
d T
yp
og
rap
hy
M
AC
S
B
irth
def
ects
pre
sen
t
K
now
n s
ynd
rom
es
P
rese
nce
of
Ep
ilep
sy
In
tell
ectu
al i
mp
airm
ent
V
isu
al i
mp
airm
ent
H
eari
ng
im
pai
rmen
t
C
om
mu
nic
atio
ns
imp
airm
ent
S
leep
iss
ues
R
esp
irat
ory
Iss
ues
P
ain
iss
ues
S
kin
In
tegri
ty/h
ealt
h
S
urg
ical
in
terv
enti
on
s
M
edic
al i
nte
rven
tio
ns
(Bo
NT
A,
Bac
lofe
n)
D
etai
ls o
f h
ip x
-ray
in
las
t 1
2 m
on
ths
R
esu
lts
of
hip
x-r
ay i
n l
ast
12 m
on
ths
P
ain
P
rim
ary
Car
er’s
Nee
ds
C
hil
d’s
Nee
ds
P
rim
ary
Car
er’s
Go
als
C
hil
d’s
Go
als
T
each
er/G
oal
s
22
2
Ru
ssel
l D
, R
ose
nb
aum
P,
Aver
y L
, L
ane
M. G
ross
Mo
tor
Fu
nct
ion
Mea
sure
(G
MF
M -
66
& G
MF
M -
88
) u
ser'
s m
anu
al.
London:
Mac
Kei
th P
ress
; 20
02
.
Wyn
ter
M, G
ibso
n N
, K
enti
sh M
, L
ov
e S
, T
ho
mas
on
P,
Ker
r G
rah
am H
. T
he
Co
nse
nsu
s S
tate
men
t o
n
Hip
Surv
eill
ance
for
Chil
dre
n w
ith C
ereb
ral
Pal
sy:
Au
stra
lian
Sta
nd
ard
s o
f C
are.
J P
edia
tr R
ehab
il M
ed
[In
tern
et].
20
11;
4(3
):[1
83-9
5 p
p.]
. A
vai
lable
fro
m:
htt
p:/
/ww
w.n
cbi.
nlm
.nih
.gov
/pu
bm
ed/2
22
07
095
.
Str
eng
ths
Wea
kn
esse
s
Pri
mar
y C
arer
’s P
rio
riti
es
Ch
ild
’s P
rio
riti
es
Gen
eral
Ap
pea
ran
ce
Beh
avio
ur
Ch
ild
in
tera
ctio
n w
ith
env
iro
nm
ent
Pri
mar
y c
arer
/ c
hil
d i
nte
ract
ion
Ho
me
Pre
sch
oo
l/S
cho
ol
(if
app
lica
ble
)
Ch
ild
care
(if
ap
pli
cab
le)
Equ
ipm
ent
Nee
ds
Ph
ysi
cal
acti
vit
y a
nd
res
t
GM
FC
S (
age
<=
18
)
FM
S (
age
4-1
8)
GM
FM
88
fo
r G
MF
CS
IV
-V
GM
FM
66
fo
r G
MF
CS
I-I
II
Sit
tin
g p
osi
tion
Tra
nsi
tio
nal
mo
vem
ents
Sta
nd
ing
Ind
epen
den
ce l
evel
Sel
f-C
are-
Fu
nct
ion
al L
evel
OG
S o
r P
RS
Ass
ista
nce
req
uir
ed
Equ
ipm
ent
requ
ired
Ort
ho
tics
use
d
2D
VG
A
Su
pin
e A
bd
uct
ion
(h
ips
0)
Su
pin
e A
bd
uct
ion
(h
ips
0)
Su
pin
e A
bd
uct
ion
(h
ips
90
)
Su
pin
e A
bd
uct
ion
(h
ips
90
)
Su
pin
e F
lex
ion
Su
pin
e H
ip E
xte
nsi
on
Pro
ne
ER
22
3
P
ron
e IR
D
un
can
Ely
D
un
can
Ely
K
nee
Ex
ten
sio
n
P
op
lite
al A
ng
le
R1
P
op
lite
al A
ng
le
R2
A
nk
le d
ors
ifle
xio
n (
kn
ee 9
0)R
1
A
nk
le d
ors
ifle
xio
n (
kn
ee 9
0)R
2
A
nk
le d
ors
ifle
xio
n(k
nee
0)R
1
A
nk
le d
ors
ifle
xio
n(k
nee
0)R
2
P
osi
tion
no
ted
R1
H
ind
foo
t (v
arus
or
val
gu
s
M
idfo
ot
sup
inat
ion
/pro
nat
ion
(k
nee
90
)
H
ind
foo
t to
fo
refo
ot
alig
nm
ent
T
oes
ali
gn
men
t
G
reat
to
e
S
tan
din
g p
osi
tio
n
S
itti
ng
po
siti
on
P
ron
e at
tem
pt
spin
al c
orr
ecti
on
S
tan
din
g p
osi
tio
n
S
itti
ng
po
siti
on
P
assi
ve
corr
ecti
on
H
ip d
ysp
lasi
a/d
isso
ciat
ion
/su
blu
xat
ion
L
eg l
eng
th d
iffe
ren
ce
T
oes
-fro
nta
l (A
bd
/ad
d)
T
oes
- sa
git
tal
(ex
t/fl
ex)
F
ore
foo
t-fr
on
tal
(abd
/add
)
F
ore
foo
t/m
idfo
ot-
sag
itta
l (c
avu
s/p
lan
us)
F
ore
foo
t/m
idfo
ot-
tran
sver
se
(su
pin
atio
n/p
ron
atio
n)
H
ind
foo
t-fr
on
tal
(var
us/
val
gus)
A
nk
le/H
indfo
ot-
sag
itta
l (D
F/P
F)
A
nk
les
(inv
/ev)
K
nee
–fr
on
tal
vie
w (
val
gu
s/var
us)
22
4
K
nee
–sa
git
tal
vie
w (
cro
uch
/rec
urv
atu
m
H
ip-f
ron
tal
(ab
d/a
dd
)
H
ip-s
agit
tal
(fle
x/e
xt)
P
elv
is-f
ron
tal
(ob
liq
uit
y)
P
elv
is-s
agit
tal
(til
t)
P
elv
is-
tran
sver
se (
rota
tio
n)
L
um
bar
–sp
ine
fro
nta
l (s
coli
osi
s)
L
um
bar
-sp
ine
sag
itta
l (l
ord
osi
s/k
yp
ho
sis)
T
ho
raci
c sp
ine-
fro
nta
l (s
coli
osi
s)
T
ho
raci
c sp
ine-
sag
itta
l(lo
rdo
sis/
ky
ph
osi
s)
S
ho
uld
er g
ird
le-f
ron
tal
(ob
liq
uit
y)
S
ho
uld
er g
ird
le-s
agit
tal
(IR
)
C
erv
ical
sp
ine-
fro
nta
l (s
idef
lex
ion
)
C
erv
ical
sp
ine
– s
agit
tal
(fle
x/e
xt)
H
ip F
lexo
rs
H
ip A
bd
uct
ors
H
ip E
xte
nso
rs
Q
uad
rice
ps
H
amst
rin
gs
A
nk
le D
ors
ifle
xo
rs
C
alv
es
A
nk
le D
ors
ifle
xio
n
H
ip F
lexo
rs
H
ip A
dd
uct
ors
Q
uad
rice
ps
H
amst
rin
gs
G
astr
ocn
emii
S
ole
i
P
hy
sio
ther
apy
ass
esse
d t
yp
e an
d t
yp
og
raph
y
Bu
rns
Y,
Mac
Donal
d J
, ed
itors
. P
hysi
oth
erap
y a
nd
th
e g
row
ing
ch
ild
. L
on
do
n:
WB
Sau
nd
ers
Ltd
;
19
96.
6 E
qu
ipm
ent
S
tan
din
g f
ram
e d
escr
ipti
on
A
ssis
tan
ce r
equ
ired
fo
r tr
ansf
ers/
use
W
her
e it
em i
ssu
ed f
rom
22
5
Wh
en i
tem
iss
ued
Sch
edu
le o
f u
se (
freq
uen
cy/s
essi
on
tim
e)
Issu
es w
ith
use
Issu
es w
ith
co
nd
itio
n
Wh
eele
d m
ob
ilit
y d
escr
ipti
on
Wh
eele
d s
eati
ng
des
crip
tio
n
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ista
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req
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ed
Wh
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tem
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es w
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use
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es w
ith
co
nd
itio
n
Low
er l
imb
ort
ho
tics
bee
n r
evie
wed
Typ
e p
resc
rib
ed
Typ
e th
e ch
ild
is
usi
ng
Aim
of
ort
ho
tic
Tim
e w
orn
(h
ou
rs/d
ay)
Du
rati
on
wo
rn (
mo
nth
s)
Issu
es (
skin
ulc
erat
ion,
com
pli
ance
) A
ust
rali
an P
hysi
oth
erap
y C
ounci
l. A
ust
rali
an S
tan
dar
ds
for
Ph
ysi
oth
erap
y:
Saf
e an
d e
ffec
tiv
e
ph
ysi
oth
erap
y J
uly
2006
[cit
ed 2
015].
Av
aila
ble
fro
m:
htt
p:/
/ww
w.p
hy
sio
coun
cil.
com
.au
/fil
es/t
he-
aust
rali
an-s
tan
dar
ds-
for-
physi
oth
erap
y.
Sec
tion
7 R
esu
lts
Dis
cuss
ion
wit
h p
rim
ary
car
er o
f re
sult
s
Act
ion
/su
pp
ort
pla
n m
ade
wit
h p
rim
ary
car
er
Act
ion
/su
pp
ort
pla
n m
ade
wit
h o
ther
pro
vid
er
22
6
Wo
rld C
onfe
der
atio
n f
or
Physi
cal
Th
erap
y.
WC
PT
gu
idel
ine
for
stan
dar
ds
of
ph
ysi
cal
ther
apy
pra
ctic
e
Lon
do
n:
WC
PT
Sec
reta
riat
; 2011 [
updat
ed 1
8 O
cto
ber
20
11
; ci
ted 2
01
2 9
Sep
tem
ber
20
12
]. A
vai
lab
le
fro
m:
htt
p:/
/ww
w.w
cpt.
org
/sit
es/w
cpt.
org
/fil
es/f
iles
/Gu
idel
ine_
stan
dar
ds_
pra
ctic
e_co
mp
lete
.pd
f
htt
p:/
/ww
w.w
cpt.
org
/guid
elin
es/s
tand
ard
s.
R
efer
ral
to o
ther
ag
enci
es
R
efer
ral
if x
-ray
req
uir
ed a
t ti
me
of
asse
ssm
ent
Au
stra
lian
Physi
oth
erap
y C
ounci
l. A
ust
rali
an S
tan
dar
ds
for
Ph
ysi
oth
erap
y:
Saf
e an
d e
ffec
tiv
e
ph
ysi
oth
erap
y J
uly
2006
[cit
ed 2
015].
Av
aila
ble
fro
m:
htt
p:/
/ww
w.p
hy
sio
coun
cil.
com
.au
/fil
es/t
he-
aust
rali
an-s
tan
dar
ds-
for-
physi
oth
erap
y.
Law
M, B
apti
ste
S,
McC
oll
M,
Opzo
om
er A
, P
ola
tajk
o H
, P
oll
ock
N.
Th
e C
anad
ian
Occ
up
atio
nal
Per
form
ance
Mea
sure
: an
outc
om
e m
easu
re f
or
occ
up
atio
nal
th
erap
y. C
anad
ian
Jo
urn
al o
f O
ccu
pat
ion
al
Th
erap
y. 199
0;5
7(2
):82
-7.
Mac
Do
ugal
l J,
Wri
gh
t V
. T
he
ICF
-CY
and G
oal
Att
ain
men
t S
cali
ng
: b
enef
its
of
thei
r co
mb
ined
use
fo
r
ped
iatr
ic p
ract
ice.
Dis
abil
Reh
abil
. 2009
;31(1
6):
13
62
-72
.
Sak
zew
ski
L, B
oyd R
, Z
ivia
ni
J. C
linim
etri
c p
rop
erti
es o
f p
arti
cip
atio
n m
easu
res
for
5-
to 1
3-y
ear-
old
chil
dre
n w
ith c
ereb
ral
pal
sy:
a sy
stem
atic
rev
iew
. D
ev M
ed C
hil
d N
euro
l. 2
00
7;4
9(3
):2
32
-40
.
Wo
rld C
onfe
der
atio
n f
or
Physi
cal
Th
erap
y.
WC
PT
gu
idel
ine
for
stan
dar
ds
of
ph
ysi
cal
ther
apy
pra
ctic
e
Lon
do
n:
WC
PT
Sec
reta
riat
; 2011 [
updat
ed 1
8 O
cto
ber
20
11
; ci
ted 2
01
2 9
Sep
tem
ber
20
12
]. A
vai
lab
le
fro
m:
htt
p:/
/ww
w.w
cpt.
org
/sit
es/w
cpt.
org
/fil
es/f
iles
/Gu
idel
ine_
stan
dar
ds_
pra
ctic
e_co
mp
lete
.pd
f
htt
p:/
/ww
w.w
cpt.
org
/guid
elin
es/s
tand
ard
s.
Sec
tion
8 O
utc
om
es
an
d I
nte
rven
tio
ns
S
ho
rt W
ritt
en a
sses
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t re
po
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oal
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o d
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e
mea
sure
men
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f p
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to
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t o
f g
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s
O
utc
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ecord
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O
utc
om
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bta
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R
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so
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O
ther
227
3.8 RESULTS OF CLINICAL AUDIT 2013
Physiotherapy Clinical Audit Report Indigenous clients Children 0-18 years
Audit Date: 29 April 2013 Period Audited: 28 February 2012- 28 February 2013
Section One: General Information
Client Composition Client Gender Male 60% (21/35)
Female 40% (14/35) AGE
0-2yrs 17% (6/35) 2-3yr 23% (8/35) 3 0% (0/35) 4-6 14% (5/35) 6-8yr 11% (4/35) 8-10yr 9% (3/35) 10-12yr 11% (4/35) 12-14yr 6% (2/35) 14-18 yr 9% (3/35)
Diagnosis/Classification/Category * an additional 4 counted in other areas of 3 prem,1 phys disability
CP= 31% (11/35) Prematurity 26% (9/35) Physical Disabilities 17% (6/35) Gross Motor Delay* 17% (6/35) Neurological Issues 3% (1/35) Other 6% (2/35)
Indigenous Status
Aboriginal 91% (32/35) Torres Strait Islander 3% (3/35) Both 6% (2/35)
Family Background
Indigenous Carer 69%(24/35) Non-Indigenous Foster Carer 14% (5/35) Foster Carer Not Stated 11% (4/35) Non-Indigenous Carer 3% (1/35) Indigenous Foster Carer 3% (1/35)
Home Language
English 49% (17/35) Not Stated 43% (15/35) Indigenous Language 3% (1/35) Aboriginal English 3% (1/35) Indigenous and English 3% (1/35)
Referral Source
Educator 23% (8/35) Physiotherapist 17% (6/35) Nurse 17% (6/35) Other Allied Health 11% (4/35) Paediatrician 9% (3/35) No referral 9% (3/35) Parent/Carer 6% (2/25) Other 6% (2/35)
228
Section Two: Attendance
Number attended in the last 12 months
83% 29/35 attended in the last year (6 did not attend)
If client has not attended initial appointment, Follow up attempted
Follow up attempted 67%(4/35) No follow up attempted 17%(1/35) Not applicable 17%(1/35)
Number of attempts made
Not able to extract. Maximum number 4 recorded.
Attempt to contact primary carer pre apt
No attempt recorded 57% (20/35) Attempt recorded 43% (15/35)
Successful Attempt to contact primary carer pre appointment
Unsuccessful 66% (23/35) Successful contact 34%(12/35)
Primary Carer Attended
Primary Carer present 60% (21/35) Primary Carer absent 37% (13/35) Not recorded 3% (1/35)
Follow up attempt with primary carer
Follow up 46%(6/13) No follow up 54% (7/13)
Location of family consultation
Office 54% (19/35) Other 11% (4/35) School 9% (3/35) Hospital 3% (1/35) Telephone 8.5% (3/35) Not recorded 8.5% (3/35) No contact 6% (2/35)
GP 3% (1/35) Aboriginal Health Worker 0% (0/35) ATSIC Liaison Officer 0% (0/35) Orthopaedist 0% (0/35) Neurologist 0% (0/35)
Location of Referral Source
Dept of Ed/Catholic Ed Office 23%(8/25) Public Hospital 20%(7/35) Other 20% (7/35) Community Care Clinic 17% (6/35) No referral found 9%(3/35) Private Hospital 6% (2/35) Indigenous Medical Centre 6% (2/35) EI Disability Services 0 Interstate Hospital 0 Private Practice 0 AHT 0
229
Interpreter use
No interpreter used 100% (18/18) Interpreter used 0% (0/18)
Section Three: Background Information (of those seen for first time during year audited)
Background Information Birth History Recorded 79% (11/14)
Not recorded 21% (3/14) General Medical History *asked but missing
Recorded 86% (12/14) Not recorded 7% (1/14) Unknown* 7% (1/14)
Developmental History Recorded 79% (11/14) Not recorded 21% (3/14)
Family History Not recorded 43% (6/14) Recorded 29% (4/14) Unknown* 29% (4/14)
Social History Recorded 79% (11/14) Not recorded 21% (3/14)
Education History Not recorded 93% (13/14) Recorded 7% (1/14)
Diagnosis Recorded 37% (13/35) Not recorded 3% (1/35) Not applicable 6% (21/35) Unknown 0% (0/35)
Risk Factors Recorded 86% (12/14) Not recorded 14% (2/14)
Section Four: Clinical Services for Gross Motor Delay
Subjective Pain Not recorded 78.2% (18/23)
Recorded 17.4% (4/23) Not applicable 4.4% (1/23)
Primary Carer’s Needs *question asked but pc did not know
Recorded 61% (14/23) Not recorded 35% (8/23) Unknown* 4% (1/23)
Child’s Needs ** below age 8 or severe intellectual impairment
Not applicable** 83% (19/23) Not recorded 13% (3/23) Recorded 4% (1/23) Unknown 0% (0/23)
Primary Carer’s Goals *pc with no concerns
Not recorded 74%(17/23) Recorded 13% (3/23) Not applicable* 13% (3/23)
Child’s Goals Not applicable** 78.26% (18/23) Not recorded 17.39% (4/23) Recorded 4.35% (1/23) Unknown 0% (0/23)
230
Strengths Not applicable** 61% (14/23) Not recorded 30% (7/23) Recorded 9% (2/23) Unknown 0% (0/23)
Weaknesses Not applicable** 61% (14/23) Not recorded 30% (7/23) Recorded 9% (2/23) Unknown 0% (0/23)
Primary Carer’s Priorities Not recorded 70%(16/23) Recorded 13% (3/23) Unknown* 4% (1/23) Not applicable** 13% (3/23)
Child’s Priorities Not applicable 74%(17/23) Not recorded 17% (4/23) Recorded 9% (2/23) Unknown 0% (0/23)
Observation General appearance Not recorded 65%(15/23)
Recorded 35% (8/23) Behaviour Recorded 78%(18/23)
Not recorded 22% (5/23)Child interaction with environment Recorded 57%(13/23)
Not recorded 39% (9/23) Not applicable 4% (1/23)
Primary Carer/child interaction Not recorded 87%(20/23) Recorded 13% (3/23)
Gross Motor Function ASQ Recorded 52%(12/23)
Not applicable 39% (9/23)Not recorded 9% (2/23)
AIMS Not applicable 61%(14/23)Not recorded 21% (5/23)Recorded 17% (4/23)
NSMDA Not recorded 61%(14/23)Not applicable 22% (5/23)Recorded 13% (3/23) Incomplete 4% (1/23)
M ABC Not applicable 78.26%(18/23)Not recorded 17.39% (4/23)Recorded 4.35% (1/23)
Neurological Recorded 52% (12/23) Not recorded 17% (9/23)Incomplete 9% (2/23)
Musculoskeletal Recorded 52% (12/23) Not recorded 48% (11/23)
Mobility Recorded 78% (18/23) Not recorded 22% (5/23)
Gait Not applicable 39% (9/23)
231
Recorded 30% (7/23) Not recorded 26% (6/23) Incomplete 4% (1/23)
Environment Home Not recorded 83% (19/23)
Recorded 17% (4/23) Preschool/school Not applicable 57% (13/23)
Recorded 26% (6/23) Not recorded 17% (4/23)
Childcare Not applicable 87% (20/23) Not recorded 13% (3/23)
Equipment needs Not applicable 56.5% (13/23) Not recorded 21.7% (5/23) Recorded 21.7% (5/23)
Physical Activity and Rest Not recorded 39% (9/23) Not applicable 35% (8/23) Recorded 26% (6/23)
Section Five: Clinical Service with Cerebral Palsy
Clinical Details CP Classification made at diagnosis Recorded 58.3% (7/12)
Not recorded 33.3% (4/12) Unknown 8.3% (1/12)
Age at diagnosis Not recorded 58.33% (7/12) Recorded 33.33% (3/12) Unknown 16.66% (2/12)
CP type and typography Recorded 91% (10/11) Not recorded 9% (1/11)
MACS Recorded 50% (6/12) Not recorded 17% (4/12) Not applicable 33% (2/12)
Birth Defects present Recorded 75% (9/12) Not recorded 25% (3/12)
Known syndromes Not recorded 83% (10/12) Recorded 17% (2/12)
Presence of epilepsy Recorded 58% (7/12) Not recorded 42% (5/12)
Intellectual impairment Not recorded 58% (7/12) Recorded 42% (5/12)
Visual impairment Recorded 83.3% (10/12) Not recorded 8.3% (1/12) Unknown 8.3% (1/12)
Hearing impairment Recorded 75% (9/12) Unknown 17% (2/12) Not recorded 8% (1/12)
Communications impairment Recorded 83% (10/12)
232
Not recorded 17% (2/12)Sleep issues Not recorded 83% (10/12)
Recorded 17% (2/12) Respiratory issues Recorded 58% (7/12)
Not recorded 42% (5/12)Pain issues Not recorded 67% (8/12)
Recorded 33% (4/12)Skin integrity/health Not recorded 67% (8/12)
Recorded 33% (4/12) Surgical interventions history Not recorded 58% (7/12)
Recorded 41% (5/12)Medical interventions history Recorded 92% (11/12)
Not recorded 8% (1/12) Details of hip x-ray in last 12 months Not recorded 66.67% (8/12)
Recorded 16.67% (2/12)Not applicable 16.67% (2/12)
Results of hip x-ray in last 12 months Not recorded 83%(10/12) Not applicable 17% (2/12)
Measurements in the last 12 months Pain Not recorded 67% (8/12)
Recorded 33% (4/12) Primary carer’s needs Not recorded 50% (6/12)
Recorded 42% (5/12) Unknown 8% (1/12)
Child’s needs Not applicable 58% (7/12)Not recorded 25% (3/12)Recorded 17% (2/12)
Primary carer’s goals Not recorded 83% (10/12)Recorded 17% (2/12)
Child’s goals Not applicable 58% (7/12) Not recorded 25% (3/12)Recorded 17% (2/12)
Teacher’s goals Not recorded 75% (9/12)Not applicable 25% (3/12)
Strengths Not recorded 58.3% (7/12)Not applicable 33.3% (4/12)Recorded 8.3% (1/12)
Weaknesses Not recorded 58.3% (7/12)Not applicable 33.3% (4/12)Recorded 8.3% (1/12)
Primary carer’s priorities Not recorded 75% (9/12)Recorded 25% (3/12)
Child’s priorities Not applicable 58% (7/12)Not recorded 25% (3/12)Recorded 17% (2/12)
233
Observation General appearance Not recorded 92% (11/12)
Recorded 8% (1/12) Behaviour Recorded 58% (7/12)
Not recorded 42% (5/12) Child interaction with environment Recorded 58% (7/12)
Not recorded 42% (5/12) Primary carer/child interaction Not recorded 92% (11/12)
Recorded 8% (1/12)
Environment Home Not recorded 83% (10/12)
Recorded 17% (2/12) Preschool/school Recorded 50% (6/12)
Not recorded 42% (5/12) Not applicable 8% (1/12)
Childcare Not applicable 83% (10/12 Not recorded 17% (2/12)
Equipment needs Recorded 66.67% (8/12) Not recorded 16.67% (2/12) Not applicable 16.67% (2/12)
Physical activity and rest Not recorded 58% (7/12) Recorded 42% (5/12)
Mobility
Functional Mobility GMFCS Recorded 58% (7/12)
Not recorded 42% (5/12) FMS Not recorded 67% (8/12)
Recorded 25% (3/12) Not applicable 8% (1/12)
Gross Motor Function Measure -88 (if GMFCS Level (IV-V)
Not recorded 50% (6/12) Not applicable 50% (6/12)
Gross Motor Function Measure -66 (if GMFCS Level (I-III)
Not applicable 25% (3/12) Not recorded 67% (8/12) Recorded 8% (1/12)
Sitting position Not recorded 42% (5/12) Recorded 33% (4/12) Incomplete 17% (2/12) Not applicable 8% (1/12)
Transitional movements Recorded 67% (8/12) Not recorded 33% (4/12)
Standing Recorded 58.33% (7/12) Not recorded 33.33% (4/12) Incomplete 8.33% (1/12)
Independence level Recorded 50% (6/12) Not recorded 33% (4/12) Not applicable 17% (2/12)
234
Self –care functional level Not recorded 50% (6/12) Recorded 33.3% (4/12) Incomplete 8.3% (1/12) Not applicable 8.3% (1/12)
Self-care assessment used Not recorded 50% (6/12) Recorded 33.3% (4/12) Unknown 8% (1/12) Not applicable…………… 8% (1/12)
Gait Observational Gait Scale or Physician Ratings Scale
Not recorded 66.67% (8/12)Recorded 16.67% (2/12) Not applicable 16.67% (2/12)
Assistance required Recorded 41.67% (5/12) Not recorded 41.67% (5/12)Not applicable 16.67% (2/12)
Equipment required Recorded 41.67% (5/12) Not recorded 41.67% (5/12)Not applicable 16.67% (2/12)
Orthotics used Not recorded 45.45% (5/12)Recorded 36.36% (4/12) Not applicable 18.18% (2/12)
2D VGA Not recorded 67% (8/12)Not applicable 25% (3/12)Recorded 8% (1/12)
Lower Limb Musculoskeletal Measurements (with a goniometre)
Hips Supine Abduction with hips at 0 – R1 Not recorded 83% (10/12)
Recorded 17% (2/12) Supine Abduction with hips at 0 – R2 Not recorded 67% (8/12)
Recorded 33% (4/12) Supine Abduction with hips at 90 –R1 Not recorded 83% (10/12)
Recorded 17% (2/12) Supine Abduction with hips at 90 –R2 Not recorded 75% (9/12)
Recorded 25% (3/12) Supine Flexion Not recorded 83% (10/12)
Recorded 17% (2/12) Supine Extension Not recorded 67% (8/12)
Recorded 33% (4/12) Staheli test or Thomas Test Not recorded 100%(12/12) Prone ER Not recorded 75% (9/12)
Recorded 25% (3/12) Prone IR Not recorded 75% (9/12)
Recorded 25% (3/12) Duncan Ely – R1 Not recorded 75% (9/12)
Recorded 17% (2/12)
235
Visual Estimate 8% (1/12) Duncan Ely – R2 Not recorded 75% (9/12)
Recorded 17% (2/12) Visual Estimate 8% (1/12)
Knees Knee Extension Not recorded 67% (8/12)
Recorded 33% (4/12) Popliteal Angle – R1 Not recorded 75% (9/12)
Recorded 25% (3/12) Popliteal Angle – R2 Not recorded 75% (9/12)
Recorded 25% (3/12)
Ankles Ankle Dorsiflexion with knees at 90–R1 Not recorded 75% (9/12)
Recorded 25% (3/12) Ankle Dorsiflexion with knees at 90–R2 Not recorded 67% (8/12)
Recorded 33% (4/12) Ankle Dorsiflexion with knees at 0–R1 Not recorded 75% (9/12)
Recorded 25% (3/12) Ankle Dorsiflexion with knees at 0–R2 Not recorded 67% (8/12)
Recorded 33% (4/12) Position noted Not recorded 100% (12/12)
Feet (non-weight bearing) Hindfoot (varus or valgus) Not recorded 92% (11/12)
Visual Estimate 8% (1/12) Midfoot (pronation/supination) Not recorded 92% (11/12)
Visual Estimate 8% (1/12) Hindfoot to fore foot alignment Not recorded 92% (11/12)
Visual Estimate 8% (1/12) Toe alignment Not recorded 92% (11/12)
Visual Estimate 8% (1/12) Great toe alignment Not recorded 92% (11/12)
Visual Estimate 8% (1/12)
Spine Standing position Not recorded 83.37% (10/12)
Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Sitting position Not recorded 75% (9/12) Recorded 25% (3/12)
Prone attempt spinal correction Not recorded 92% (11/12) Not applicable 8% (1/12)
Pelvis/Leg length
236
Standing position Not recorded 83.3% (10/12)Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Sitting position Not recorded 75% (9/12)Recorded 25% (3/12)
Passive correction Not recorded 92% (11/12)Not applicable 8% (1/12)
Hip dysplasia/dissociation/subluxation Not recorded 83% (10/12)Recorded 17% (2/12)
Leg length difference Not recorded 83.3% (10/12)Recorded 8.3% (1/12) Visual Estimate 8.3% (1/12)
Standing posture/alignment Toes-frontal view (ABD-ADD) Not recorded 83.3% (10/12)
Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Toes – sagittal view (Ext-Flexion) Not recorded 92% (11/12) Not applicable 8% (1/12)
Forefoot –frontal view (ABD/ADD) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Forefoot/midfoot sagittal view (Cavus/Planus)
Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Forefoot/midfoot transverse view (Supination/Pronation)
Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Ankle-sagittal view (DF/PF) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Ankle- frontal view (INV/EV) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Knee –frontal view (valgus/varus) Not recorded 92% (11/12) Not applicable 8% (1/12)
Knee –sagittal view (crouch/recurvatum) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Hip-frontal view(ABD/ADD) Not recorded 92% (11/12) Not applicable 8% (1/12)
Hip-sagittal view(Flex/ext) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Pelvis-frontal (obliquity) Not recorded 92% (11/12) Not applicable 8% (1/12)
Pelvis-sagittal (tilt) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Pelvis-transverse(rotation) Not recorded 92% (11/12)
237
Not applicable 8% (1/12) Lumbar spine-frontal Not recorded 83.3% (10/12)
Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Lumbar spine-sagittal (lordosis/kyphosis)
Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Thoracic spine-frontal view (scoliosis) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Thoracic spine-sagittal view (lordosis/kyphosis)
Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Shoulder girdle-frontal view (obliquity) Not recorded 92% (11/12) Not applicable 8% (1/12)
Shoulder girdle-sagittal view (IR) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Cervical Spine –frontal view (sideflexion)
Not recorded 92% (11/12) Not applicable 8% (1/12)
Cervical Spine –sagittal view (flex/ext) Not recorded 83.3% (10/12) Recorded 8.3% (1/12) Not applicable 8.3% (1/12)
Motor Function
Lower Limb Strength Hip flexors Not recorded 75% (9/12)
Not applicable 17% (2/12) Recorded 8% (1/12)
Hip abductors Not recorded 75% (9/12) Not applicable 17% (2/12) Recorded 8% (1/12)
Hip extensors Not recorded 75% (9/12) Recorded 8% (1/12) Not applicable 17% (2/12)
Quadriceps Not recorded 75% (9/12) Not applicable 17% (2/12) Recorded 8% (1/12)
Hamstrings Not recorded 75% (9/12) Not applicable 17% (2/12) Recorded 8% (1/12)
Ankle dorsiflexors Not recorded 75% (9/12) Not applicable 17% (2/12) Recorded 8% (1/12)
Calves Not recorded 75% (9/12) Not applicable 17% (2/12) Recorded 8% (1/12)
Selective Motor Control
238
Ankle dorsiflexion Not recorded 66.67% (8/12)Recorded 16.67% (2/12) Not applicable 16.67% (2/12)
Lower LimbSpasticity Hip Flexors Not recorded 100% (12/12) Hip Adductors Not recorded 83% (10/12)
Recorded 17% (2/12) Quadriceps Not recorded 83% (10/12)
Recorded 17% (2/12 Hamstrings Not recorded 75% (9/12)
Recorded 25% (3/12) Gastrocnemii Not recorded 75% (9/12)
Recorded 25% (3/12) Solei Not recorded 75% (9/12)
Recorded 25% (3/12)
CP Type and Typography Physiotherapy assessed type and typography (if not provided by doctors)
Not recorded 50% (6/12) Not applicable 33.3% (4/12)Recorded 8.3% (1/12) Unknown 8.3% (1/12)
Section Six: Equipment
Standing Frames Standing frame description Not applicable 89% (32/35)
Recorded 11% (3/35) Assistance required for transfers/use Not applicable 89% (32/35)
Recorded 9% (2/35) Not recorded 3% (1/35)
Source of equipment Not applicable 91% (32/35)Recorded 9% (3/35)
Date of issue Not applicable 91% (32/35) Recorded 6% (2/35) Not recorded 3% (1/35)
Schedule of use (frequency/ session time)
Not applicable 91% (32/35) Recorded 6% (2/35) Not recorded 3% (1/35)
Issues with use Not applicable 91% (32/35) Not recorded 6% (2/35)Recorded 3% (1/35)
Issues with condition Not applicable 94% (33/35) Not recorded 3% (1/35)Recorded 3% (1/35)
Wheeled mobility
239
Wheeled mobility description Not applicable 74% (26/35) Recorded 23% (8/35) Incomplete 3% (1/35)
Wheeled seating description Not applicable 74% (26/35) Incomplete 14% (5/35) Recorded 9% (3/35) Not recorded 3% (1/35)
Assistance required for transfers Not applicable 74% (26/35) Recorded 20% (7/35) Not recorded 3% (1/35) Incomplete 14% (1/35)
Source of equipment Not applicable 74% (26/35) Recorded 23% (8/35) Not recorded 3% (1/35)
Date of issue Not applicable 74.29% (26/35) Recorded 17.14% (6/35) Not recorded 8.57% (3/35)
Issues with use Not applicable 74.29% (26/35) Recorded 17.14% (6/35) Not recorded 8.57% (3/35)
Issues with condition Not applicable 89% (31/35) Not recorded 11% (4/35)
Alternative seating Seating device description Not applicable 83% (29/35)
Recorded 14% (5/35) Not recorded 3% (1/35)
Assistance required for transfers Not applicable 83% (29/35) Recorded 8.57% (3/35) Not recorded 8.57% (3/35)
Source of equipment Not applicable 82.86% (29/35) Recorded 8.57% (3/35) Not recorded 5.71% (2/35) Incomplete 3% (1/35)
Date of issue Not applicable 83% (29/35) Recorded 11% (4/35) Not recorded 6% (2/35)
Issues with use Not applicable 74% (26/35) Recorded 17% (6/35) Not recorded 9% (3/35)
Issues with condition Not applicable 83% (29/35) Not recorded 14% (5/35) Recorded 3% (1/35)
Mobility Equipment: Gait Aides Equipment description Not applicable 80% (28/35)
Recorded 17% (6/35) Incomplete 3% (1/35)
240
Assistance required Not applicable 80% (28/35) Recorded 17% (6/35) Incomplete 3% (1/35)
Source of equipment Not applicable 80% (28/35) Recorded 8.57% (3/35) Not recorded 8.57% (3/35) Incomplete 2.57% (1/35)
Date of issue Not applicable 80% (28/35 Recorded 14% (5/35) Not recorded 6% ( 2/35)
Issues with use Not applicable 80% (28/35) Recorded 17% (6/35) Not recorded 3% (1/35)
Issues with condition Not applicable 89% (31/35) Not recorded 11% (4/35)
Lower Limb Orthotics Lower limb orthotics been reviewed Not applicable 71% (25/35)
Recorded 23% (8/35) Not recorded 6% (2/35)
Type prescribed Not applicable 71% (25/35)Recorded 20% (7/35) Not recorded 9% (3/35)
Type child is using Not applicable 71% (25/35)Recorded 23% (8/35) Not recorded 6% (2/35)
Aim of orthotic Not applicable 71% (25/35)Recorded 17% (6/35) Not recorded 9% (3/35)Incomplete 3% (1/35)
Schedule/Time Worn (hours/day) Not applicable 71.43% (25/35)Not recorded 22.86% (8/35)Recorded 2.86% (1/35) Incomplete 2.86% (1/35)
Duration worn (number of months) Not applicable 71.43% (25/35)Not recorded 25.71% (9/35)Recorded 2.86% (1/35)
Issues (skin ulceration, compliance) Not applicable 71% (25/35)Recorded 23% (8/35) Not recorded 6% (2/35)
Section Seven: Results
Results Discussion with primary carer of results Recorded 48.6% (17/35)
Not recorded 48.6% (17/35)Not applicable 2.86% (1/35)
Action/support plan made with primary carer
Not recorded 49% (17/35)Recorded 43% (15/35)
241
Section Eight: Outcomes and Interventions
Goal Setting and Outcomes Short written assessment report Not recorded 46% (16/35)
Recorded 51% (18/35) Not applicable 3% (1/35)
Goals set Not recorded 54% (19/35) Recorded 34% (12/35) Not applicable 3% (4/35)
COPM goals Not recorded 80% (28/35) Not applicable 14% (5/35) Recorded 6% (2/35)
GAS goals Not recorded 83% (29/35) Not applicable 14% (5/35) Recorded 3% (2/35)
Review plan developed to direct measurement of progress towards achievement of goals
Not applicable 63% (22/35) Not recorded 23% (8/35) Recorded 14% (5/35)
Outcomes recorded Not applicable 60% (21/35) Incomplete 20% (7/35) Recorded 11% (4/35) Not recorded 9% (3/35)
Outcomes obtained Not applicable 60% (21/35) Recorded 11% (4/35) Not recorded 14% (5/35) Incomplete 14% (5/35)
Intervention Type Adaptive/therapeutic aides/equipment 14 Functional mobility training 14 Exercise (fitness, therapeutic) 9 Casting/splinting 2 Referral to external source 4 Other 25
Mode of Delivery Individual Sessions 26 Group Sessions 6
Not applicable 9% (3/35)Action/support plan made with other provider (e.g. teacher)
Not recorded 37% (13/35)Not applicable 49% (14/35)Recorded 23% (8/35)
Referral to other agencies (e.g. paediatrician, audiology)
Recorded 37% (13/35) Not recorded 31% (11/35)Not applicable 31% (11/35)
Referral if X-Ray required at time of assessment
Not applicable 74% (26/35)Not recorded 20% (7/35) Recorded 6% (2/35)
242
Integrated into everyday activities 2 School program 15 Home program 5 Other 11
24
3
3.9
RE
SU
LT
S O
F T
HE
SY
ST
EM
S A
SS
ES
SM
EN
T T
OO
L 2
01
3
Re
sult
s o
f Sy
ste
ms
Ass
ess
me
nt
Too
l Dis
cuss
ion
20
13
24
4
Sum
mar
y o
f R
esu
lts
Co
mp
on
ent
Leve
l of
Sup
po
rt
Del
iver
y Sy
stem
Des
ign
4
.35
BA
SIC
-A
HT
4.0
BA
SIC
-PT
Info
rmat
ion
Sys
tem
s an
d D
ecis
ion
Su
pp
ort
2
.6 L
IMIT
ED
Self
-man
age
men
t Su
pp
ort
2
.1 L
IMIT
ED
Lin
ks w
ith
th
e co
mm
un
ity,
oth
er h
ealt
h s
ervi
ces
and
oth
er s
ervi
ces
and
res
ou
rces
1
.2 L
IMIT
ED
Org
anis
atio
nal
infl
uen
ce a
nd
inte
grat
ion
4
.7 B
ASI
C
KEY
: 0-2
No
or
Lim
ited
Su
pp
ort
3
-5 B
asic
Su
pp
ort
6-8
Go
od
Su
pp
ort
9-1
1 F
ully
De
velo
ped
Su
pp
ort
4.4
2.6
2.1
1
.2
4.7
Serv
ice
Del
iver
yD
esig
n
Info
rmat
ion
Sys
tem
san
d D
ecis
ion
Su
pp
ort
Self
-Man
agem
ent
sup
po
rtLi
nks
Org
anis
atio
nIn
flu
ence
an
dIn
tegr
atio
n
Syst
em
s A
sse
ssm
en
t To
ol
-113579
11
Syst
em
s A
sse
ssm
en
t To
ol-
PT
24
5
Stre
ngt
hs
(Go
od
an
d F
ully
De
velo
pe
d S
up
po
rt):
Team
ap
pro
ach
Team
lead
ersh
ip s
tru
ctu
re w
ith
in e
nti
re A
HT
Co
mm
un
icat
ion
an
d c
oh
esio
n (
PT
grea
ter
than
en
tire
AH
T b
ut
bo
th in
th
e go
od
cat
ego
ry)
Staf
fin
g an
d s
taff
rel
atio
nsh
ips
and
mo
rale
.
Sup
po
rt f
or
dev
elo
pin
g te
am m
emb
er’s
ski
lls a
nd
ro
les
Gen
eral
tra
inin
g an
d in
serv
ice
op
po
rtu
nit
ies
Ab
ility
to
ide
nti
fy a
bn
orm
al f
ind
ings
Ab
ility
to
fo
llow
-up
on
ab
no
rmal
fin
din
gs u
sin
g st
aff
and
co
mm
un
ity
kno
wle
dge
.
Iden
tifi
cati
on
an
d p
roce
ss t
o a
dd
ress
ge
nd
er-r
elat
ed is
sues
Ava
ilab
ility
of
elec
tro
nic
list
of
clie
nts
Ava
ilab
ility
of
ph
ysic
al in
fras
tru
ctu
re
Ava
ilab
ility
of
con
sum
able
s
We
akn
ess
es
(No
or
Lim
ite
d S
up
po
rt):
Ab
sen
ce o
f cl
inic
al le
ader
ship
Lack
of
rou
tin
e p
lan
nin
g o
f ap
po
intm
ents
Lack
of
cult
ura
l acc
ess
com
pet
ence
in a
vaila
bili
ty o
f In
dig
eno
us
hea
lth
wo
rker
s
Lack
of
mai
nte
nan
ce a
nd
use
of
elec
tro
nic
clie
nt
list
to id
enti
fy s
up
po
rt p
lan
nin
g an
d d
eliv
ery
for
gen
eral
clie
nt
po
pu
lati
on
an
d t
ho
se w
ith
sp
ecia
l nee
ds.
Lack
of
use
of
elec
tro
nic
clie
nt
list
to r
each
sp
ecif
ic c
lien
t gr
ou
ps
Lack
of
stra
tegi
c ap
pro
ach
to
sp
ecia
list
gen
eral
ist
colla
bo
rati
on
to
pro
vid
e ev
iden
ce-b
ase
d g
uid
elin
es
Lack
of
sup
po
rt f
or
self
-man
agem
en
t n
eed
s o
f cl
ien
ts r
eally
nee
din
g su
pp
ort
.
Ab
sen
ce o
f se
lf-m
anag
em
ent
trai
nin
g fo
r st
aff.
Lim
ite
d s
up
po
rt f
or
self
-man
agem
ent
ed
uca
tio
n, s
up
po
rt, i
nvo
lvem
ent
of
fam
ily, b
ehav
iou
ral r
isk
red
uct
ion
res
ou
rces
.
Ab
sen
ce o
f h
ealt
h p
rogr
am p
rovi
sio
n w
ith
str
on
g h
ealt
h o
rien
tati
on
.
Lack
of
com
mu
nit
y h
ealt
h p
rom
oti
on
/dev
elo
pm
en
t ac
tivi
ties
an
d in
tegr
atio
n in
to h
ealt
h s
erv
ice’
s p
rogr
am.
Ab
sen
ce o
f re
gula
rly
up
dat
ed r
eso
urc
e d
irec
tory
an
d in
tegr
atio
n in
sta
ff o
rien
tati
on
an
d in
serv
ice
pro
gram
s.
Ab
sen
ce o
f co
mm
un
ity
inp
ut
to h
ealt
h s
ervi
ce g
ove
rnan
ce, i
nvo
lvem
ent
of
serv
ice
po
pu
lati
on
fo
rmal
agr
eem
ents
be
twee
n h
ealt
h s
ervi
ce
and
mai
nst
ream
pri
mar
y ca
re s
ervi
ces
24
6
Ab
sen
ce o
f in
pu
t o
f h
ealt
h s
ervi
ce o
n r
egi
on
– w
ide
pla
nn
ing
and
allo
cati
on
of
reso
urc
es.
Lim
ite
d o
rgan
isat
ion
al c
om
mit
men
t to
ser
vice
s fo
r cl
ien
t gr
ou
p in
str
ateg
ic a
nd
bu
sin
ess
pla
ns.
Ab
sen
ce o
f fu
nd
ing
serv
ice
s fo
r cl
ien
t gr
ou
p in
str
ate
gic
and
bu
sin
ess
pla
ns.
24
7
Are
as o
f St
ren
gth
D
eliv
ery
Syst
em D
esig
n
1.1
i
Tea
m a
pp
roac
h
A
HT
5
PT
8
1.1
ii
Team
Lea
der
ship
A
HT
9
1.1
iv C
om
mu
nic
atio
n a
nd
co
hes
ion
A
HT
6
PT
8
1.1
v
Dev
elo
pin
g te
am m
emb
er’s
ski
lls a
nd
ro
les
AH
T 8
P
T 7
1.5
iii
Ab
no
rmal
ass
essm
ent
fin
din
gs
9
1.5
iv H
ealt
h s
ervi
ce s
taff
an
d c
om
mu
nit
y kn
ow
led
ge a
nd
res
ou
rces
use
d t
o e
nh
ance
fo
llow
up
8
1.7
iii
Gen
de
r –
rela
ted
issu
es
7
1.8
i
Ph
ysic
al in
fra
stru
ctu
re
6
1.8
ii
Sup
plie
s o
f co
nsu
mab
les
8
2 In
form
atio
n S
yste
ms
and
Dec
isio
n S
up
po
rt
2.1
i
Ele
ctro
nic
list
s o
f cl
ien
ts a
vaila
ble
9
5 O
rgan
isat
ion
al in
flu
ence
an
d in
tegr
atio
n
5.1
ii
Staf
fin
g 8
5.1
iv S
taff
re
lati
on
ship
s an
d m
ora
le
8
24
8
A
reas
of
We
akn
ess
1. D
eliv
ery
Syst
em D
esig
n
1.2
i
Clin
ical
Le
ader
ship
est
ablis
hm
ent
ii
Clin
ical
Lea
der
ship
co
ntr
ibu
tio
n
iii
Clin
ical
Le
ader
ship
co
ntr
ibu
tio
n t
o k
no
wle
dge
ab
ou
t re
sear
ch e
vid
ence
AH
T 0
No
t A
vaila
ble
= 0
N
ot
Ava
ilab
le =
0
No
t A
vaila
ble
= 0
1.3
iii
Ap
po
intm
en
ts P
lan
nin
g an
d s
ched
ulin
g co
mm
un
ity-
bas
ed a
ctiv
itie
s ro
uti
ne
pra
ctic
e
2
1.7
iv
Clie
nt
acce
ss/c
ult
ura
l co
mp
eten
ce -
Ind
igen
ou
s kn
ow
led
ge a
nd
exp
erie
nce
1
2 In
form
atio
n S
yste
ms
and
Dec
isio
n S
up
po
rt
2.1
ii M
ain
ten
ance
an
d u
se o
f el
ectr
on
ic c
lien
t lis
t -
regu
lar
clie
nt
list
rou
tin
ely
use
d t
o id
enti
fy
s
up
po
rt s
ervi
ce p
lan
nin
g an
d d
eliv
ery
1
2.1
iii M
ain
ten
ance
an
d u
se o
f el
ectr
on
ic c
lien
t lis
t -
clie
nt
wit
h s
pe
cifi
c n
eed
s lis
t ro
uti
nel
y u
sed
to
id
enti
fy s
up
po
rt s
ervi
ce p
lan
nin
g an
d d
eliv
ery
1
2.1
iv M
ain
ten
ance
an
d u
se o
f el
ectr
on
ic c
lien
t lis
t -
str
ateg
ies
in p
lace
to
rea
ch c
lien
t gr
ou
ps
par
t
of
rou
tin
e p
ract
ice
0
2.2
i
Evid
en
ce b
ase
d g
uid
elin
es –
str
ateg
ic a
pp
roac
h t
o s
pec
ialis
t-ge
ner
alis
t co
llab
ora
tio
n
2
3 S
elf-
man
agem
ent
Sup
po
rt
3.1
ii
Ass
essm
ent
and
do
cum
en
tati
on
-ro
uti
ne
asse
ssm
ent
and
sta
nd
ard
do
cum
enta
tio
n o
f se
lf –
m
anag
emen
t n
eed
s o
f cl
ien
ts
0
3.2
i
Ro
uti
ne
pro
visi
on
of
self
-man
age
men
t ed
uca
tio
n b
y st
aff
wit
h r
eco
gniz
ed t
rain
ing
and
ski
lls
in s
elf
– m
anag
emen
t su
pp
ort
0
3.2
ii
Ro
uti
ne
invo
lvem
en
t o
f fa
mili
es in
sel
f-m
anag
emen
t e
du
cati
on
2
3.2
iii
Syst
em
atic
ap
pro
ach
to
beh
avio
r ch
ange
inte
rven
tio
ns
for
risk
red
uct
ion
0
3.2
iv R
ou
tin
e u
se o
f go
od
qu
alit
y ed
uca
tio
n r
eso
urc
es u
sed
fo
r cl
ien
ts a
nd
fam
ilies
to
su
pp
ort
beh
avio
ura
l ris
k re
du
ctio
n in
sel
f-m
anag
emen
t
4 L
inks
wit
h t
he
com
mu
nit
y, o
ther
hea
lth
ser
vice
s, a
nd
oth
er s
ervi
ces
and
res
ou
rces
4.1
i.
Co
mm
un
ity
inp
ut
to h
ealt
h s
ervi
ce g
ove
rnan
ce
0
4.1
ii
Co
mm
un
icat
ion
an
d c
oo
per
atio
n o
n g
ove
rnan
ce a
nd
op
erat
ion
of
the
hea
lth
ser
vice
an
d
oth
er c
om
mu
nit
y b
ased
org
anis
atio
ns
and
pro
gram
s –
invo
lvem
ent
of
serv
ice
po
pu
lati
on
0
4.1
iv F
orm
al a
gree
men
ts b
etw
een
hea
lth
ser
vice
an
d
0
24
9
m
ain
stre
am p
rim
ary
care
ser
vice
s
4.1
vi
Hea
lth
ori
enta
tio
n in
co
mm
un
ity,
so
cial
, ed
uca
tio
n a
nd
oth
er p
rogr
ams
0
4.2
ii
Reg
ula
rly
up
dat
ed, a
cces
sib
le a
nd
wid
ely
use
d r
eso
urc
e d
irec
tory
0
4.2
iii
Lin
kage
arr
ange
me
nts
inte
grat
ing
reso
urc
es in
to s
taff
ori
en
tati
on
an
d in
serv
ice
trai
nin
g
pro
gram
s 0
4.3
i
Staf
f e
nga
gem
ent
in c
om
mu
nit
y h
ealt
h p
rom
oti
on
dev
elo
pm
ent
acti
viti
es
1
4.3
iii
Inte
grat
ion
of
com
mu
nit
y ac
tivi
ties
in h
ealt
h s
ervi
ce p
rogr
am
0
4.4
i
Hea
lth
ser
vice
sta
ff a
ctiv
ely
enga
ged
in a
nd
pro
mo
tin
g re
gio
nal
pla
nn
ing
0
4.4
ii
Hea
lth
ser
vice
sta
ff a
ctiv
ely
con
trib
ute
to
th
e d
evel
op
men
t an
d p
rom
oti
on
of
stan
dar
d
reso
urc
es f
or
hea
lth
ser
vice
s w
ith
reg
ion
-wid
e re
leva
nce
. 0
4.5
iii L
oca
l co
mm
un
ity
pla
ns
syst
emat
ical
ly u
sed
to
info
rm r
egio
nal
pla
nn
ing
pro
cess
es a
nd
allo
cati
on
of
reso
urc
es
0
5 O
rgan
isat
ion
al in
flu
ence
an
d in
tegr
atio
n
5.1
i R
efle
ctio
n o
f co
mm
itm
ent
to c
lien
t gr
ou
p in
str
ateg
ic a
nd
bu
sin
ess
pla
ns
1
5.1
ii S
pec
ific
ad
equ
ate
an
d lo
ng
term
fu
nd
ing
for
this
are
a
0
5.2
ii Q
ual
ity
imp
rove
men
t p
roce
sses
sys
tem
atic
0
5.2
iii E
lect
ron
ic c
lien
t in
form
atio
n u
sed
ro
uti
nel
y fo
r h
ealt
h s
ervi
ce p
erfo
rman
ce r
epo
rtin
g 0
5.3
iv
Syst
emat
ic p
roce
sse
s fo
r d
ealin
g w
ith
err
ors
an
d p
rob
lem
s 0
25
0
Co
mp
on
en
t O
ne
: D
eliv
ery
Sys
tem
De
sign
AH
T 4
.35
(B
ASI
C)
P
T 4
.04
(B
ASI
C)
Ave
ragi
ng
ite
m s
core
s
3
.95
7
3.7
6
1.1
Tea
m S
tru
ctu
re a
nd
Fu
nct
ion
A
HT
7
(G
OO
D)
P
T 5
.6 (
BA
SIC
)
i.
Tea
m a
pp
roac
h
5
8
ii.
Lea
der
ship
9
0
iii.
Def
init
ion
of
role
s an
d r
esp
on
sib
iliti
es a
nd
lin
es o
f re
po
rtin
g 7
5
iv.
Co
mm
un
icat
ion
an
d c
oh
esio
n
6
8
v.
Dev
elo
pin
g te
am m
em
ber
s’ s
kills
an
d r
ole
s 8
7
1.2
Clin
ical
Le
ader
ship
A
HT
0 (
NO
SU
PP
OR
T)
P
T 0
(N
O S
UP
PO
RT)
i.
Clin
ical
Lea
der
ship
N
A (
no
t av
aila
ble
=0
)
NA
(n
ot
avai
lab
le =
0)
ii.
Co
ntr
ibu
tio
n
NA
(n
ot
avai
lab
le =
0)
N
A (
no
t av
aila
ble
=0
)
iii.
Kn
ow
led
ge a
bo
ut
rese
arch
evi
den
ce
NA
(n
ot
avai
lab
le =
0)
N
A (
no
t av
aila
ble
=0
)
1.3
Ap
po
intm
ents
an
d S
ched
ulin
g A
HT
3
.7 (
BA
SIC
)
i.
Ap
po
intm
ent
syst
em
5
ii.
Sp
ecif
ic c
linic
s an
d/o
r se
ssio
ns
4
iii.
Pla
nn
ing
and
sch
edu
ling
2
1.4
Car
e P
lan
nin
g A
HT
3
.5 (
BA
SIC
)
i.
Ro
uti
ne
pra
ctic
e
4
ii.
Ele
men
ts o
f ca
re p
lan
nin
g 3
1.5
Sys
tem
atic
Ap
pro
ach
to
Fo
llow
-U
p
AH
T
6.2
5 (
GO
OD
)
i.
Elec
tro
nic
Re
min
der
s 5
ii.
Reg
ula
r se
rvic
es a
nd
rev
iew
s 3
iii. A
bn
orm
al a
sses
smen
t fi
nd
ings
9
iv. H
ealt
h s
ervi
ce s
taff
an
d c
om
mu
nit
y kn
ow
led
ge a
nd
res
ou
rces
use
d t
o e
nh
ance
fo
llow
up
8
1.6
Co
nti
nu
ity
of
Car
e
AH
T
3.5
(B
ASI
C)
i.
Del
iver
y sy
stem
des
ign
ed t
o e
nh
ance
co
nti
nu
ity
of
care
4
ii.
Co
mm
un
icat
ion
bet
wee
n h
osp
ital
an
d h
ealt
h s
ervi
ce
3
1.7
Clie
nt
Acc
ess/
Cu
ltu
ral C
om
pet
ence
A
HT
3
.75
(B
ASI
C)
25
1
i.
Ph
ysic
al, c
om
mu
nic
atio
n a
nd
tra
nsp
ort
bar
rier
s to
acc
ess
3
ii.
Staf
fin
g 4
iii.
Ge
nd
er-r
ela
ted
issu
es
7
iv. I
nd
igen
ou
s kn
ow
led
ge a
nd
AH
W e
xper
ien
ce
1
Co
mp
on
en
t Tw
o:
Info
rmat
ion
Sys
tem
s an
d D
eci
sio
n M
akin
g
A
HT
2.6
2.1
Mai
nte
nan
ce a
nd
Use
of
Elec
tro
nic
Clie
nt
List
A
HT
2.7
5
i.
Ele
ctro
nic
list
of
clie
nts
9
ii.
Reg
ula
r cl
ien
ts
1
iii.
Reg
ula
r cl
ien
ts w
ith
sp
ecif
ic c
on
dit
ion
s 1
iv.
Rea
chin
g cl
ien
t gr
ou
ps
0
2.2
Evi
de
nce
Bas
ed G
uid
elin
es
AH
T 2
i.
Sp
ecia
list-
gen
eral
ist
colla
bo
rati
on
2
Co
mp
on
en
t Th
ree
: Se
lf-m
anag
em
en
t Su
pp
ort
A
HT
2.1
1
3.1
Ass
essm
ent
and
do
cum
enta
tio
n
AH
T 3
.25
i.
Sel
f-m
anag
emen
t fo
r cl
ien
ts in
th
is a
rea
is c
entr
al a
nd
str
ateg
ic p
art
of
hea
lth
car
e
6
ii.
Sel
f-m
anag
emen
t n
eed
s fo
r cl
ien
ts in
th
is a
rea
are
rou
tin
ely
a
sses
sed
an
d d
ocu
me
nte
d in
a s
tan
dar
d w
ay
0
iii.
Clie
nts
/fam
ilies
in t
his
are
a ar
e ro
uti
nel
y e
nga
ged
in t
he
asse
ssm
ent
and
do
cum
enta
tio
n p
roce
sses
. 3
iv.
Use
of
clie
nt
hel
d r
eco
rds
to p
rom
ote
sel
f-m
anag
emen
t p
art
of
r
ou
tin
e p
ract
ice
in t
his
are
a 4
3.2
Sel
f-m
anag
emen
t ed
uca
tio
n a
nd
su
pp
ort
, beh
avio
ral r
isk
red
uct
ion
an
d p
eer
sup
po
rt
AH
T 1
.5
i.
Sel
f-m
anag
emen
t e
du
cati
on
an
d s
up
po
rt r
ou
tin
e p
rovi
ded
by
staf
f w
ith
rec
ogn
ized
tr
ain
ing
and
ski
lls in
sel
f-m
anag
emen
t su
pp
ort
0
ii.
Invo
lvem
ent
of
fam
ilies
in s
elf-
man
agem
ent
ed
uca
tio
n
2
iii.
Beh
avio
ura
l ris
k re
du
ctio
n
0
25
2
iv.
Ed
uca
tio
n r
eso
urc
es
0
v.
Co
mm
un
ity
pe
er s
up
po
rt
4
Co
mp
on
en
t Fo
ur:
Lin
ks w
ith
th
e c
om
mu
nit
y, o
the
r h
eal
th s
erv
ice
s,
A
HT
1.2
(LI
MIT
ED S
UP
PO
RT
) an
d o
the
r se
rvic
es
and
re
sou
rce
s
4.1
Co
mm
un
icat
ion
an
d C
oo
per
atio
n o
n G
ove
rnan
ce a
nd
Op
erat
ion
of
the
Hea
lth
ser
vice
an
d O
ther
Co
mm
un
ity
Bas
ed O
rgan
isat
ion
s an
d P
rogr
ams
AH
T 1
.33
(LI
MIT
ED S
UP
PO
RT)
i.
Co
mm
un
ity
inp
ut
to h
eal
th s
ervi
ce g
ove
rnan
ce
0
ii.
Invo
lvem
ent
of
serv
ice
po
pu
lati
on
0
iii.
Clie
nt
sati
sfac
tio
n w
ith
th
e h
ealt
h s
erv
ice
4
iv. F
orm
al a
gree
men
ts b
etw
een
th
e h
ealt
h s
ervi
ce a
nd
mai
nst
ream
p
rim
ary
care
ser
vice
s an
d o
ther
hea
lth
an
d c
om
mu
nit
y se
rvic
es
0
v. P
artn
ersh
ips
wit
h r
elev
ant
com
mu
nit
y gr
ou
ps
4
vi.
Hea
lth
ori
enta
tio
n
0
4.2
Co
mm
un
icat
ion
an
d C
oo
per
atio
n o
n G
ove
rnan
ce a
nd
Op
erat
ion
o
f th
e H
eal
th s
ervi
ce a
nd
Oth
er C
om
mu
nit
y B
ased
Org
anis
atio
ns
a
nd
Pro
gram
s
AH
T 1
.67
(LI
MIT
ED S
UP
PO
RT)
i.
Th
ere
are
sys
tem
atic
arr
ange
men
ts in
pla
ce t
o li
nk
ind
ivid
ual
c
lien
ts in
th
is a
rea
to o
uts
ide
hea
lth
an
d h
ealt
h-r
ela
ted
ser
vice
s 5
ii.
Res
ou
rce
dir
ecto
ry t
hat
su
pp
ort
s th
ese
arra
nge
men
ts is
c
om
pre
hen
sive
, reg
ula
rly
up
dat
ed a
nd
eas
ily a
cces
sib
le.
0
iii.
Lin
kage
arr
ange
men
ts r
elat
ing
to t
hes
e re
sou
rces
are
wel
l-
inte
grat
ed in
to s
taff
ori
enta
tio
n a
nd
in-s
ervi
ce t
rain
ing
pro
gram
s 0
4.3
Wo
rkin
g O
ut
in t
he
Co
mm
un
ity
A
HT
1.6
7 (
LIM
ITED
SU
PP
OR
T)
i.
Staf
f en
gage
men
t 1
ii.
Des
ign
of
com
mu
nit
y ac
tivi
ties
4
iii.
Inte
grat
ion
0
4.4
Co
mm
un
icat
ion
an
d c
oo
per
atio
n o
n r
egio
nal
hea
lth
pla
nn
ing
and
dev
elo
pm
ent
of
hea
lth
res
ou
rces
A
HT
0 (
NO
SU
PP
OR
T)
i.
Reg
ion
al p
lan
nin
g 0
ii.
Hea
lth
res
ou
rces
0
25
3
iii.
Loca
l co
mm
un
ity
pla
ns
0
Co
mp
on
en
t Fi
ve:
Org
anis
atio
nal
infl
ue
nce
an
d in
tegr
atio
n
A
HT
2.9
(LIM
ITE
D S
UP
PO
RT)
A
vera
gin
g sc
ore
s
2
.14
5.1
Org
anis
atio
nal
co
mm
itm
ent
4.6
7 (
BA
SIC
SU
PP
OR
T)
i.
Stra
tegi
c an
d b
usi
nes
s p
lan
s 1
ii.
Fun
din
g 0
iii.
Staf
fin
g 8
iv. S
taff
rel
atio
nsh
ips
and
mo
rale
8
v. T
rain
ing
6
vi.
Serv
ice
de
liver
y st
rate
gies
5
5.2
Qu
alit
y im
pro
vem
ent
stra
tegi
es
0.7
5 (
LIM
ITED
SU
PP
OR
T)
i.
Sen
ior
staf
f su
pp
ort
fo
r q
ual
ity
imp
rove
men
t 3
ii.
Qu
alit
y im
pro
vem
ent
pro
cess
es
0
iii.
Hea
lth
ser
vice
per
form
ance
re
po
rtin
g 0
iv. P
roce
sses
fo
r d
ealin
g w
ith
err
ors
an
d p
rob
lem
s 0
5.3
Inte
grat
ion
of
hea
lth
sys
tem
co
mp
on
ents
1
(LI
MIT
ED S
UP
PO
RT)
i.
Inte
grat
ion
1
25
4
Exam
ple
s o
f it
em s
core
s an
d c
om
po
ne
nts
Ite
m 1
.3: A
pp
oin
tme
nts
an
d s
che
du
ling
A
HT
3.6
i. A
pp
oin
tme
nt
syst
em
–
is t
her
e an
es
tab
lish
ed
app
oin
tmen
t sy
stem
fo
r th
is a
rea?
Do
es it
h
ave
the
flex
ibili
ty t
o
syst
emat
ical
ly
acco
mm
od
ate
the
nee
ds
of
the
clie
nt
gro
up
incl
ud
ing
a)
dro
p –
in
un
anti
cip
ate
d u
rgen
t re
ferr
als/
issu
es b
) lo
ng
or
un
exp
ecte
dly
co
mp
lex
con
sult
atio
ns;
an
d c
) cl
ien
ts s
eein
g m
ult
iple
pro
vid
ers
in
a si
ngl
e vi
sit
as
req
uir
ed?
5 A
HT
AH
T 5
BA
SIC
Es
tab
lish
ed s
yste
m
Has
ad
ho
c fl
exib
ility
bu
t n
ot
for
init
ial a
pp
oin
tmen
t La
cks
dro
p in
clin
ic
Go
od
su
pp
ort
be
twee
n d
isci
plin
es (
if in
take
ap
pt
nee
ds
ou
tsid
e o
f P
T se
rvic
e)
Syst
em g
ener
ally
do
es n
ot
mee
t n
eed
s o
f In
dig
eno
us
clie
nts
M
uch
ro
om
fo
r im
pro
vem
ent…
sys
tem
mad
e m
ore
fo
r ef
fici
ency
M
eeti
ng
ou
r n
eed
s ra
ther
th
an t
he
clie
nt
ne
eds
ii El
em
en
ts o
f C
are
is it
co
nsi
sten
t w
ith
bes
t p
ract
ice
guid
elin
es?
Is it
3 A
HT
AH
T 3
BA
SIC
A
d h
oc…
do
n’t
do
wit
h e
very
clie
nt
25
5
do
ne
join
tly
by
pro
vid
ers
and
clie
nts
/fam
ilies
? In
clu
de
goal
set
tin
g?
Inco
rpo
rate
s se
lf-
man
agem
ent
goal
s an
d
stra
tegi
es
Mis
s go
al s
etti
ng
… d
epen
ds
on
ho
w m
uch
th
e cl
ien
t p
arti
cip
ates
. H
app
ens
wit
h O
CF
staf
f, o
ther
wis
e ju
st w
ith
fam
ilies
. W
ork
wit
h e
very
on
e b
ut
pro
bab
ly n
ot
do
ing
bes
t p
ract
ice.
Ite
m 1
.5:
Syst
em
atic
ap
pro
ach
to
fo
llow
-up
AH
T 6
.25
i. El
ect
ron
ic r
em
ind
ers
–
are
they
use
d t
o
sup
po
rt c
lien
t ca
re in
th
is a
rea?
Is t
hei
r u
se
con
sist
ent
acro
ss t
he
clin
ical
are
a?
5 A
HT
AH
T 5
BA
SIC
N
ot
con
sist
entl
y u
sed
by
all s
taff
(in
div
idu
ally
, yes
… a
cro
ss t
he
team
, no
) V
ery
hel
pfu
l to
so
me
D
oes
no
t w
ork
wit
h s
om
e o
f th
e jo
b r
ole
s… f
or
inst
ance
if o
nly
do
ing
revi
ew o
n r
equ
est
mo
de.
Th
ere
are
CP
ch
arts
to
en
sure
th
ings
do
ne
ever
y ye
ar b
ut
enti
re t
eam
do
es n
ot
fill
ou
t.
VP
RS
is r
em
ind
er t
o A
HT
re h
ip x
-ray
bu
t so
me
kid
s d
o n
ot
go o
ften
an
d t
hey
are
th
e In
dig
eno
us
kid
s d
esp
ite
lots
of
effo
rt b
y P
T In
tere
st in
usi
ng
rem
ind
ers.
ii.
Re
gula
r se
rvic
es
and
re
vie
ws
– ar
e c
lien
ts
follo
wed
-up
in
acco
rdan
ce w
ith
bes
t p
ract
ice?
Is t
his
par
t o
f ro
uti
ne
pra
ctic
e?
3 A
HT
AH
T 3
BA
SIC
C
lien
ts n
ot
follo
wed
up
in a
cco
rdan
ce w
ith
bes
t p
ract
ice
W
hee
lch
air
use
rs d
o n
ot
hav
e re
gula
r p
ress
ure
car
e fo
llow
up
. A
d h
oc
revi
ew
s
Ite
m 1
.8:
Ph
ysic
al in
fras
tru
ctu
re, s
up
plie
s an
d e
qu
ipm
en
t A
HT
6
25
6
i. P
hys
ical
infr
astr
uct
ure
– is
it
suit
able
fo
r p
rovi
sio
n o
f ca
re?
6 A
HT
AH
T 6
GO
OD
O
ffic
e s
pac
e a
vaila
ble
C
on
dit
ion
of
off
ice
spac
e p
oo
r –
filt
hy
and
co
ld
Lift
is p
rob
lem
ii.
Sup
plie
s o
f co
nsu
mab
les
– ar
e th
ey a
pp
rop
riat
e an
d
avai
lab
le?
8 A
HT
AH
T 8
GO
OD
W
e ge
t w
hat
we
wan
t N
oth
ing
we
nee
d t
hat
we
can
no
t ge
t b
ut
it is
no
t ea
sy t
o g
et…
we
hav
e to
fill
in f
orm
s an
d
wai
t w
eeks
.
iii.
Equ
ipm
en
t –
is it
ap
pro
pri
ate
and
ava
ilab
le?
Is it
of
goo
d
qu
alit
y an
d v
ery
wel
l m
ain
tain
ed
(e.
g. d
oes
no
t n
eed
to
be
shar
ed b
etw
een
or
bo
rro
wed
fro
m o
ther
co
nsu
ltin
g ar
eas
du
e to
lim
ited
av
aila
bili
ty o
r p
oo
r m
ain
ten
ance
)?
4 A
HT
AH
T 4
BA
SIC
Eq
uip
me
nt
to lo
an is
ver
y lim
ited
– e
.g. b
oo
ks, t
oys
M
ain
ten
ance
is b
asic
, wh
en
yo
u t
hin
k so
met
hin
g is
fix
ed [
afte
r b
ein
g se
rvic
ed]
and
it’s
sti
ll n
ot
fixe
d.
Bas
ic w
hen
co
nsi
der
ing
be
st p
ract
ice
.
25
7
3.1
0 C
OM
PA
RIS
ON
OF
TH
E C
LIN
ICA
L A
UD
ITS
RE
SU
LT
S 2
01
3/
2014
Ph
ysio
thera
py C
lin
ical
Au
dit
Rep
ort
In
dig
en
ou
s c
lie
nts
Ch
ild
ren
0-1
8 y
ears
A
ud
it D
ate
: 28
Ap
ril 2
014
P
eri
od
Au
dit
ed
: 2
9 F
eb
ruary
20
12
- 28 F
eb
ruary
20
14
Secti
on
On
e:
Gen
era
l In
form
ati
on
C
lient
Com
positio
n
2
01
3
20
14
Clie
nt G
en
der
.
Ma
le
Fe
ma
le
60
%(2
1/3
5)
40
%(1
4/3
5)
62
.5%
(2
0/3
2)
37
.5%
(12
/32
)
Mal
e, 2
1
Mal
e, 2
0
Fem
ale,
14
Fe
mal
e, 1
2
0%
20
%
40
%
60
%
80
%
10
0%
20
13
20
14
25
8
Age
0
-2ye
ars
2
-3ye
ar
3
ye
ars
4
-6ye
ars
6
-8ye
ars
8
-10
ye
ars
1
0-1
2ye
ars
1
2-1
4ye
a s
1
4-1
8 y
ears
17%
(6/3
5)
23%
(8/3
5)
0%
(0/3
5)
14%
(5/3
5)
11%
(4/3
5)
9%
(3/3
5)
11%
(4/3
5)
6%
(2/3
5)
9%
(3/3
5)
16%
(5/3
2)
9%
(3/3
2)
16%
(5/3
2)
6%
(2/3
2)
22%
(7/3
2)
3%
(1/3
2)
9%
(3/3
2)
13%
(4/3
2)
6%
(2/3
2)
6
8
0
5
4
3
4
2
3
5
3
5
2
7
1
3
4
2
0123456789
0-2
Year
s2
-3Ye
ars
3-4
Year
s4
-6Ye
ars
6-8
Year
s8
-10
Year
s1
0-1
2Ye
ars
12
-14
Year
s1
4-1
8Ye
ars
20
13
20
14
25
9
Dia
gnosis
/ C
lassific
ation
/ /C
ate
gory
CP
P
rem
atu
rity
P
hysic
al D
isabili
ties
Gro
ss M
oto
r D
ela
y*
Neuro
logic
al Is
su
es
Oth
er
31
% (
11
/35
) 26%
(9/3
5)
17%
(6/3
5)
17%
(6
/35
) 3
%
(1/3
5)
6%
(
2/3
5)
34%
(
11/3
2)
22%
(7/3
2)
13%
(4/3
2)
31%
(
10/3
2)
Cer
ebra
l P
alsy
3
1%
Pre
mat
uri
ty
26
%
Ph
ysic
al
Dis
abili
ties
1
7%
Gro
ss
Mo
tor
Del
ay
17
%
Neu
rolo
gica
l Is
sues
3
%
Oth
er
6%
20
13
Cer
ebra
l P
alsy
3
4%
Pre
mat
uri
ty
22
%
Ph
ysic
al
Dis
abili
ties
1
3%
Gro
ss
Mo
tor
Del
ay
31
%
Neu
rolo
gica
l Is
sues
0
%
Oth
er
0%
20
14
26
0
In
dig
eno
us
Sta
tus
Abori
gin
al
Torr
es S
trait Isla
nde
r B
oth
91
%(3
2/3
5)
3%
(1
/35
) 6%
(2
/35
)
84
% (2
7/3
2)
6%
(2
/32
)
9%
(3
/32
)
11
11
9 7
6
4
6
10
1
0
2 0
0%
50
%1
00
%
20
13
20
14
Cer
ebra
l Pal
sy
Pre
mat
uri
ty
Ph
ysic
al D
isab
iliti
es
Gro
ss M
oto
r D
elay
Neu
rolo
gica
l Iss
ues
Oth
er
32
2
7
1
2
2
3
05
10
15
20
25
30
35
20
13
20
14
Ab
ori
gin
al
Torr
es S
trai
t Is
lan
der
Bo
th
26
1
Fam
ily
Backg
rou
nd
Ind
ige
no
us C
are
r
No
n-I
nd
ige
nou
s C
are
r
Ind
ige
no
us F
oste
r C
are
r
Non
-Indig
en
ous F
oste
r C
are
r
Fo
ste
r C
are
r N
ot
Sta
ted
69
%(2
4/3
5)
3%
(1
/35
) 3
% (
1/3
5)
14%
(5/3
5)
11
% (
4/3
5)
63
% (2
0/3
2)
3
% (
1/3
2)
9
% (
3/3
2)
16%
(5
/32)
9
% (
3/3
2)
H
om
e
La
ng
ua
ge
En
glis
h
No
t S
tate
d
Ind
ige
no
us L
an
gu
ag
e
Ab
orig
ina
l E
ng
lish
In
dig
eno
us a
nd
En
glis
h
49
%(1
7/3
5)
43
%(1
5/3
5)
3%
(1
/35
) 3
% (1
/35
) 3
% (1
/35
)
78
%(2
5/3
2)
3
% (1
/32
) 1
3%
(4
/32
) 3
% (
1/3
2)
3
% (
1/3
2)
24
1
1
5
4
20
1
3
5
3
051
01
52
02
53
0
20
13
20
14
17
1
1
1
15
25
4
1
1
1
05
10
15
20
25
30
Engl
ish
Ind
igen
ou
sA
bo
rigi
nal
Engl
ish
Ind
igen
ou
san
dEn
glis
h
No
t St
ated
20
13
20
14
26
2
Refe
rral
Sourc
e
Educato
r P
hysio
thera
pis
t N
urs
e
Oth
er
Alli
ed H
ealth
Paed
iatr
icia
n
No r
efe
rra
l
Pare
nt/C
are
r
Oth
er
GP
A
borigin
al H
ealth W
ork
er
AT
SIC
Lia
ison
Offic
er
Ort
hop
aed
ist
Neuro
logis
t
23%
(8/3
5)
17%
(6/3
5)
17%
(6/3
5)
11%
(4/3
5)
9%
(3/3
5)
9%
(3/3
5)
6%
(2/2
5)
6%
(2/3
5)
3%
(1/3
5)
0%
(0/3
5)
0%
(0/3
5)
0%
(0/3
5)
0%
(0/3
5)
31%
(10
/32
) 6
%
(2/3
2)
16
% (
5/3
2)
22
% (
7/3
2)
9%
(3/3
2)
9%
(3/3
2)
6
% (
2/3
2)
0%
(0/3
2)
0%
(0/3
2)
0%
(0/3
2)
0%
(0/3
2)
0%
(0/3
2)
0%
(0/3
2)
Location o
f R
efe
rral
Sourc
e
Dept of E
d/C
ath
Ed O
ffic
e
Public
Hosp
ital
Oth
er
Com
munity C
are
Clin
ic
No r
efe
rra
l fo
und
Private
Hospita
l In
dig
en
ous M
edic
al
Centr
e
EI*
Dis
ab
ility
Serv
ice
In
ters
tate
P
rivate
Pra
ctice
AH
T**
*E
arl
y I
nte
rve
ntion
**
Alli
ed H
ea
lth T
eam
23%
(8/2
5)
20%
(7/3
5)
20%
(7
/35
) 1
7%
(6
/35
)
9%
(3/3
5)
6%
(2/3
5)
6
% (
2/3
5)
0
% (
0/3
5)
0
% (
0/3
5)
0
% (
0/3
5)
0
% (
0/3
5)
0
% (
0/3
5)
31%
(1
0/3
2)
6%
(2
/32)
22%
(7/3
2)
19%
(6/3
2)
9%
(3
/32)
9%
(3
/32)
0%
(0
/32)
0%
(0
/32)
0%
(0
/32)
0%
(0
/32)
0%
(0
/32)
6%
(2
/32)
roun
din
g e
rror
8
6
6
4
3
3
2
2
1
10
2
5
7
3
3
2
02468
10
12
20
13
20
14
8
7
7
6
3
2
2
10
2
7
5
3
3
2
024681
01
2
20
13
20
14
26
3
Secti
on
Tw
o:
Att
en
da
nce
20
13
2
01
4
Atten
dan
ce
Atten
ded
N
ot a
tten
ded
83
% (2
9/3
5)
17%
(
6/3
5)
10
0%
(32
/32)
0
% (
0/3
6)
F
ollo
w u
p
atte
mpte
d
(If clie
nt
has
no
t a
tte
nd
ed
initia
l a
pp
oin
tme
nt)
Follo
w u
p
atte
mpte
d
No fo
llow
up
atte
mpte
d
Not a
pplic
able
67
%
(4/3
5)
17
%
(1/3
5)
17
%
(1/3
5)
No
observ
atio
ns
as
all
liste
d
have
att
en
de
d.
N
um
ber
of
atte
mpts
ma
de
N
ot a
ble
to
extr
act.
Maxim
um
num
be
r 4
record
ed.
No
observ
ations
Atte
mp
t to
co
nta
ct
prim
ary
ca
rer
–
be
fore
in
itia
l a
pp
oin
tme
nt
No
t R
ecord
ed
R
eco
rde
d
No
t a
pp
lica
ble
57
% (
20
/35
) 4
3%
(1
5/3
5)
0%
34
% (1
1/3
2)
56
.3%
(1
8/3
2)
9
.3%
(3
/32
)
29
32
6
0%
20
%4
0%
60
%8
0%
10
0%
20
13
20
14
Att
end
end
No
t A
tten
ded
4
0 1
0 1
0
01
23
45
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
15
18
20
11
0 3
05
10
15
20
25
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
26
4
Su
cce
ssfu
l A
tte
mp
t to
C
on
tact
Prim
ary
C
are
r prior
to
Ap
po
intm
en
t
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
34
% (
12
/35
) 66%
(23
/35
) 0
%
(0/3
5)
56
.3%
(1
8/3
2)
34
%
(1
1/3
2)
9
.3%
(3
/32)
P
rim
ary
Care
r A
tten
ded
Prim
ary
Care
r pre
se
nt
Prim
ary
Care
r abse
nt
Not re
co
rde
d
60%
(21
/35
) 3
7%
(13
/35
) 3
%
(1/3
5)
63%
(20
/32
) 38%
(12
/32
)
F
ollo
w U
p
Attem
pt w
ith
P
rim
ary
Care
r
Follo
w u
p
No fo
llow
up
4
6%
(6/1
3)
54%
(7/1
3)
55
%
(6/1
1)
45
%
(5/1
1)
12
18
23
11
0 3
05
10
15
20
25
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
21
20
14
12
05
10
15
20
25
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
6
6
7
5
02
46
8
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
26
5
Location o
f F
am
ily
co
nsultation
AH
T*
Off
ice
Oth
er
S
chool
Hospital
Tele
phon
e
N
ot
record
ed
N
o c
onta
ct
Em
ail
*A
llied H
ealth T
eam
54%
(1
9/3
5)
11%
(
4/3
5)
9%
(3/3
5)
3%
(1/3
5)
8.5
%
(3/3
5)
8.5
%
(3/3
5)
6%
(2/3
5)
0
%
(0
/35)
53.0
%
(17/3
2)
9%
(
3/3
2)
15.6
%
(5/3
2)
0%
(
0/3
2)
9%
(
3/3
2)
6%
(
2/3
2)
3%
(
1/3
2)
0%
(0
/32)
In
terp
rete
r u
se
No inte
rpre
ter
used
Inte
rpre
ter
use
d
100
% (
18/1
8)
0%
(0/1
8)
100
% (
7/7
) 0
%
(
0/7
)
0
3
19
1
3
0
4
3
2
1
5
17
0
3
0
3
2
1
05
10
15
20
20
13
20
14
05
10
15
20
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
26
6
Secti
on
Th
ree:
Backg
rou
nd
In
form
ati
on
(o
f th
ose s
een
fo
r fi
rst
tim
e d
uri
ng
year
au
dit
ed
) Backg
rou
nd
In
form
ati
on
2013
2014
Birth
His
tory
Record
ed
N
ot re
co
rde
d
79%
(11
/14
) 21%
(3
/14
) 1
00
%(1
5/1
5)
0%
(0
/15
)
G
enera
l M
edic
al H
isto
ry
Record
ed
Not re
co
rde
d
U
nknow
n*
86%
(12
/14
)
7%
(1/1
4)
7%
(1/1
4)
10
0%
(15
/15
)
0%
(0
/15)
11
15
3
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
26
7
*asked b
ut m
issin
g
info
rmation
Develo
pm
enta
l H
isto
ry
Record
ed
Not re
co
rde
d
79
% (
11
/14
) 2
1%
(3
/14)
10
0%
(1
5/1
5)
0
%
(0/1
5)
Fam
ily H
isto
ry
Not re
co
rde
d
R
ecord
ed
Unknow
n*
43%
(6/1
4)
29%
(4/1
4)
29%
(4/1
4)
7
%
(1
/15)
67
% (
10
/15
) 2
7%
(
4/1
5)
12
15
1
1
75
%8
0%
85
%9
0%
95
%1
00
%
20
13
20
14
Rec
ord
ed
No
t R
eco
rded
Un
kno
wn
12
15
1
1
05
10
15
20
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
4
9
6
1
4
4
02
46
81
0
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
26
8
Socia
l H
isto
ry
Record
ed
N
ot re
co
rde
d
79%
(11
/14
) 2
1%
(3/1
4)
93
% (
14
/15
)
7%
(
1/1
5)
Education
His
tory
Record
ed
N
ot re
co
rde
d
Unknow
n*
7%
(1/1
4)
93%
(13
/14
)
40%
(6
/15
) 53%
(8
/15
)
7%
(1
/15
)
D
iag
nosis
Record
ed
N
ot re
co
rde
d
Unknow
n
Not A
pplic
able
37%
(1
3/3
5)
3%
(
1/3
5)
0%
(
0/3
5)
6%
(2
1/3
5)
34%
(1
1/3
2)
6%
(2
/32)
6%
(2
/32)
53%
(1
7/3
2)
1
6
13
8
0
1
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
13
11
1 2
0 2
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
11
14
3
1
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
26
9
Ris
k F
acto
rs
Record
ed
N
ot re
co
rde
d
86%
(12
/14
) 14%
(2
/14
) 80%
(12
/15
) 20%
(
3/1
5)
S
ecti
on
Fo
ur:
Clin
ical
Serv
ices f
or
Gro
ss M
oto
r D
ela
y
Su
bje
cti
ve
N
OT
E:
Su
bset
of
ove
rall
reco
rds –
tho
se r
efe
rred
in
past
12 m
on
ths o
f au
dit
P
ain
Not re
co
rde
d
Record
ed
Not
app
lica
ble
78.2
% (
18
/23
) 1
7.4
%
(4/2
3)
4.4
%
(1/2
3)
80%
(16
/20
) 20%
(
4/2
0)
P
rim
ary
C
are
r’s N
eed
s
Record
ed
Not re
co
rde
d
U
nknow
n*
*q
ue
stion a
sked
but pc d
id n
ot
know
61%
(14
/23
) 35%
(8/2
3)
4%
(
1/2
3)
95%
(1
9/2
0)
5%
(1
/20)
12
12
2 3
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
4
4
18
16
05
10
15
20
2…
2…
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
14
19
8
1
0
0
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
27
0
Child
’s N
eeds
Not
app
lica
ble
**
Not re
co
rde
d
Record
ed
Unknow
n
** b
elo
w a
ge 8
or
severe
inte
llectu
al
impair
ment
83%
(1
9/2
3)
13
%
(3
/23
) 4%
(
1/2
3)
0%
(
0/2
3)
95%
(1
9/2
0)
0%
(
0/2
0)
5%
(
1/2
0)
0%
(
0/2
0)
P
rim
ary
C
are
r’s G
oals
Not re
co
rde
d
Record
ed
N
ot
ap
plic
ab
le*
* no c
oncern
s
74%
(17
/23
) 13%
(3
/23
13%
(3
/23
)
45%
(
9/2
0)
5%
(
1/2
0)
50%
(1
0/2
0)
C
hild
’s G
oals
Not app
licable
**
Not re
co
rde
d
R
ecord
ed
Unknow
n
78.2
6%
(18
/23
) 1
7.3
9%
(4
/23
) 4
.35
%
(1
/23
) 0%
(
0/2
3)
95%
(1
9/2
0)
0%
(
0/2
0)
5%
(
1/2
0)
0%
(
0/2
0)
1
1 3
0
19
19
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
3
1
17
9
3
10
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
1
1
4
0
18
19
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
27
1
Str
en
gth
s
Not
app
lica
ble
**
Not re
co
rde
d
Record
ed
U
nknow
n
61%
(14
/23
) 30%
(
7/2
3)
9%
(
2/2
3)
0%
(
0/2
3)
50%
(1
0/2
0)
45%
(
9/2
0)
5%
(
1/2
0)
0%
(0
/20
)
W
ea
kn
esses
N
ot
app
lica
ble
**
Not re
co
rde
d
R
ecord
ed
Unknow
n
61%
(14
/23
) 30%
(7
/23
) 9%
(2
/23
) 0%
(0
/23
)
50%
(1
0/2
0)
40%
(
8/2
0)
10%
(2
/20
)
0%
(0
/20
)
P
rim
ary
C
are
r’s
Prio
ritie
s
Not re
co
rde
d
Record
ed
Unknow
n*
N
ot
app
lica
ble
**
70%
(16
/23
) 13%
(3/2
3)
4%
(1
/23
) 13%
(3/2
3)
15%
(3/2
0)
60%
(12
/20
)
0%
(
0/2
0)
25%
(
5/2
0)
2
1
7
9
14
10
05
10
15
20
13
20
14
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
2
2
7 8
14
10
05
10
15
20
13
20
14
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
3
12
16
3
3 5
1
0
05
10
15
20
20
13
20
14
Un
kno
wn
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
27
2
Child
’s
Prio
ritie
s
No
t a
pp
lica
ble
Not re
co
rde
d
Record
ed
Unknow
n
74
%
(17
/23
) 17%
(4/2
3)
9%
(2/2
3)
0%
(0
/23
)
95%
(19
/20
)
0%
(
0/2
0)
5%
(
1/2
0)
0
% (0
/20
)
Ob
serv
ati
on
Genera
l A
ppe
ara
nce
Not re
co
rde
d
Record
ed
65
%
(15
/23
) 35%
(8
/23
) 7
0%
(1
4/2
0)
30%
(6
/20
)
B
eha
vio
ur
Record
ed
Not re
co
rde
d
78
%
(18
/23
) 22%
(5
/23
) 9
0%
(1
8/2
0)
10%
(2
/20
)
2
1
4
0
17
19
05
10
15
20
20
13
20
14
Un
kno
wn
No
t A
pp
licab
le
Un
reco
rded
Rec
ord
ed
8
6
15
14
05
10
15
20
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
18
18
5
2
05
10
15
20
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
27
3
Child
/Envir
onm
ent
Inte
raction
Record
ed
Not re
co
rde
d
No
t a
pp
lica
ble
57
%
(13
/23
) 39%
(9
/23
) 4
%
(1
/23)
80
%
(16
/20
) 2
0%
(4
/20
) 0
%
(0
/20)
P
rim
ary
C
are
r/C
hild
In
tera
ctio
n
Not re
co
rde
d
Record
ed
87
%
(20
/23
) 13%
(3
/23
) 6
5%
(1
3/2
0)
35
%
(7/2
0)
Gro
ss M
oto
r F
un
cti
on
Ages a
nd
Sta
ges
Questio
nna
ire
Record
ed
Not a
pplic
able
N
ot re
co
rde
d
52%
(12
/23
) 39%
(9
/23
)
9%
(2
/23
)
70
%
(14
/20
) 3
0%
(6/2
0)
0%
(0/2
0)
13
16
9
4
1
0
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
7
20
13
05
10
15
20
25
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
12
14
2
0
9
6
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
27
4
Alb
ert
a I
nfa
nt
Moto
r S
ca
le
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
61%
(14
/23
) 21%
(5
/23
) 17%
(4/2
3)
70
%
(14
/20
) 2
0%
(
4/2
0)
10
%
(2/2
0)
N
euro
logic
al
Sensory
Mo
tor
Develo
pm
enta
l A
ssessm
en
t
Not re
co
rde
d
Not a
pplic
able
R
ecord
ed
Incom
ple
te
61%
(14
/23
) 22%
(5
/23
) 13%
(3
/23
) 4%
(1
/23
)
20
%
(4/2
0)
45
%
(9/2
0)
30
%
(6/2
0)
5
%
(1/2
0)
M
ove
ment-
AB
C
-2
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
78
.3%
(18
/23
)
17
.4%
(4
/23
) 4
.35
%
1/2
3)
65
% (1
3/2
0)
20
%
(4/2
0)
15
%
(3/2
0)
N
euro
logic
al
Record
ed
Not re
co
rde
d
Incom
ple
te
52%
(12
/23
) 17%
(9
/23
) 9%
(2
/23
)
50
%
(10
/20
) 5
0%
(1
0/2
0)
0%
(0/2
0)
4
2
5
4
14
14
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
6
14
4
1
1
5
9
05
10
15
20
13
20
14
No
t A
pp
licab
le
Inco
mp
lete
No
t R
eco
rded
Rec
ord
ed
1 3
4
4
18
13
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
12
10
9 10
2
0
05
10
15
20
13
20
14
Inco
mp
lete
No
t R
eco
rded
Rec
ord
ed
27
5
Musculo
ske
leta
l
Record
ed
Not re
co
rde
d
52%
(12
/23
) 48%
(11
/23
) 5
0%
(1
0/2
0)
50
%
(10
/20
)
M
obili
ty
R
ecord
ed
Not re
co
rde
d
78%
(18
/23
) 22%
(
5/2
3)
100
% (
20/2
0)
0
% (0
/20
)
G
ait
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
Incom
ple
te
39%
(9
/23
) 30%
(
7/2
3)
26%
(6
/23
)
4%
(1
/23
)
30
%
(6/2
0)
65
%
(13
/20
)
5%
(
1/2
0)
0
%
(0/2
0)
E
nvir
on
me
nt
Hom
e
Not re
co
rde
d
Record
ed
83
% (
19
/23
) 17%
(
4/2
3)
70%
(
14/2
0)
30%
(
6/2
0)
12
10
11
10
91
01
11
21
3
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
18
20
5
0
05
10
15
20
25
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
7
13
6
1
1
0
9
6
05
10
15
20
13
20
14
No
t A
pp
licab
le
Inco
mp
lete
No
t R
eco
rded
Rec
ord
ed
4
6
19
14
05
10
15
20
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
27
6
Pre
sch
ool/scho
ol
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
57%
(13
/23
) 26%
(
6/2
3)
17%
(
4/2
3)
55%
(
11/2
0)
40%
(
8/2
0)
5%
(
1/2
0)
C
hild
care
Not a
pplic
able
N
ot re
co
rde
d
87%
(20
/23
) 13%
(
3/2
3)
95%
(
19/2
0)
5%
(
1/2
0)
E
quip
ment
Need
s
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
56
.5%
(13
/23
)
21
.7%
(5/2
3
21
.7%
(5/2
3)
80
% (1
6/2
0)
0%
(0/2
0)
20
%
(4
/20
)
P
hysic
al A
ctivity
an
d R
est
N
ot re
co
rde
d
Not a
pplic
able
R
ecord
ed
39%
(
9/2
3)
35%
(8
/23
) 26%
(6
/23
)
10%
(2/2
0)
15%
(3/2
0)
65%
(13
/20
)
6
8
4
1
13
11
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0
0 3
1
20
19
05
10
15
20
25
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
5
4 5
0
13
16
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
6
13
9
2
8
3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
27
7
S
ecti
on
Fiv
e:
Cli
nic
al
Serv
ices w
ith
Cere
bra
l P
als
y
Clin
ical D
eta
ils
N
B:
Sm
alle
r subset
of overa
ll pop
ula
tion
C
P C
lassific
ation
made a
t dia
gn
osis
N
ote
d tha
t clie
nts
w
ere
refe
rred
by
the
ir t
ype o
f da
mage
with
out
the
word
s C
P
used b
y d
octo
rs
(e.g
. tr
aum
atic
bra
in in
jury
, lis
senceph
aly
)
Record
ed
Not re
co
rde
d
Unknow
n
58
%
(7/1
2)
33
%
(4/1
2)
8
%
(1/1
2)
66
.6%
(8
/12)
16
.6%
(2
/12)
16
.6%
(2
/12)
Chart
no
t availa
ble
Age a
t d
iagno
sis
Not re
co
rde
d
Record
ed
U
nknow
n
58
%
(7/1
2)
33
%
(3/1
2)
16
% (
2/1
2)
41
.7%
(5
/12
) 4
1.7
% (
5/1
2)
16
.7%
(2
/12
)
C
P T
ype a
nd
Typogra
phy
Record
ed
Not re
co
rde
d
91%
(10
/11
)
9%
(
1/1
1)
10
0%
(
12
/12
)
0
%
(0
/12)
3
5
7
5
2
2
02
46
8
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
10
12
1
0
1
0
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
27
8
MA
CS
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
50
% (
6/1
2)
17
%
(4/1
2)
33
%
(2/1
2)
92
%
(1
1/1
2)
8
%
(1/1
2)
0
%
(0/1
2)
B
irth
Defe
cts
P
resent
Record
ed
Not re
co
rde
d
Unknow
n
75
%
(
9/1
2)
25
%
(
3/1
2)
0
%
(0
/12)
58
.3%
(
7/1
2)
33
.3%
(
4/1
2)
8
.3%
(
1/1
2)
K
now
n
Syndro
mes
Not re
co
rde
d
Record
ed
Unknow
n
83
%
(10
/12
) 1
7%
(2/1
2)
0
%
(
0/1
2)
58
.3%
(
7/1
2)
33
.3%
(
4/1
2)
8
.3%
(
1/1
2)
P
resence o
f E
pile
psy
Record
ed
Not re
co
rde
d
58
%
(
7/1
2)
42
%
(
5/1
2)
58
%
(7/1
2)
42
%
(5/1
2)
6
11
4
1 2
0
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
9
7
3 4
0 1
02
46
81
0
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
2
4
10
7
0
1
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
7
7
5
5
02
46
8
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
27
9
Inte
llectu
al
Impairm
en
t
Record
ed
N
ot re
co
rde
d
42
%
(
5/1
2)
58
%
(
7/1
2)
75
%
(
9/1
2)
25
%
(
3/1
2)
V
isual
impair
ment
Record
ed
Not re
co
rde
d
Unknow
n
83
.3%
(10
/12
) 8
.3%
(
1/1
2)
8.3
%
(1
/12
)
10
0%
(
12
/12
)
0
%
(0/1
2)
0%
(
0/1
2)
H
eari
ng
impair
ment
Record
ed
Unknow
n
Not re
co
rde
d
75
%
(
9/1
2)
17
%
(
2/1
2)
8
%
(
1/1
2)
10
0%
(
12
/12
)
0
%
(0/1
2)
0%
(
0/1
2)
5
9
7
3
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
10
12
1
0
1
0
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
9
12
1
0 2
0
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
28
0
Com
munic
ations
impair
ment
Record
ed
U
nknow
n
Not re
co
rde
d
83
%
(10
/12
) 1
7%
(2/1
2)
0
%
(
0/1
2)
10
0%
(
12
/12
)
0
%
(0/1
2)
0%
(
0/1
2)
S
leep issu
es
Not re
co
rde
d
Record
ed
83
%
(10
/12
) 1
7%
(2/1
2)
58
%
(
7/1
2)
42
%
(
5/1
2)
R
espir
ato
ry
Issues
Record
ed
Not re
co
rde
d
58
%
(
7/1
2)
42
%
(
5/1
2)
58
%
(
7/1
2)
42
%
(
5/1
2)
10
12
2
0
0
0
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
2
5
10
7
0
0
05
10
15
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
7
7
5
5
02
46
8
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
28
1
Pain
Issues
Record
ed
N
ot re
co
rde
d
33
%
(
4/1
2)
67
%
(
8/1
2)
75
%
(
9/1
2)
25
%
(
3/1
2)
S
kin
In
tegri
ty/H
ea
lth
Record
ed
N
ot re
co
rde
d
33
%
(
4/1
2)
67
%
(
8/1
2)
67
%
(
8/1
2)
33
%
(
4/1
2)
S
urg
ica
l in
terv
entio
ns
his
tory
Record
ed
Not re
co
rde
d
41
%
(
5/1
2)
58
%
(
7/1
2)
58
%
(
7/1
2)
41
%
(
5/1
2)
4
9
8
3
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
4
8
8
4
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
5
8
7
4
02
46
81
0
20
13
20
14
Un
kno
wn
No
t R
eco
rded
Rec
ord
ed
28
2
Medic
al
inte
rventio
ns
his
tory
Record
ed
Not re
co
rde
d
92
%
(11
/12
)
8%
(1/1
2)
10
0%
(
12
/12
)
0
%
(0
/12)
D
eta
ils o
f hip
x-
ray in
la
st
12
month
s
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
16
.67
%(2
/12)
66
.67
%(8
/12)
16
.67
%(2
/12)
67
%
(
8/1
2)
8
%
(
1/1
2)
2
5%
(
3/1
2)
R
esults o
f hip
x-
ray in
la
st
12
month
s
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
0
%
(
0/1
2)
83
%
(10
/12
) 1
7%
(2/1
2)
67
%
(8/1
2)
8
%
(1/1
2)
2
5%
(
3/1
2)
Measure
ments
in t
he
last
12 m
onth
s
11
12
1
0
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
2
8
8
1 2
3
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0
8 1
0
1 2 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
28
3
Pain
Record
ed
N
ot re
co
rde
d
33
%
(4
/12)
67
%
(
8/1
2)
75%
(9
/12
) 2
5%
(
3/1
2)
P
rim
ary
C
are
r’s
Ne
ed
s
Record
ed
Not re
co
rde
d
Unknow
n
42
%
(
5/1
2)
50
%
(
6/1
2)
8
%
(
1/1
2)
75
%
(9/1
2)
25
%
(3/1
2)
0
%
(0/1
2)
C
hild
’s
Ne
ed
s
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
58
%
(
7/1
2)
17
%
(
2/1
2)
25
%
(
3/1
2)
58
%
(7/1
2)
42
%
(5/1
2)
0
%
(0/1
2)
4
9
8
3
0
0
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
5
9
6
3
1
0
02
46
81
0
20
13
20
14
Un
kno
wn
No
tR
eco
rded
Rec
ord
ed
2
5
3
0
7
7
02
46
8
12N
ot
Ap
plic
able
No
t R
eco
rded
Rec
ord
ed
28
4
Prim
ary
ca
rer’
s g
oa
ls
Not re
co
rde
d
Record
ed
83
%
(10
/12
) 1
7%
(2
/12
)
75
%
(9/1
2)
25
%
(3/1
2)
C
hild
’s g
oa
ls
N
ot a
pplic
able
R
ecord
ed
N
ot re
co
rde
d
58
%
(
7/1
2)
17
%
(
2/1
2)
25
%
(
3/1
2)
58
%
(
7/1
2)
33
%
(
4/1
2)
8
%
(
1/1
2)
T
ea
ch
er’
s
Go
als
Not re
co
rde
d
Not a
pplic
able
R
ecord
ed
75
%
(
9/1
2)
25
%
(
3/1
2)
0
%
(
0/1
2)
67
%
(
8/1
2)
25
%
(
3/1
2)
8
%
(
1/1
2)
S
tren
gth
s
No
t re
cord
ed
R
eco
rde
d
No
t a
pp
lica
ble
58
.3%
(7
/12
)
8.3
%
(1/1
2)
33
.3%
(4
/12)
50
%
(
6/1
2)
42
%
(
5/1
2)
8
%
(
1/1
2)
2 3
10
9
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
2
4
3
1
7
7
02
46
8
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0 1
9
8
3
3
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
5
7
6
4
1
02
46
8
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
28
5
Wea
kn
esses
Not re
co
rde
d
Record
ed
N
ot a
pplic
able
58
.3%
(7
/12
) 8
.3%
(1/1
2)
33
.3%
(4
/12)
67
%
(
8/1
2)
25
%
(
3/1
2)
8
%
(
1/1
2)
P
rim
ary
C
are
r’s
Prio
ritie
s
Record
ed
Not re
co
rde
d
25
%
(
3/1
2)
75
%
(
9/1
2)
58
%
(
7/1
2)
42
%
(
5/1
2)
C
hild
’s
Prio
ritie
s
Not a
pplic
able
R
ecord
ed
N
ot re
co
rde
d
58
%
(
7/1
2)
17
%
(
2/1
2)
25
%
(
3/1
2)
58
.3%
(7
/12)
33
.3%
(4
/12)
8
.3%
(1
/12)
Observ
ation
1
3
7 8
4
1
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
7
9
5
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
2
4
3
1
7
7
02
46
8
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
28
6
Genera
l A
ppe
ara
nce
Record
ed
Not re
co
rde
d
8%
(1/1
2)
92
%(1
1/1
2)
58%
(
7/1
2)
42%
(
5/1
2)
B
eha
vio
ur
Record
ed
Not re
co
rde
d
58
%(7
/12)
42
% (
5/1
2)
83
%(1
0/1
2)
17
% (
2/1
2)
C
hild
In
tera
ction
W
ith
E
nviro
nm
en
t
Record
ed
Not re
co
rde
d
58
%(7
/12)
42
%(5
/12)
67
%
(8/1
2)
33
%
(4/1
2)
1
7
11
5
02
46
81
01
2
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
7
10
5
2
02
46
81
01
2
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
7
8
5
4
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
28
7
Prim
ary
C
are
r/C
hild
In
tera
ction
Not re
co
rde
d
Record
ed
92
%(1
1/1
2)
8
% (1
/12
) 7
5%
(9
/12
) 2
5%
(3
/12
)
Environ
me
nt
H
om
e
Record
ed
N
ot re
co
rde
d
17%
(2
/12
) 8
3%
(1
0/1
2)
67
%
(8/1
2)
33
% (
4/1
2)
P
resch
ool/S
ch
ool
R
ecord
ed
Not a
pplic
able
N
ot re
co
rde
d
50%
(6
/12
)
8%
(1
/12
) 42%
(5
/12
)
75
%
(9/1
2)
17
%
(2/1
2)
8%
(1
/12
)
1
3
11
9
02
46
81
01
2
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
2
8
10
4
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
6
9
5
1
1 2
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
28
8
Child
care
Not a
pplic
able
R
ecord
ed
N
ot re
co
rde
d
83
%
(10
/12
)
0%
(0
/12)
17%
(2
/12
)
92
%
(11
/12
) 8
%
(
1/1
2)
0%
(0/1
2)
E
quip
ment
Ne
ed
s
Record
ed
Not a
pplic
able
Not re
co
rde
d
66
.67
% (
8/1
2)
16
.67
% (
2/1
2)
16
.67
% (
2/1
2)
83
%
(10
/12
) 1
7%
(
2/1
2)
0
%
(0/1
2)
P
hysic
al a
ctivity
and
rest
Record
ed
Not re
co
rde
d
42
%
(5/1
2)
58
%
(7/1
2)
92
%
(11
/12
)
8%
(
1/1
2)
0
1 2
0
10
11
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
8 1
0
2
0 2
2
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
5
11
7
1
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
28
9
Mobili
ty
Functional M
obili
ty
GM
FC
S
R
ecord
ed
Not re
co
rde
d
5
8%
(7/1
2)
42
%
(
5/1
2)
92
%
(11
/12
)
8%
(1/1
2)
F
MS
Record
ed
N
ot a
pplic
able
Not re
co
rde
d
25
%
(
3/1
2)
8
%
(
1/1
2)
67
%
(
8/1
2)
83
%
(10
/12
) 1
7%
(2/1
2)
0
%
(
0/1
2)
G
ross M
oto
r F
un
ctio
n M
easure
-8
8 (
if G
MF
CS
Le
ve
l (I
V-V
)
Not a
pplic
able
Not re
co
rde
d
Record
ed
50
%
(
6/1
2)
50
%
(
6/1
2)
0
%
(
0/1
2)
67
%
(
8/1
2)
25
%
(
3/1
2)
8
%
(
1/1
2)
7
11
5
1
02
46
81
01
2
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
3
10
8
0
1 2
02
46
81
01
2
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0 1
6
3
6
8
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
29
0
Gro
ss M
oto
r F
un
ctio
n M
easure
-6
6 (
if G
MF
CS
Le
ve
l (I
-III)
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
25
%
(
3/1
2)
67
%
(
8/1
2)
8
%
(
1/1
2)
58
%
(
7/1
2)
42
%
(
5/1
2)
0
%
(
0/1
2)
S
ittin
g P
ositio
n
R
ecord
ed
Not re
co
rde
d
In
com
ple
te
N
ot a
pplic
able
33
%
(
4/1
2)
42
%
(
5/1
2)
17
%
(
2/1
2)
8
%
(
1/1
2)
58
.3%
(7
/12)
33
.3%
(4
/12)
8
.3%
(1
/12)
0%
(0
/12)
T
ran
sitio
nal
Move
ments
Record
ed
N
ot re
co
rde
d
67
%
(
8/1
2)
33
%
(
4/1
2)
83
%
(10
/12
) 1
7%
(2/1
2)
1
0
8
5
3
7
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
4
7
5
4
1
0
2
1
02
46
8
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
8
10
4
2
02
46
81
01
2
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
29
1
Sta
ndin
g
Record
ed
Not a
pplic
able
N
ot re
co
rde
d
Incom
ple
te
58
.33
% (
7/1
2)
0
%
(
0/1
2)
33
.33
%(4
/12)
8
.33
% (
1/1
2)
67
%
(
8/1
2)
25
%
(
3/1
2)
8
%
(
1/1
2)
0
%
(
0/1
2)
In
de
pe
nd
en
ce
Level
Record
ed
Not re
co
rde
d
Not a
pplic
able
50
%
(6/1
2)
33
%
(4/1
2)
17
%
(2/1
2)
92
%
(11
/12
)
8%
(1
/12
)
0%
(0/1
2)
S
elf –
Care
F
un
ctio
nal L
evel
Record
ed
N
ot re
co
rde
d
Incom
ple
te
Not a
pplic
able
33
.3%
(4/1
2)
50
%
(6/1
2)
8
.3%
(1/1
2)
8
.3%
(1/1
2)
50
%
(
6/1
2)
33
.3%
(4
/12)
8
%
(
1/1
2)
8
%
(
1/1
2)
S
elf-c
are
asse
ssm
ent used
Not re
co
rde
d
Record
ed
Unknow
n
Not a
pplic
able
50
%
(6/1
2)
33
.3%
(4/1
2)
8
%
(1/1
2)
8
%
(1/1
2)
92
%
(11
/12
)
8%
(1/1
2)
0
%
(
0/1
2)
0
%
(
0/1
2)
7
8
4
1
0
3
1
0
02
46
81
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
6
11
4
1 2
0
02
46
81
01
2
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
4
6
6
4
1
1
1
1
02
46
8
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
29
2
Gait
Obse
rvatio
nal G
ait S
ca
le
or
Ph
ysic
ian R
atin
gs
Sca
le
Record
ed
Not re
co
rde
d
Not a
pplic
able
16
.67
% (
2/1
2)
66
.67
% (
8/1
2)
16
.67
% (
2/1
2)
50%
(6
/12
) 25%
(3
/12
) 25%
(3
/12
)
A
ssis
tan
ce R
equ
ire
d
Record
ed
Not re
co
rde
d
Not a
pplic
able
41
.67
% (
5/1
2)
41
.67
% (
5/1
2)
16
.67
% (
2/1
2)
67%
(8
/12
)
8%
(1
/12
) 25%
(3
/12
)
E
quip
ment
Requ
ire
d
Record
ed
Not a
pplic
able
N
ot re
co
rde
d
41
.67
% (
5/1
2)
16
.67
% (
2/1
2)
41
.67
% (
5/1
2)
67%
(8
/12
) 33%
(4
/12
)
0%
(0
/12)
2
6
8
3
2 3
05
10
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
5
8
5
1 2
3
05
10
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
5
8
5
0 2
4
05
10
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
29
3
Ort
hotics U
sed
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
36
.36
% (
4/1
2)
45
.45
% (
5/1
2)
18
.18
% (
2/1
2)
67%
(8
/12
) 33%
(4
/12
)
0%
(0
/12)
2D
VG
A
Not re
co
rde
d
Record
ed
Not a
pplic
able
67
%
(8
/12
)
8%
(1
/12)
25
%
(3/1
2)
42%
(5
/12
) 33%
(4
/12
) 25%
(3
/12
)
Low
er
Lim
b M
usculo
ske
leta
l M
ea
su
rem
ents
(w
ith a
go
nio
metr
e)
Hip
s
Supin
e A
bdu
ctio
n w
ith
hip
s a
t 0 –
R1
Record
ed
Not re
co
rde
d
17
% (
2/1
2)
83
%(1
0/1
2)
75%
(9/1
2)
25%
(3/1
2)
4
8
5
0 2
4
05
10
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
4
8
5
3
3
05
10
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
2
9 10
3
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
29
4
Supin
e A
bdu
ctio
n w
ith
hip
s a
t 0 –
R2
Record
ed
N
ot re
co
rde
d
33
%
(4/1
2)
67%
(8/1
2)
83%
(10
/12
) 17%
(2/1
2)
S
upin
e A
bdu
ctio
n w
ith
Hip
s a
t 9
0 –
R1
Record
ed
Not re
co
rde
d
17%
(2
/12
) 83%
(10
/12
) 75%
(9/1
2)
25%
(3/1
2)
S
upin
e A
bdu
ctio
n w
ith
Hip
s a
t 9
0 –
R2
Record
ed
N
ot re
co
rde
d
25%
(3
/12
) 75%
(9/1
2)
83
% (
10
/12
) 17%
(2/1
2)
4
10
8
2
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
2
9 10
3
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
3
10
9
2
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
29
5
Supin
e F
lexio
n
Not re
co
rde
d
Vis
ua
l E
stim
ate
Record
ed
83%
(10
/12
)
0%
(0/1
2)
17%
(2
/12
)
58%
(7/1
2)
25%
(3/1
2)
17%
(2/1
2)
S
upin
e E
xte
nsio
n
Record
ed
Not re
co
rde
d
33%
(4
/12
) 67%
(8
/12
) 83%
(10
/12
) 17%
(2/1
2)
S
tah
eli
test
or
Thom
as
Test
Record
ed
N
ot re
co
rde
d
10
0%
(12
/12)
0 (
0/1
2)
17%
(2/1
2)
83%
(10
/12
)
2
2
10
7
0 3
05
10
15
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
4
10
8
2
0
0
05
10
15
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
0 2
12
10
05
10
15
20
13
20
14
No
tR
eco
rded
Rec
ord
ed
29
6
Pro
ne
ER
Record
ed
N
ot re
co
rde
d
25%
(3
/12
) 75%
(9
/12
) 75%
(9
/12
) 25%
(3
/12
)
P
rone
IR
Record
ed
Not re
co
rde
d
25%
(3
/12
) 75%
(9
/12
) 75%
(9
/12
) 2
5%
(3
/12)
D
uncan E
ly –
R1
Record
ed
N
ot re
co
rde
d
Vis
ua
l E
stim
ate
17%
(2
/12
) 75%
(9
/12
)
8%
(1
/12
)
67%
(8/1
2)
33%
(4
/12
)
0%
(0
/12
)
3
9
9
3
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
3
9
9
3
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
2
8 9
4
05
10
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
29
7
Duncan E
ly –
R2
Record
ed
Not re
co
rde
d
Vis
ua
l E
stim
ate
17
%
(2/1
2)
75%
(9
/12
)
8%
(1
/12
)
67%
(8/1
2)
33%
(4
/12
)
0%
(0
/12)
Knees
K
nee
E
xte
nsio
n
Record
ed
Not re
cord
ed
Vis
ual E
stim
ate
33
% (
4/1
2)
67
% (
8/1
2)
0
% (
0/1
2)
58
.3%
(7/1
2)
33
.3%
(4/1
2)
8
.3%
(1/1
2)
P
oplit
eal
Angle
– R
1
Record
ed
Not re
cord
ed
25
% (3
/12
) 7
5%
(9
/12
) 6
7%
(8
/12)
33
% (4
/12
)
2
8 9
4
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
4
7
8
4
0 1
02
46
81
0
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
3
8
9
4
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
29
8
Poplit
eal
Angle
– R
2
Record
ed
No
t re
co
rde
d
25%
(3
/12
) 75%
(9
/12
) 67%
(8
/12
) 33%
(4
/12
)
Ankle
s
A
nkle
Dors
ifle
xio
n w
ith
K
nee
s a
t 9
0–
R1
Record
ed
N
ot re
co
rde
d
25
%
(3/1
2)
75
%
(9/1
2)
67
%
(8/1
2)
33
%
(4/1
2)
A
nkle
Dors
ifle
xio
n w
ith
K
nee
s a
t 9
0–
R2
Record
ed
N
ot re
co
rde
d
33
%
(4/1
2)
67
%
(8/1
2)
67
%
(8/1
2)
33
%
(4/1
2)
3
8 9
4
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
3
8 9
4
05
10
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
4
8
8
4
05
10
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
29
9
Ankle
Dors
ifle
xio
n w
ith
K
nee
s a
t 0
–R
1
Record
ed
Not re
co
rde
d
25
%
(3/1
2)
75
%
(9/1
2)
67
%
(8/1
2)
33%
(4
/12
)
A
nkle
Dors
ifle
xio
n w
ith
K
nee
s a
t 0
–R
2
Record
ed
Not re
co
rde
d
33
%(4
/12)
67%
(8
/12
) 6
7%
(8/1
2)
33%
(4/1
2)
P
ositio
n N
ote
d
Not re
co
rde
d
10
0%
(1
2/1
2)
10
0%
(12
/12
)
3
8 9
4
05
10
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
4
8
8
4
05
10
20
13
20
14
No
tR
eco
rded
Rec
ord
ed
0
0
12
12
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
30
0
Feet
(non
-weig
ht
bearing)
H
ind
foo
t (V
aru
s
or
Va
lgus)
Not re
co
rde
d
Record
ed
V
isu
al E
stim
ate
92
%(1
1/1
2)
0
%
(0/1
2)
8%
(1
/12
)
75
%(9
/12)
25
%
(3/1
2)
0%
(0
/12)
M
idfo
ot
(Pro
na
tio
n/S
up
ina
tio
n)
Not re
co
rde
d
Record
ed
V
isu
al E
stim
ate
92
%(1
1/1
2)
0
%
(0/1
2)
8%
(1
/12
)
83
% (
10
/12
) 1
7%
(2
/12)
0
%
(0/1
2)
H
ind
foo
t to
fo
re f
oo
t alig
nm
ent
Not re
co
rde
d
Record
ed
V
isu
al E
stim
ate
92
%(1
1/1
2)
0
%
(0/1
2)
8%
(1
/12
)
75%
(9
/12
) 25%
(3
/12
)
0%
(0
/12)
0
3
11
9
1
0
02
46
81
01
2
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
0 2
11
10
1
0
02
46
81
01
2
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
0
3
11
9
1
0
02
46
81
01
2
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
30
1
Toe
alig
nm
ent
Not re
co
rde
d
Record
ed
V
isu
al E
stim
ate
92
%(1
1/1
2)
0
%
(0/1
2)
8%
(1
/12
)
92%
(11
/12
)
8%
(
1/1
2)
0
%
(0/1
2)
G
reat
To
e
Alig
nm
en
t
Not re
co
rde
d
Record
ed
V
isu
al E
stim
ate
92
%(1
1/1
2)
0
% (
0/1
2)
8
% (
1/1
2)
92%
(11
/12
)
8%
(
1/1
2)
0
%
(0/1
2)
Spin
e
S
tan
din
g
Positio
n
Not re
co
rde
d
Record
ed
Not a
pplic
able
83
.4%
(10
/12
) 8
.3%
(1/1
2)
8.3
%
(
1/1
2)
41
.67
% (
5/1
2)
41
.67
% (
5/1
2)
16
.67
% (
2/1
2)
0
1
11
11
1
0
02
46
81
01
2
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
0
1
11
11
1
0
02
46
81
01
2
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
1
5
10
5
1 2
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
30
2
Sittin
g
Positio
n
Not re
co
rde
d
Record
ed
75
%
(
9/1
2)
25
%
(
3/1
2)
50
% (
6/1
2)
50%
(6/1
2)
P
rone
A
ttem
pt
Spin
al
Corr
ectio
n
Not a
pplic
able
N
ot re
co
rde
d
R
ecord
ed
8%
(1/1
2)
92
% (
11
/12
)
0%
(
0/1
2)
50
%
(6
/12)
42
%
(5
/12)
8
%
(1
/12)
Pelv
is/L
eg length
Sta
ndin
g P
ositio
n
Record
ed
Not re
cord
ed
Not a
pplic
able
8.3
%
(1
/12
) 83.3
% (
10
/12
) 8
.3%
(
1/1
2)
42%
(5/1
2)
33%
(4/1
2)
25%
(3/1
2)
3
6
9
6
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
0
1
11
6
1
5
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
5
10
4
1
3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
30
3
Sittin
g P
ositio
n
Not re
co
rde
d
Record
ed
7
5%
(9/1
2)
25
%
(3
/12
) 58%
(7/1
2)
42%
(5/1
2)
P
assiv
e
Corr
ectio
n
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
0%
(0/1
2)
92
%
(1
1/1
2)
8
%
(1
/12)
25%
(3
/12
) 58%
(7/1
2)
17
%
(2/1
2)
H
ip D
yspla
sia
/ D
isso
cia
tio
n/
Sublu
xatio
n
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
17
%
(2
/12)
83
%
(1
0/1
2)
0%
(0
/12)
25%
(3
/12
) 4
2%
(5
/12)
33
%
(4/1
2)
3
5
9
7
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
1 3
11
7
0 2
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
2 3
10
5
0
4
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
30
4
Le
g L
en
gth
D
iffe
rence
Record
ed
N
ot re
co
rde
d
Vis
ua
l E
stim
ate
8
.3%
(
1/1
2)
83.3
% (
10
/12
)
8.3
%
(1
/12
)
17
%
(2/1
2)
83%
(10
/12
)
0%
(0
/12)
S
tandin
g p
ostu
re/a
lignm
ent
To
es-F
ron
tal V
iew
(A
BD
-AD
D)
Record
ed
Not re
co
rde
d
Not a
pplic
able
8.3
%
(1
/12
) 83.3
% (
10
/12
) 8
.3%
(
1/1
2)
33%
(4
/12
) 42%
(5
/12
) 25%
(3
/12
)
T
oe
s –
Sagitta
l V
iew
(E
xt-
Fle
xio
n)
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
0%
(
0/1
2)
92%
(
11/1
2)
8
% (
1/1
2)
33%
(4
/12
) 4
2%
(5
/12)
25%
(3
/12
)
1 2
10
10
1
0
05
10
15
20
13
20
14
Vis
ual
Est
imat
e
No
t R
eco
rded
Rec
ord
ed
1
4
10
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0
4
11
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
30
5
Fo
refo
ot
–F
ron
tal V
iew
(A
BD
/AD
D)
Not re
co
rde
d
Record
ed
Not a
pplic
able
83.3
% (
10
/12
)
8.3
% (
1/1
2)
8.3
% (
1/1
2)
42%
(5
/12
) 33%
(4
/12
) 25%
(3
/12
)
F
ore
foo
t/M
idfo
ot
Sa
gitta
l V
iew
(C
avus/P
lan
us)
Record
ed
Not re
co
rde
d
Not a
pplic
able
8.3
%
(
1/1
2)
83.3
% (
10
/12
)
8.3
%
(1/1
2)
33%
(4
/12
) 4
2%
(5
/12)
25%
(3
/12
)
F
ore
foo
t/M
idfo
ot
Tra
nsvers
e V
iew
(S
upin
atio
n/P
rona
tio
n)
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
8.3
%
(1/1
2)
83.3
% (
10
/12
)
8.3
% (
1/1
2)
50%
(6/1
2)
25%
(3/1
2)
25%
(3/1
2)
1 4
10
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
6
10
3
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
4
10
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
30
6
Hin
dfo
ot-
Sagitta
l V
iew
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
8
.3%
(
1/1
2)
83.3
% (
10
/12
)
8.3
%
(1/1
2)
50%
(6/1
2)
25%
(3/1
2)
25%
(3/1
2)
A
nkle
-Sagitta
l V
iew
(D
F/P
F)
Record
ed
Not re
co
rde
d
Not a
pplic
able
8
.3%
(
1/1
2)
83
.3%
(10
/12
)
8.3
%
(1/1
2)
33%
(4
/12
) 4
2%
(5
/12)
25%
(3
/12
)
A
nkle
- F
ron
tal V
iew
(I
nvers
ion/E
vers
ion
)
Record
ed
N
ot re
co
rde
d
N
ot a
pplic
able
8
.3%
(1/1
2)
83
.3%
(10
/12
)
8.3
% (
1/1
2)
42%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
1
5
10
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
5
10
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
5
10
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
30
7
Knee
–F
ron
tal V
iew
(V
alg
us/V
aru
s)
Record
ed
N
ot re
co
rde
d
N
ot a
pplic
able
0
%
(0
/12)
92
%
(1
1/1
2)
8
%
(1
/12)
33%
(4
/12
) 42%
(5/1
2)
25%
(3
/12
)
K
nee
–S
agitta
l V
iew
(C
rouch/R
ecurv
atu
m)
Record
ed
Not re
co
rde
d
Not a
pplic
able
8
.3%
(1
/12)
83
.3%
(1
0/1
2)
8
.3%
(1
/12)
42%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
Hip
-Fro
nta
l V
iew
(A
BD
uctio
n/A
DD
uctio
n)
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
0
%
(0
/12)
92
%
(1
1/1
2)
8
%
(1
/12)
42%
(5/1
2)
33
%
(4/1
2)
25%
(3
/12
)
0
4
11
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0
5
11
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
5
10
4
1
3
05
10
20
13
20
14
No
tA
pp
licab
le
No
tR
eco
rded
Rec
ord
ed
30
8
Hip
-Sagitta
l V
iew
(F
lexio
n/E
xte
nsio
n)
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
8.3
%
(1
/12)
83
.3%
(10
/12
) 8
.3%
(
1/1
2)
42%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
P
elv
is-F
ron
tal
(Ob
liqu
ity)
Not re
co
rde
d
Record
ed
N
ot a
pplic
able
92
%
(11
/12
) 0
%
(0
/12)
8%
(1
/12)
42%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
P
elv
is-S
agitta
l (T
ilt)
Record
ed
Not re
co
rde
d
Not a
pplic
able
8
.3%
(
1/1
2)
83
.3%
(1
0/1
2)
8.3
%
(1/1
2)
42%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
1
5
10
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0
4
11
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
5
10
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
30
9
Pelv
is-
Tra
nsvers
e(R
ota
tio
n)
Not re
co
rde
d
Record
ed
N
ot a
pplic
able
92
%
(
11
/12)
0
%
(
0/1
2)
8%
(1
/12)
42%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
Lum
ba
r spin
e-f
ron
tal
Not re
co
rde
d
Record
ed
Not a
pplic
able
83.3
%(1
0/1
2)
8.3
%
(1
/12
) 8
.3%
(
1/1
2)
42%
(5/1
2)
33%
(4
/12
) 2
5%
(3
/12)
Lum
ba
r spin
e-s
agitta
l (lo
rdo
sis
/kyphosis
)
Record
ed
Not re
co
rde
d
Not a
pplic
able
8
.3%
(1
/12)
83
.3%
(1
0/1
2)
8
.3%
(1
/12)
42
%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
0 4
1 3
11
5
05
10
15
20
13
20
14
No
t R
eco
rded
No
t A
pp
licab
le
Rec
ord
ed
1
4
10
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
5
10
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
0
Tho
racic
spin
e-f
ron
tal
vie
w (
sco
liosis
)
Not re
co
rde
d
Record
ed
Not a
pplic
able
83
.3%
(1
0/1
2)
8.3
%
(1/1
2)
8
.3%
(1/1
2)
50
%
(6/1
2)
25
%
(3/1
2)
25
%
(3/1
2)
T
ho
racic
spin
e-s
agitta
l vie
w
(lo
rdo
sis
/kyphosis
)
Not re
co
rde
d
Record
ed
N
ot a
pplic
able
83
.3%
(1
0/1
2)
8
.3%
(
1/1
2)
8
.3%
(
1/1
2)
50
%
(6/1
2)
25
%
(3/1
2)
25
%
(3/1
2)
S
hou
lder
gird
le-f
ron
tal
vie
w (
ob
liquity)
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
0
%
(
0/1
2)
92
%
(
11
/12)
8
%
(
1/1
2)
42
%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
1 3
10
6
1 3
05
10
15
20
13
20
14
No
tA
pp
licab
leN
ot
Rec
ord
edR
eco
rded
1 3
10
6
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0
5
11
4
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
1
Shou
lder
gird
le-s
agitta
l vie
w
(pro
tractio
n/r
etr
actio
n)
Not re
co
rde
d)
Record
ed
Not a
pplic
able
83
.3%
(1
0/1
2)
8
.3%
(1
/12)
8
.3%
(1
/12)
50
%
(6/1
2)
25
%
(3/1
2)
25
%
(3/1
2)
C
erv
ical S
pin
e –
fron
tal
vie
w (
sid
eflexio
n)
Not re
co
rde
d
Record
ed
Not a
pplic
able
92
%
(1
1/1
2)
0
%
(
0/1
2)
8
%
(
1/1
2)
42
%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
C
erv
ical S
pin
e –
sa
gitta
l vie
w
(fle
xio
n/e
xte
nsio
n)
Not re
co
rde
d
Record
ed
Not a
pplic
able
83
.3%
(1
0/1
2)
8
.3%
(1
/12)
8
.3%
(1
/12)
42
%
(5/1
2)
33%
(4
/12
) 25%
(3
/12
)
1 3
10
6
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0 4
11
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1 4
10
5
1 3
05
10
15
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
2
Mo
tor
Fu
ncti
on
Low
er
Lim
b S
trength
Hip
Fle
xors
No
t a
pp
lica
ble
Not re
co
rde
d
R
ecord
ed
17
% (
2/1
2)
75
% (
9/1
2)
8
% (
1/1
2)
58
%
(7/1
2)
25
%
(3/1
2)
17
%
(2/1
2)
H
ip
Abdu
cto
rs
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
17
% (
2/1
2)
75
% (
9/1
2)
8
% (
1/1
2)
58
%
(7/1
2)
25
%
(3/1
2)
17
%
(2/1
2)
H
ip
Exte
nsors
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
17
% (
2/1
2)
8
% (
1/1
2)
75
% (
9/1
2)
58
%
(7/1
2)
25
%
(3/1
2)
17
%
(2/1
2)
1 2
9
3
2
7
05
10
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1 2
9
3
2
7
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
3
9
2
2
7
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
3
Quadri
ce
ps
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
17
% (
2/1
2)
75
% (
9/1
2)
8
% (
1/1
2)
58
%
(7/1
2)
25
%
(3/1
2)
17
%
(2/1
2)
H
am
str
ings
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
17
% (
2/1
2)
8
% (
1/1
2)
75
% (
9/1
2)
58
%
(7/1
2)
25
%
(3/1
2)
17
%
(2/1
2)
A
nkle
D
ors
ifle
xors
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
17
% (
2/1
2)
8
% (
1/1
2)
75
% (
9/1
2)
58
%
(7/1
2)
25
%
(3/1
2)
17
%
(2/1
2)
1 2
9
3
2
7
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
3
9
2
2
7
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
3
9
2
2
7
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
4
Calv
es
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
17
%(2
/12)
75%
(9
/12
)
8%
(1
/12
)
58
.3%
(7/1
2)
33
.3%
(
4/1
2)
8
.3%
(
1/1
2)
Sele
ctive M
oto
r C
ontr
ol
Ankle
D
ors
ifle
xio
n
Record
ed
Not re
co
rde
d
Not a
pplic
able
16
.67
%
(2/1
2)
66
.67
%
(8/1
2)
16
.67
%
(2/1
2)
42
%
(5/1
2)
33
%
(4/1
2)
25
%
(3/1
2)
Low
er
Lim
b S
pasticity
H
ip F
lexors
Not re
co
rde
d
Record
ed
10
0%
(12
/12
)
0
%
(0/1
2)
83%
(10
/12
) 1
7%
(2
/12)
1
1
9
4
2
7
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
2
5
8
4
2 3
02
46
81
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0 2
12
10
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
31
5
Hip
Addu
cto
rs
Record
ed
Not re
co
rde
d
17
% (
2/1
2)
83
%(1
0/1
2)
67
%(8
/12)
33%
(4
/12
)
Q
uadri
ce
ps
Record
ed
Not re
co
rde
d
17
%
(2/1
2)
83
%
(10
/12
) 6
7%
(8
/12)
33
%
(4/1
2)
H
am
str
ings
Record
ed
N
ot re
co
rde
d
25
%
(3
/12
) 7
5%
(9/1
2)
67
%
(8/1
2)
33
%
(4/1
2)
2
8 1
0
4
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
2
8 1
0
4
05
10
15
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
3
8 9
4
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
31
6
Gastr
ocnem
ii
Record
ed
Not re
co
rde
d
25
%
(3
/12
) 7
5%
(9/1
2)
67
%
(8/1
2)
33
%
(4/1
2)
S
ole
i
Record
ed
Not re
co
rde
d
25
%
(3
/12
) 7
5%
(9/1
2)
67
%
(8/1
2)
33
%
(4/1
2)
CP
Type a
nd T
ypogra
phy
Physio
thera
py
asse
ssed type
and
typogra
ph
y
(if
no
t pro
vid
ed
by d
octo
rs)
Record
ed
N
ot re
cord
ed
Not app
licable
Unkno
wn
8.3
% (
1/1
2)
50%
(6
/12)
33.3
% (
4/1
2)
8.3
% (
1/1
2)
92%
(
11/1
2)
8%
(1
/12)
0%
(0
/12)
0%
(0
/12)
3
8 9
4
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
3
8 9
4
02
46
81
0
20
13
20
14
No
t R
eco
rded
Rec
ord
ed
1
11
6
1
4
0 1
0
02
46
81
01
2
20
13
20
14
Un
kno
wn
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
7
Eq
uip
men
t
Sta
ndin
g F
ram
es
S
tan
din
g
Fra
me
Descri
ptio
n
Not a
pplic
able
R
ecord
ed
89%
(3
2/3
5)
11
%
(3/3
5)
94
%
(30
/32
)
6%
(2
/32)
A
ssis
tan
ce
Requ
ire
d fo
r T
ransfe
rs/
Use
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
89
%
(32
/35
)
9%
(2
/35)
3
%
(1/3
5)
94
%
(30
/32
)
6%
(2
/32)
0
%
(0/3
2)
S
ourc
e o
f E
quip
men
t
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
91%
(3
2/3
5)
9
%
(3
/35)
0
%
(0
/35)
94
%
(30
/32
)
3%
(1
/32)
3
%
(1/3
2)
4
2
0
0
31
30
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
2
1
31
31
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
1
0
1
30
28
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
8
Date
of
Issue
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
91
%
(32
/35
)
6%
(2
/35)
3
%
(1/3
5)
94
%
(30
/32
)
3%
(1
/32)
3
%
(1/3
2)
S
ch
edu
le o
f U
se
(F
requency/
Sessio
n T
ime)
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
91
%
(32
/35
)
6%
(2
/35)
3
%
(1/3
5)
94%
(30
/32
)
6%
(2/3
2)
0
% (
0/3
2)
Is
su
es w
ith
U
se
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
91
%
(32
/35
)
3%
(1
/35)
6
%
(2/3
5)
94
%
(30
/32
)
6%
(
2/3
2)
0
%
(0/3
2)
2
1
1
1
31
29
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
2
2
1
0
32
30
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
2
2
0
32
30
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
31
9
Issu
es w
ith
C
on
ditio
n
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
94
%
(33
/35
)
3%
(1
/35)
3
%
(1/3
5)
94%
(3
0/3
2)
6
%
(2/3
2)
0
%
(0/3
2)
W
heele
d m
obili
ty
W
he
ele
d
Mobili
ty
Descri
ptio
n
Not a
pplic
able
R
ecord
ed
Incom
ple
te
Not re
co
rde
d
74
%
(26
/35
) 23%
(8
/35
)
3%
(1
/35
)
0%
(0
/35)
72
%(2
3/3
2)
28
%
(9/3
2)
0
%
(0/3
2)
0
%
(0/3
2)
W
he
ele
d
Seatin
g
Descri
ptio
n
Not a
pplic
able
R
ecord
ed
Incom
ple
te
Not re
co
rde
d
74%
(26
/35
)
9%
(3
/35)
14%
(5
/35
)
3%
(1
/35)
72%
(23
/32
) 2
8%
(9
/32)
0
%
(0/3
2)
0
%
(0/3
2)
1
0
1
2
33
30
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
8 9
0
0
26
23
1
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
9
1
0
26
23
5
0
05
10
15
20
25
30
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
0
Assis
tan
ce
Requ
ire
d fo
r T
ran
sfe
rs
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
Incom
ple
te
74
%
(26
/35
) 2
0%
(7/3
5)
3
%
(1
/35)
14
%
(1
/35)
72
%
(23
/32
) 19%
(6
/32
)
9%
(3
/32
)
0%
(0
/32)
S
ourc
e o
f equ
ipm
ent
N
ot a
pplic
able
R
ecord
ed
Not re
co
rde
d
74
%
(26
/35
) 2
3%
(8/3
5)
3
%
(1
/35)
72
%
(23
/32
) 2
8%
(9
/32)
0
%
(0/3
2)
D
ate
of
issu
e
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
74
.3%
(26
/35
) 17
.1 %
(6
/35)
8.6
%
(3
/35)
72
%(2
3/3
2)
28
%
(9/3
2)
0
%
(0/3
2)
Issu
es w
ith
U
se
N
ot a
pplic
able
R
ecord
ed
Not re
co
rde
d
74
.29
%
(26
/35
) 1
7.1
4%
(6
/35)
8.5
7%
(3/3
5)
72
%
(23
/32
) 2
2%
(7
/32)
6
%
(2/3
2)
Is
su
es w
ith
N
ot a
pplic
able
8
9%
(31
/35
) 7
8%
(25
/32
) C
hart
no
t availa
ble
7
6
1 3
26
23
1
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
8 9
1
0
26
23
01
02
03
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
6 7
3
2
26
23
01
02
03
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
1
Co
nd
itio
n
Record
ed
Not re
co
rde
d
0%
(0
/35
) 1
1%
(4
/35)
16
%
(5/3
2)
6
%
(2/3
2)
Altern
ative s
eating
Seatin
g
Devic
e
Descri
ptio
n
No
t a
pp
lica
ble
R
eco
rde
d
No
t re
cord
ed
83
% (
29
/35
) 1
4%
(
5/3
5)
3
%
(1
/35
)
97
%(3
1/3
2)
3
% (
1/3
2)
0
% (
0/3
2)
A
ssis
tan
ce
Requ
ire
d fo
r T
ran
sfe
rs
No
t a
pp
lica
ble
R
eco
rde
d
No
t re
cord
ed
83
% (2
9/3
5)
8
.6%
(
3/3
5)
8
.6%
(
3/3
5)
97
% (
31
/32
) 3
% (1
/32
) 0
% (0
/32
)
S
ourc
e o
f E
quip
ment
No
t a
pp
lica
ble
R
eco
rde
d
No
t re
cord
ed
In
co
mp
lete
82
.86
%(2
9/3
5)
8
.57
% (3
/35
) 5
.71
% (2
/35
) 3
%
(
1/3
5)
97
% (
31
/32
) 3
% (1
/32
) 0
% (0
/32
) 0
% (0
/32
)
5
1
1
0
29
31
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
1
3
0
29
31
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3
1
2
0
29
31
1
0
01
02
03
04
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
2
Date
of Is
sue
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
83
%
(29/3
5)
11
%
(
4/3
5)
6
%
(2/3
5)
97
% (
31
/32
) 3
% (1
/32
) 0
% (0
/32
)
Is
su
es w
ith
U
se
Record
ed
Not re
co
rde
d
Not a
pplic
able
17
%
(2
/35)
9
%
(
4/3
5)
74
%
(29/3
5)
3%
(1
/32
) 0
% (0
/32
) 9
7%
(3
1/3
2)
Issu
es w
ith
C
on
ditio
n
Re
co
rde
d
No
t re
cord
ed
N
ot a
pp
lica
ble
3%
(1
/35
) 1
4%
(
5/3
5)
83
% (
29
/35)
3%
(1
/32
) 0
% (0
/32
) 9
7%
(3
1/3
2)
4
1
2
0
29
31
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
1 5
0
29
31
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
3
Mobili
ty E
quip
ment:
Gait
Aid
es
Eq
uip
men
t D
escrip
tio
n
No
t a
pp
lica
ble
R
eco
rde
d
Inco
mp
lete
80
% (
28
/35
) 1
7%
(
6/3
5)
3%
(1
/35
)
84
% (
27
/32
) 1
6%
(
5/3
2)
A
ssis
tance
R
equ
ire
d
No
t a
pp
lica
ble
R
eco
rde
d
No
t re
cord
ed
Inco
mp
lete
80
% (
28
/35
) 1
7%
(
6/3
5)
0
%
(0
/35
) 3
%
(1
/35
)
84
.38
% (
27
/32
) 9
.38
% (3
/32
) 6
.25
% (2
/32
) 0
%
(
0/3
2)
S
ou
rce
of
Eq
uip
men
t
No
t a
pp
lica
ble
R
eco
rde
d
No
t re
cord
ed
In
co
mp
lete
80
% (
28
/35
) 8
.6%
(3
/35
) 8
.6%
(3
/35
) 2
.6%
(1
/35
)
84
% (
27
/32
) 1
6%
(5
/32
) 0
%
(0/3
2)
0
%
(0/3
2)
6
5
0
0
28
27
1
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
6
3
0
2
28
27
1
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
3 5
3
0
28
27
1
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
4
Date
of
Issue
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
80
%
(28
/35
) 1
4%
(5/3
5)
6
%
(2
/35)
84
%
(27
/32
) 1
6%
(5/3
2)
0
%
(
0/3
2)
Is
su
es
with
Use
N
ot a
pplic
able
R
ecord
ed
N
ot re
co
rde
d
80
%
(28
/35
) 1
7%
(6/3
5)
3
%
(1
/35)
84
%
(27
/32
)
9%
(
3/3
2)
6
%
(2/3
2)
Is
su
es
with
C
on
ditio
n
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
0%
(0/3
5)
1%
(4/3
5)
89
% (
31
/35
)
3%
(1/3
2)
13
%
(
4/3
2)
84
%
(27
/32
)
5
5
2
0
28
27
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
6
3
1
2
28
27
0
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
0
1 4
4
31
27
0
0
01
02
03
04
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
leN
ot
Rec
ord
ed
32
5
Low
er
Lim
b O
rthotics
Low
er
Lim
b
Ort
ho
tics
Revie
w
Record
ed
Incom
ple
te
Not re
co
rde
d
Not a
pplic
able
23
%
(8/3
5)
0
%
(0/3
5)
6
%
(2/3
5)
71
% (
25
/35
)
34
%
(11
/32
)
3%
(1/3
2)
0
%
(
0/3
2)
63
%
(20
/32
)
T
ype
pre
scrib
ed
Record
ed
Not re
co
rde
d
Not a
pplic
able
20
%
(7/3
5)
9
%
(3/3
5)
71
% (
25
/35
)
37
.5%
(12
/32
)
0%
(0
/32
) 6
2.5
%(2
0/3
2)
T
ype c
hild
is
usin
g
Record
ed
Not re
co
rde
d
Not a
pplic
able
23
%
(8/3
5)
6
%
(2/3
5)
71%
(25
/35
)
37
.5%
(12
/32
)
0%
(0
/32
) 6
2.5
%(2
0/3
2)
8 1
1
2
0
25
20
0
1
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
7
12
3
0
25
20
0
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
8
12
2
0
25
20
0
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
6
Aim
of
ort
hotic
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
Incom
ple
te
71
% (
25
/35
) 1
7%
(
6/3
5)
9
%
(3/3
5)
3
%
(1/3
5)
63
%
(20
/32
) 3
1%
(
10
/32
)
6%
(2
/32
)
0%
(0
/32
)
S
ch
ed
ule
/Tim
e
Wo
rn
(ho
urs
/da
y)
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
Incom
ple
te
71
%(2
5/3
5)
22
.9%
(8/3
5)
2
.9%
(1/3
5)
2
.9%
(1/3
5)
63
%
(20
/32
) 2
8%
(9
/32
)
9%
(3
/32
)
0%
(0
/32
)
D
ura
tio
n
Worn
(n
um
be
r o
f m
on
ths)
Not a
pplic
able
N
ot re
co
rde
d
Record
ed
71
.4%
(25
/35
)
25
.7%
(9/3
5)
2.8
6%
(1/3
5)
63
%
(20
/32
) 2
8%
(9
/32
)
9%
(3
/32
)
6
10
3
2
25
20
1
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1 3
8 9
25
20
1
0
05
10
15
20
25
30
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1 3
9
9
25
20
0
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
7
Issu
es (
skin
ulc
era
tion,
co
mplia
nce)
Not a
pplic
able
R
ecord
ed
Not re
co
rde
d
71
% (
25
/35
) 2
3 %
(8
/35)
6
%
(2/3
5)
63
%
(20
/32
) 3
1%
(
10
/32
)
6%
(2
/32
)
8 10
2
2
25
20
0
0
05
10
15
20
25
30
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
8
Secti
on
Se
ven
: R
esu
lts
Results
D
iscu
ssio
n o
f R
esults w
ith
Prim
ary
Care
r
Record
ed
Not re
co
rde
d
Not
app
lica
ble
48
.6%
(17
/35
) 4
8.6
% (
17
/35
)
2.8
6%
(4
/35
)
78
%(2
5/3
2)
22
%
(7/3
2)
0
%
(0/3
2)
A
ctio
n/S
upp
or
t P
lan
–
Made w
ith
Prim
ary
Care
r
Record
ed
Not re
co
rde
d
Not
app
lica
ble
43
%
(1
5/3
5)
49
%
(1
7/3
5)
9
%
(3
/35
)
47
%(1
5/3
2)
31
%(1
0/3
2)
22
%
(7/3
2)
A
ctio
n/S
uppo
rt
Pla
n -
Made
with
Oth
er
Pro
vid
er
(e.g
. te
ach
er)
Record
ed
N
ot re
co
rde
d
Not
app
lica
ble
23
%
(
8/3
5)
37%
(
13/3
5)
49%
(
14/3
5)
22
%
(7
/32)
19
%
(6
/32)
59
%
(19
/32
)
17
25
14
7
4
0
01
02
03
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
15
15
17
7
3
10
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
8
7
13
6
14
19
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
32
9
Sectio
n E
ight:
Outc
om
es a
nd I
nte
rventions
Goal S
ett
ing a
nd O
utc
om
es
S
hort
Wri
tten
A
ssessm
en
t R
epo
rt
Record
ed
Not re
co
rde
d
Not a
pplic
able
51%
(1
8/3
5)
46
%
(16
/35
)
3%
(1
/35
)
91%
(2
9/3
2)
9%
(3
/32
)
0%
(0
/32
)
18
29
16
3
1
0
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
Refe
rral to
O
the
r A
gen
cie
s (
e.g
. p
ae
dia
tric
ian
, a
ud
iolo
gy)
Record
ed
Not re
co
rde
d
Not
app
lica
ble
37
%
(13
/35
) 3
1%
(
11
/35
) 3
1%
(
11
/35
)
56
%
(18
/32
) 3
%
(1/3
2)
41
%
(13
/32
)
R
efe
rral if X
-R
ay R
equ
ire
d
At tim
e o
f A
ssessm
en
t
Record
ed
N
ot re
co
rde
d
Not
app
lica
ble
6%
(2
/35)
20
%
(
7/3
5)
74%
(
26/3
5)
25
%
(8/3
2)
3
%
(1/3
2)
72
%
(23
/32
)
13
18
11
1
11
13
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
2
8
7
1
26
23
01
02
03
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
33
0
Goals
Se
t
Record
ed
N
ot re
co
rde
d
Not
app
lica
ble
34
% (
12
/35
) 5
4%
(19
/35
) 3%
(4
/35
)
31%
(1
0/3
2)
28%
(9
/32
) 41%
(1
3/3
2)
C
OP
M G
oa
ls
Record
ed
N
ot re
co
rde
d
N
ot
app
lica
ble
6%
(2
/35
) 8
0%
(28
/35
) 14%
(5
/35
)
6%
(2/3
2)
53%
(1
7/3
2)
41%
(1
3/3
2)
G
AS
goals
Not re
co
rde
d
N
ot a
pplic
able
Record
ed
83%
(29
/35
) 14%
(5
/35
)
3%
(2
/35
)
56%
(1
8/3
2)
41%
(1
3/3
2)
3%
(1
/32
)
12
10
19
9
4
13
05
10
15
20
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
2
2
28
17
5
13
01
02
03
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
1
1
29
18
5
13
01
02
03
04
0
20
13
20
14
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
33
1
Revie
w P
lan
Record
ed
N
ot re
co
rde
d
Not a
pplic
able
14%
(5
/35
) 23%
(
8/3
5)
63%
(22
/35
)
22%
(7
/32
)
6%
(2
/32
) 72%
(2
3/3
2)
O
utc
om
es
Record
ed
Record
ed
Not re
co
rde
d
In
com
ple
te
N
ot a
pplic
able
11%
(4
/35
) 9%
(3
/35)
20
%
(7/3
5)
60
% (
21
/35
)
16%
(5/3
2)
6%
(2/3
2)
0%
(0/3
2)
78%
(25
/32
)
O
utc
om
es
Ob
tain
ed
Not
app
lica
ble
Record
ed
Not re
co
rde
d
Incom
ple
te
60%
(21
/35
) 11%
(4/3
5)
14%
(5/3
5)
14%
(5/3
5)
78%
(25
/32
) 16%
(5/3
2)
6%
(2/3
2)
0%
(0/3
2)
5 7
8
2
22
23
01
02
03
0
20
13
20
14
No
tA
pp
licab
le
No
tR
eco
rded
Rec
ord
ed
4 5
3
2
21
25
7
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
4 5
5
2
21
25
5
0
01
02
03
0
20
13
20
14
Inco
mp
lete
No
t A
pp
licab
le
No
t R
eco
rded
Rec
ord
ed
33
2
Inte
rvention T
ype
2013
2014
Adap
tive/th
era
peu
tic a
ides/e
quip
ment
14
1
3
Fun
ctio
nal m
obili
ty tra
inin
g
14
2
2
Exerc
ise (
fitn
ess,
the
rapeutic)
9
5
Castin
g/s
plin
ting
2
2
Refe
rral to
exte
rna
l sourc
e
4
15
Oth
er
25
1
7
Mode o
f D
eliv
ery
2013
2014
Ind
ivid
ual S
essio
ns
26
3
0
Gro
up S
essio
ns
6
3
Inte
gra
ted
in
to e
ve
ryd
ay a
ctivitie
s
2
4
Sch
ool pro
gra
m
15
1
4
Hom
e p
rogra
m
5
14
Oth
er
11
1
1
051
01
52
02
53
0
20
13
20
14
051
01
52
02
53
03
5
20
13
20
14
33
3
3.1
1 C
OM
PA
RIS
ON
OF
SY
ST
EM
S A
SS
ES
SM
EN
T T
OO
L R
ES
UL
TS
BE
TW
EE
N 2
013
/2014
Ph
ysio
thera
py S
ys
tem
s A
sses
sm
en
t T
oo
l
R
esu
lts
of
Syst
em
Ass
ess
me
nt
Too
l Dis
cuss
ion
20
14
33
4
Ta
ble
of
Co
nte
nts
Su
mm
ary
of
SAT
20
14
.....
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
. 33
2
Rad
ar P
lot .
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
......
.. 3
32
Tab
le o
f C
om
po
nen
t Sc
ore
s ....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
......
.....
.. 3
33
Bar
Ch
art
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
.....
......
......
......
......
......
.....
33
4
Sco
res .
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
.....
......
.. 3
35
Item
an
d C
om
po
nen
t Sc
ore
s ...
......
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
.....
......
......
......
......
......
.....
......
......
......
......
......
.. 3
35
Ele
men
t an
d It
em S
core
s ...
......
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
.....
......
. 33
7
Stre
ngt
hs .
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
......
. 34
2
Wea
knes
ses
......
......
......
......
......
......
.....
......
......
......
......
......
......
......
......
......
.....
......
......
......
......
.....
......
......
......
......
......
.....
......
......
......
......
......
34
4
Exam
ple
s o
f SA
T C
om
po
nen
t an
d It
em d
iscu
ssio
ns:
Sco
res
and
Co
mm
ents
fo
r 2
01
4 ..
......
.....
......
......
......
......
......
......
......
......
......
......
......
. 34
8
33
5
7.7
7
6.5
2.5
6.4
5
4.4
2.6
2.1
1
.2
4.7
012345678D
eliv
ery
Syst
em D
esig
n
Info
rmat
ion
Sys
tem
s an
d D
ecis
ion
Sup
po
rt
Self
-Man
agem
ent
Sup
po
rtLi
nks
wit
h t
he
com
mu
nit
y, o
ther
hea
lth
serv
ices
an
d o
ther
ser
vice
s an
dre
sou
rces
Org
aniz
atio
nal
infl
uen
ce a
nd
Inte
grat
ion
Syst
em
s A
sse
ssm
en
t To
ol R
esu
lts
20
14
20
13
33
6
T
able
of
Co
mp
on
en
t Sc
ore
s Co
mp
on
en
t Le
vel o
f Su
pp
ort
20
13
2
01
4
Del
iver
y Sy
stem
Des
ign
4
.35
BA
SIC
-A
HT
7
.7 G
OO
D -
AH
T
Info
rmat
ion
Sys
tem
s an
d D
ecis
ion
Su
pp
ort
2
.6 L
IMIT
ED
7 G
OO
D
Self
-man
agem
ent
Sup
po
rt
2.1
LIM
ITED
6
.5 G
OO
D
Lin
ks w
ith
th
e co
mm
un
ity,
oth
er h
ealt
h s
ervi
ces
and
oth
er s
ervi
ces
and
res
ou
rces
1
.2 L
IMIT
ED
2.5
LIM
ITED
Org
anis
atio
nal
infl
uen
ce a
nd
inte
grat
ion
4
.7 B
ASI
C
6.4
5 G
OO
D
KEY
: 0-2
No
or
Lim
ited
Su
pp
ort
3-5
Bas
ic S
up
po
rt
6
-8 G
oo
d S
up
po
rt
9
-11
Fu
lly D
evel
op
ed
Sup
po
rt
20
13
Re
sult
s in
Red
2
01
4 R
esu
lts
in B
lack
33
7
Bar
Ch
art
K
EY: 0
-2 N
o o
r Li
mit
ed S
up
po
rt
3-5
Bas
ic S
up
po
rt
6
-8 G
oo
d S
up
po
rt
9
-11
Fu
lly D
evel
op
ed S
up
po
rt
Del
iver
y Sy
stem
Des
ign
Info
rmat
ion
Sys
tem
san
d D
ecis
ion
Su
pp
ort
Self
-Man
agem
ent
Sup
po
rt
Lin
ks w
ith
th
eco
mm
un
ity,
oth
erh
ealt
h s
ervi
ces
and
oth
er s
ervi
ces
and
reso
urc
es
Org
aniz
atio
nal
infl
uen
ce a
nd
Inte
grat
ion
20
14
7.7
76
.52
.56
.45
20
13
4.4
2.6
2.1
1.2
4.7
0123456789
Level of Support
Co
mp
on
en
ts
Syst
em
s A
sse
ssm
en
t To
ol R
esu
lts
20
14
20
13
33
8
Sco
res
Ite
m a
nd
Co
mp
on
en
t Sc
ore
s
Co
mp
on
en
t O
ne
: D
eliv
ery
Sys
tem
De
sign
2
01
4 A
HT
7.6
9 G
OO
D
20
13
AH
T 4
.35
B
ASI
C
1.1
Tea
m S
tru
ctu
re a
nd
Fu
nct
ion
A
HT
8.6
7
P
T
5.6
5
.6
1.2
Clin
ical
Lea
der
ship
A
HT
3.7
0
P
T
2.3
0
1.3
Ap
po
intm
ents
an
d S
ched
ulin
g A
HT
10
3
.7
P
T
10
0
1.4
Car
e P
lan
nin
g A
HT
7
3.5
PT
7
NA
1.5
Sys
tem
atic
Ap
pro
ach
to
Fo
llow
-U
p
AH
T 9
6
.25
P
T
NA
N
A
1.6
Co
nti
nu
ity
of
Car
e A
HT
8
5
PT
8
NA
1.7
Clie
nt
Acc
ess/
Cu
ltu
ral C
om
pet
ence
A
HT
7
3.7
5
1.8
Ph
ysic
al in
fras
tru
ctu
re, s
up
plie
s an
d e
qu
ipm
ent
AH
T 7
.3 6
Co
mp
on
en
t Tw
o:
Info
rmat
ion
Sys
tem
s an
d D
eci
sio
n M
akin
g
2
01
4 A
HT
7 G
OO
D
2
01
3 A
HT
2.6
LI
MIT
ED
2.1
Mai
nte
nan
ce a
nd
Use
of
Ele
ctro
nic
Clie
nt
List
A
HT
8.5
2.7
5
PT
8.5
N
A
2.2
Evi
den
ce B
ased
Gu
idel
ine
s A
HT
6
2
PT
6
N
A
Co
mp
on
en
t Th
ree
: Se
lf-m
anag
em
ent
20
14
AH
T 6
.5 G
OO
D
2
01
3 A
HT
2.1
LI
MIT
ED
3.1
Ass
essm
ent
and
do
cum
en
tati
on
A
HT
6.5
3
.25
3.2
Sel
f-m
anag
emen
t ed
uca
tio
n a
nd
su
pp
ort
, beh
avio
ral r
isk
red
uct
ion
an
d p
eer
sup
po
rt
AH
T 6
.4
1.5
33
9
Co
mp
on
en
t Fo
ur:
Lin
ks w
ith
th
e c
om
mu
nit
y, o
the
r h
eal
th s
erv
ices
,
20
14
AH
T 2
.45
LIM
ITED
20
13
AH
T1.2
LI
MIT
ED
and
oth
er
serv
ice
s an
d r
eso
urc
es
4.1
Co
mm
un
icat
ion
an
d C
oo
per
atio
n o
n G
ove
rnan
ce a
nd
Op
erat
ion
of
the
Hea
lth
se
rvic
e a
nd
Oth
er C
om
mu
nit
y B
ased
Org
anis
atio
ns
and
Pro
gram
s A
HT
3.5
1
.33
P
T 3
.5 N
A
4.2
Co
mm
un
icat
ion
an
d C
oo
per
atio
n o
n G
ove
rnan
ce a
nd
Op
erat
ion
o
f th
e H
ealt
h s
ervi
ce a
nd
Oth
er C
om
mu
nit
y B
ased
Org
anis
atio
ns
a
nd
Pro
gram
s
AH
T 3
1 .6
7
4.3
Wo
rkin
g O
ut
in t
he
Co
mm
un
ity
A
HT
3.
1.6
7
4.4
Co
mm
un
icat
ion
an
d c
oo
per
atio
n o
n r
egio
nal
hea
lth
pla
nn
ing
and
dev
elo
pm
ent
of
hea
lth
res
ou
rce
s A
HT
0
0
Co
mp
on
en
t Fi
ve:
Org
anis
atio
nal
infl
ue
nce
an
d in
tegr
atio
n
2
01
4 A
HT
6 B
ASI
C
20
13
AH
T 2
.9LI
MIT
ED
5.1
Org
anis
atio
nal
co
mm
itm
en
t 6
.8
4
.67
5.2
Qu
alit
y im
pro
vem
ent
stra
tegi
es
6.2
5
0.7
5
5.3
Inte
grat
ion
of
hea
lth
sys
tem
co
mp
on
ents
5
1
K
EY: 0
-2 N
o o
r Li
mit
ed S
up
po
rt
3
-5 B
asic
Su
pp
ort
6-8
Go
od
Su
pp
ort
9-1
1 F
ully
Dev
elo
ped
Su
pp
ort
2
01
3 R
esu
lts
in R
ed
20
14
Re
sult
s in
Bla
ck
34
0
E
lem
en
t an
d It
em
Sco
res
Co
mp
on
en
t O
ne
: D
eliv
ery
Sys
tem
De
sign
2
01
4 A
HT
7.6
9 G
OO
D
20
13
AH
T 4
.35
BA
SIC
P
T
7.0
3 G
OO
D
P
T 4
.04
BA
SIC
1.1
Tea
m S
tru
ctu
re a
nd
Fu
nct
ion
A
HT
8.6
GO
OD
7
PT
5.6
BA
SIC
5.6
i.
Tea
m a
pp
roac
h
11
5
1
1
8
ii.
Lea
der
ship
1
0
9
0
0
iii.
Def
init
ion
of
role
s an
d r
esp
on
sib
iliti
es a
nd
lin
es o
f re
po
rtin
g
9
7
0
5
iv.
Co
mm
un
icat
ion
an
d c
oh
esio
n
10
6
1
0
8
v.
Dev
elo
pin
g te
am m
emb
ers’
ski
lls a
nd
ro
les
3
8
7
7
(S
up
po
rt 1
1 S
trat
egy
3)
(Su
pp
ort
11
Str
ate
gy 7
)
1.2
Clin
ical
Lea
der
ship
A
HT
3.7
GO
OD
0
P
T 2
.3 L
IMIT
ED
0
i.
Clin
ical
Lea
der
ship
0
0
0
0
ii.
Co
ntr
ibu
tio
n
4
0
0
0
iii.
Kn
ow
led
ge a
bo
ut
rese
arch
evi
den
ce
7
0
7
0
1.3
Ap
po
intm
ents
an
d S
ched
ulin
g A
HT
10
FU
LLY
DEV
3.7
P
T 1
0 F
ULL
Y D
EV
NA
i.
Ap
po
intm
ent
syst
em
10
5
1
0
NA
ii.
Sp
ecif
ic c
linic
s an
d/o
r se
ssio
ns
10
4
1
0
NA
iii.
Pla
nn
ing
and
sch
ed
ulin
g 1
0
2
10
N
A
1.4
Car
e P
lan
nin
g A
HT
7 G
OO
D 3
.5
PT
7 G
OO
D
NA
i.
Ro
uti
ne
pra
ctic
e
9
4
9
N
A
ii.
Ele
me
nts
of
care
pla
nn
ing
5
3
5
NA
1.5
Sys
tem
atic
Ap
pro
ach
to
Fo
llow
-U
p
AH
T 9
FU
LLY
DEV
6.2
5
PT
9 F
ULL
Y D
EV
NA
i.
Elec
tro
nic
Re
min
der
s
6
5
?6
N
A
34
1
ii.
Reg
ula
r se
rvic
es a
nd
rev
iew
s
9
3
10
N
A
iii. A
bn
orm
al a
sses
smen
t fi
nd
ings
1
1
9
11
N
A
iv. H
ealt
h s
ervi
ce s
taff
an
d c
om
mu
nit
y kn
ow
led
ge a
nd
res
ou
rce
s
use
d t
o e
nh
ance
fo
llow
up
1
0
8
10
N
A
1.6
Co
nti
nu
ity
of
Car
e A
HT
8 G
OO
D 3
.5
PT
8 G
OO
D
NA
i.
Del
iver
y sy
stem
des
ign
ed t
o e
nh
ance
co
nti
nu
ity
of
care
9
4
9
N
A
ii.
Co
mm
un
icat
ion
bet
we
en h
osp
ital
an
d h
ealt
h s
ervi
ce
7
3
7
NA
1.7
Clie
nt
Acc
ess/
Cu
ltu
ral C
om
pet
ence
A
HT
7
GO
OD
3.7
5
P
T 7
GO
OD
N
A
i.
Ph
ysic
al, c
om
mu
nic
atio
n a
nd
tra
nsp
ort
bar
rier
s to
acc
ess
7
3
7
NA
ii.
Staf
fin
g
8
4
8
N
A
iii.
Gen
der
-rel
ated
issu
es
7
7
7
NA
iv. I
nd
igen
ou
s kn
ow
led
ge a
nd
AH
W e
xper
ien
ce
6
1
6
NA
1.8
Ph
ysic
al in
fras
tru
ctu
re, s
up
plie
s an
d e
qu
ipm
ent
AH
T 7
.3 G
OO
D 6
PT
7.3
GO
OD
N
A
i.
Ph
ysic
al in
fras
tru
ctu
re
6
6
6
NA
ii.
Su
pp
lies
of
con
sum
able
s 1
0
8
1
0
NA
iii.
Eq
uip
men
t
6
4
6
NA
Co
mp
on
en
t Tw
o:
Info
rmat
ion
Sys
tem
s an
d D
eci
sio
n M
akin
g
2
01
4 A
HT
7 G
OO
D
20
13
AH
T 2
.6
LIM
ITED
2.1
Mai
nte
nan
ce a
nd
Use
of
Ele
ctro
nic
Clie
nt
List
A
HT
8.5
GO
OD
2.7
5
PT
8.5
GO
OD
N
A
i.
Ele
ctro
nic
list
of
clie
nts
1
0
9
1
0
ii.
Reg
ula
r cl
ien
ts
10
1
10
iii.
Re
gula
r cl
ien
ts w
ith
sp
ecif
ic c
on
dit
ion
s
7
1
7
iv.
Rea
chin
g cl
ien
t gr
ou
ps
7
0
7
2.2
Evi
den
ce B
ased
Gu
idel
ine
s A
HT
6 B
ASI
C 2
PT
6 G
OO
D
34
2
NA
i.
Sp
ecia
list
– ge
ner
alis
t co
llab
ora
tio
n
6
2
6
Co
mp
on
en
t Th
ree
: Se
lf-m
anag
em
ent
Sup
po
rt
20
14
6.5
AH
T G
OO
D
20
13
AH
T 2
.11
LI
MIT
ED
3.1
Ass
essm
ent
and
do
cum
en
tati
on
A
HT
6.5
GO
OD
3.2
5
i.
Sel
f-m
anag
emen
t fo
r cl
ien
ts in
th
is a
rea
is c
entr
al a
nd
str
ateg
ic p
art
of
hea
lth
ca
re
4
6
ii.
Sel
f-m
anag
em
ent
nee
ds
for
clie
nts
in t
his
are
a ar
e ro
uti
nel
y
ass
esse
d a
nd
do
cum
ente
d in
a s
tan
dar
d w
ay
4
0
iii.
Clie
nts
/fam
ilies
in t
his
are
a ar
e ro
uti
nel
y en
gage
d in
th
e
as
sess
men
t an
d d
ocu
men
tati
on
pro
cess
es.
9
3
iv.
Use
of
clie
nt
hel
d r
eco
rds
to p
rom
ote
sel
f-m
anag
em
ent
par
t o
f
ro
uti
ne
pra
ctic
e in
th
is a
rea
9
4
3.2
Sel
f-m
anag
emen
t ed
uca
tio
n a
nd
su
pp
ort
, beh
avio
ral r
isk
red
uct
ion
an
d p
eer
sup
po
rt
AH
T 6
.4 G
OO
D 1
.5
i.
Sel
f-m
anag
emen
t ed
uca
tio
n a
nd
su
pp
ort
ro
uti
ne
pro
vid
ed b
y st
aff
wit
h
reco
gniz
ed t
rain
ing
and
ski
lls in
sel
f-m
anag
em
ent
sup
po
rt
10
0
ii.
Invo
lvem
ent
of
fam
ilies
in s
elf-
man
age
men
t ed
uca
tio
n
9
2
iii.
Beh
avio
ura
l ris
k re
du
ctio
n
2
0
iv.
Ed
uca
tio
n r
eso
urc
es
3
0
v.
Co
mm
un
ity
pee
r su
pp
ort
8
4
Co
mp
on
en
t Fo
ur:
Lin
ks w
ith
th
e c
om
mu
nit
y, o
the
r h
eal
th s
erv
ices
,
20
14
AH
T 2
.45
LIM
ITED
20
13
AH
T 1
.2
LIM
ITED
an
d o
the
r se
rvic
es
and
re
sou
rce
s
34
3
4.1
Co
mm
un
icat
ion
an
d C
oo
per
atio
n o
n G
ove
rnan
ce a
nd
Op
erat
ion
of
the
Hea
lth
se
rvic
e a
nd
Oth
er C
om
mu
nit
y B
ased
Org
anis
atio
ns
and
Pro
gram
s A
HT
3.5
BA
SIC
1.3
3
PT
3.5
NA
i.
Co
mm
un
ity
inp
ut
to h
eal
th s
ervi
ce g
ove
rnan
ce
0 0
0
ii.
Invo
lve
men
t o
f se
rvic
e p
op
ula
tio
n
0 0
0
iii.
Clie
nt
sati
sfac
tio
n w
ith
th
e h
ealt
h s
ervi
ce
7 4
7
iv. F
orm
al a
gree
men
ts b
etw
een
th
e h
ealt
h s
ervi
ce a
nd
mai
nst
ream
p
rim
ary
care
ser
vice
s an
d o
ther
hea
lth
an
d c
om
mu
nit
y se
rvic
es
3 0
3
v. P
artn
ersh
ips
wit
h r
ele
van
t co
mm
un
ity
gro
up
s 6
4
6
vi.
He
alth
ori
enta
tio
n
5 0
5
4.2
Co
mm
un
icat
ion
an
d C
oo
per
atio
n o
n G
ove
rnan
ce a
nd
Op
erat
ion
o
f th
e H
ealt
h s
ervi
ce a
nd
Oth
er C
om
mu
nit
y B
ased
Org
anis
atio
ns
a
nd
Pro
gram
s
AH
T 3
BA
SIC
1
.67
i.
Th
ere
are
syst
emat
ic a
rran
gem
ents
in p
lace
to
lin
k in
div
idu
al
clie
nts
in t
his
are
a to
ou
tsid
e h
eal
th a
nd
hea
lth
-rel
ated
ser
vice
s
5
5
ii.
Res
ou
rce
dir
ecto
ry t
hat
su
pp
ort
s th
ese
arra
nge
men
ts is
c
om
pre
he
nsi
ve, r
egu
larl
y u
pd
ated
an
d e
asily
acc
essi
ble
.
0
0
iii.
Lin
kage
arr
ange
men
ts r
elat
ing
to t
hes
e re
sou
rce
s ar
e w
ell-
in
tegr
ated
into
sta
ff o
rien
tati
on
an
d in
-ser
vice
tra
inin
g p
rogr
ams
4
0
4.3
Wo
rkin
g O
ut
in t
he
Co
mm
un
ity
A
HT
3.3
BA
SIC
1
.67
i.
Staf
f en
gage
men
t 1
0
1
ii.
Des
ign
of
com
mu
nit
y ac
tivi
ties
0
4
iii.
Inte
grat
ion
0
0
4.4
Co
mm
un
icat
ion
an
d c
oo
per
atio
n o
n r
egio
nal
hea
lth
pla
nn
ing
and
dev
elo
pm
ent
of
hea
lth
res
ou
rces
A
HT
0 N
O S
UP
PO
RT
0
i.
Reg
ion
al p
lan
nin
g
0
0
ii.
Hea
lth
re
sou
rces
0
0
iii.
Loca
l co
mm
un
ity
pla
ns
0
0
34
4
Co
mp
on
en
t Fi
ve:
Org
anis
atio
nal
infl
ue
nce
an
d in
tegr
atio
n
2
01
4 A
HT
6 B
ASI
C
2
01
3 A
HT
2.9
LIM
ITED
5.1
Org
anis
atio
nal
co
mm
itm
en
t 6
.8 G
OO
D 4
.67
i.
Stra
tegi
c an
d b
usi
nes
s p
lan
s
7
1
ii.
Fun
din
g
1
0
iii.
Staf
fin
g
5
8
PT
4 N
A
iv. S
taff
rel
atio
nsh
ips
and
mo
rale
9
8
v. T
rain
ing
11
6
vi.
Serv
ice
del
iver
y st
rate
gies
8
5
5.2
Qu
alit
y im
pro
vem
ent
stra
tegi
es
6.2
5 G
OO
D
0.7
5
i.
Sen
ior
staf
f su
pp
ort
fo
r q
ual
ity
imp
rove
men
t 1
0
3
ii.
Qu
alit
y im
pro
vem
ent
pro
cess
es
10
0
iii.
He
alth
ser
vice
per
form
ance
rep
ort
ing
1
0
iv. P
roce
sses
fo
r d
ealin
g w
ith
err
ors
an
d p
rob
lem
s
4
0
5.3
Inte
grat
ion
of
hea
lth
sys
tem
co
mp
on
ents
5
BA
SIC
1
i.
Inte
grat
ion
5
1
K
EY: 0
-2 N
o o
r Li
mit
ed S
up
po
rt
3
-5 B
asic
Su
pp
ort
6-8
Go
od
Su
pp
ort
9-1
1 F
ully
Dev
elo
ped
Su
pp
ort
2
01
3 R
esu
lts
in R
ed
20
14
Re
sult
s in
Bla
ck
34
5
S
tre
ng
ths
Ta
ble
of
Iden
tifi
ed
Str
engt
h S
core
s
Are
as o
f St
ren
gth
Ide
nti
fie
d 2
01
3
20
13
2
01
4
Del
iver
y Sy
stem
Des
ign
1.3
i
Team
ap
pro
ach
AH
T 5
AH
T 1
1
PT
8
PT
1
1
1.1
ii
Team
Lea
der
ship
A
HT
9
A
HT
10
P
T
0
P
T
0
1.1
iv C
om
mu
nic
atio
n a
nd
co
hes
ion
A
HT
6
A
HT
10
P
T
8
P
T
10
1.1
v
Dev
elo
pin
g te
am m
emb
er’s
ski
lls a
nd
ro
les
AH
T 8
AH
T
3*
PT
7
P
T
7*
1.5
iii
Ab
no
rmal
ass
essm
ent
fin
din
gs
AH
T 9
AH
T 1
1
1.5
iv H
eal
th s
ervi
ce s
taff
an
d c
om
mu
nit
y kn
ow
led
ge a
nd
res
ou
rces
use
d t
o e
nh
ance
fo
llow
up
A
HT
8
A
HT
10
1.7
iii
Gen
der
– r
elat
ed is
sues
A
HT
7
A
HT
7
1.8
i
Ph
ysic
al in
fra
stru
ctu
re
AH
T 6
AH
T
6
1.8
ii
Sup
plie
s o
f co
nsu
mab
les
AH
T 8
AH
T 1
0
2 In
form
atio
n S
yste
ms
and
Dec
isio
n S
up
po
rt
2.1
i
Ele
ctro
nic
list
s o
f cl
ien
ts a
vaila
ble
A
HT
9
A
HT
10
5 O
rgan
isat
ion
al in
flu
ence
an
d in
tegr
atio
n
5.1
ii
Staf
fin
g A
HT
8
A
HT
5
P
T
4
5.1
iv S
taff
rel
atio
nsh
ips
and
mo
rale
A
HT
8
A
HT
9
K
EY: 0
-2 N
o o
r Li
mit
ed S
up
po
rt
3
-5 B
asic
Su
pp
ort
6-8
Go
od
Su
pp
ort
9-1
1 F
ully
Dev
elo
ped
Su
pp
ort
2
01
3 R
esu
lts
in R
ed
2
01
4 R
esu
lts
in B
lack
34
6
T
able
of
Ide
nti
fied
Str
engt
h A
reas
20
13
Str
en
gth
s (G
oo
d a
nd
Fu
lly D
eve
lop
ed
Su
pp
ort
)
20
14
Str
en
gth
s (G
oo
d a
nd
Fu
lly D
eve
lop
ed
Su
pp
ort
)
Team
ap
pro
ach
Team
lead
ersh
ip s
tru
ctu
re w
ith
in e
nti
re A
HT
Co
mm
un
icat
ion
an
d c
oh
esio
n (
PT
grea
ter
than
en
tire
AH
T b
ut
bo
th in
th
e go
od
cat
ego
ry)
Staf
fin
g an
d s
taff
rel
atio
nsh
ips
and
mo
rale
.
Sup
po
rt f
or
dev
elo
pin
g te
am m
emb
er’s
ski
lls a
nd
ro
les
Gen
eral
tra
inin
g an
d in
serv
ice
op
po
rtu
nit
ies
Ab
ility
to
ide
nti
fy a
bn
orm
al f
ind
ings
Ab
ility
to
fo
llow
-up
on
ab
no
rmal
fin
din
gs u
sin
g st
aff
and
co
mm
un
ity
kno
wle
dge
.
Iden
tifi
cati
on
an
d p
roce
ss t
o a
dd
ress
ge
nd
er-r
elat
ed is
sues
Ava
ilab
ility
of
elec
tro
nic
list
of
clie
nts
Ava
ilab
ility
of
ph
ysic
al in
fras
tru
ctu
re
Ava
ilab
ility
of
con
sum
able
s
Team
ap
pro
ach
Team
lead
ersh
ip s
tru
ctu
re w
ith
in e
nti
re A
HT
Co
mm
un
icat
ion
an
d c
oh
esio
n (
PT
grea
ter
than
en
tire
AH
T b
ut
bo
th
in t
he
goo
d c
ateg
ory
)
Staf
fin
g an
d s
taff
rel
atio
nsh
ips
and
mo
rale
Exce
llen
t Su
pp
ort
fo
r d
evel
op
ing
team
mem
ber
’s s
kills
an
d r
ole
s
Gen
eral
tra
inin
g an
d in
serv
ice
op
po
rtu
nit
ies
Ava
ilab
ility
of
elec
tro
nic
list
of
clie
nts
Ab
ility
to
ide
nti
fy a
bn
orm
al f
ind
ings
Ab
ility
to
fo
llow
-up
on
ab
no
rmal
fin
din
gs u
sin
g st
aff
and
co
mm
un
ity
kno
wle
dge
.
Ava
ilab
ility
of
con
sum
able
s
Ap
po
intm
ents
an
d s
ched
ulin
g fl
exi
ble
an
d p
art
of
rou
tin
e p
ract
ice
Ap
po
intm
ent
pla
nn
ing
and
sch
edu
ling
acti
viti
es is
ro
uti
ne
Car
e p
lan
nin
g is
ro
uti
ne
Co
nti
nu
ity
of
care
wit
hin
th
e te
am a
nd
wit
h s
om
e a
gen
cies
Res
pe
ct f
or
cult
ura
l kn
ow
led
ge.
KEY
: 0-2
No
or
Lim
ited
Su
pp
ort
3-5
Bas
ic S
up
po
rt
6
-8 G
oo
d S
up
po
rt
9
-11
Fu
lly D
evel
op
ed
Sup
po
rt
20
13
Re
sult
s in
Red
2
01
4 N
ew R
esu
lts
in B
lack
2
01
3 it
ems
that
are
re
pea
ted
in 2
01
4 a
re m
arke
d in
blu
e
34
7
W
ea
kn
ess
es
T
able
of
Ide
nti
fied
Wea
knes
s Sc
ore
s
Are
as o
f W
eak
ne
ss id
en
tifi
ed
20
13
2
01
3
20
14
1. D
eliv
ery
Syst
em D
esig
n
1.4
i
Clin
ical
Lea
der
ship
est
ablis
hm
ent
ii
Clin
ical
Lea
der
ship
co
ntr
ibu
tio
n
iii
Clin
ical
Lea
der
ship
co
ntr
ibu
tio
n t
o k
no
wle
dge
ab
ou
t re
sear
ch e
vid
ence
AH
T 0
PT0
AH
T 0
PT0
A
HT
0 P
T0
A
HT
4 P
T 0
A
HT
0 P
T0
A
HT
7 P
T 7
1.3
iii
Ap
po
intm
ents
Pla
nn
ing
and
sch
edu
ling
com
mu
nit
y-b
ased
act
ivit
ies
rou
tin
e p
ract
ice
AH
T 2
A
HT
10
1.7
iv
Clie
nt
acce
ss/c
ult
ura
l co
mp
eten
ce -
Ind
igen
ou
s kn
ow
led
ge a
nd
exp
eri
ence
A
HT
1
AH
T 6
2 In
form
atio
n S
yste
ms
and
Dec
isio
n S
up
po
rt
2.1
ii M
ain
ten
ance
an
d u
se o
f el
ect
ron
ic c
lien
t lis
t -
regu
lar
clie
nt
list
rou
tin
ely
use
d t
o id
enti
fy
sup
po
rt s
ervi
ce p
lan
nin
g an
d d
eliv
ery
AH
T 1
A
HT
10
2.1
iii M
ain
ten
ance
an
d u
se o
f el
ect
ron
ic c
lien
t lis
t -
clie
nt
wit
h s
pec
ific
nee
ds
list
rou
tin
ely
use
d
to id
enti
fy s
up
po
rt s
ervi
ce p
lan
nin
g an
d d
eliv
ery
AH
T 1
A
HT
7
2.1
iv M
ain
ten
ance
an
d u
se o
f el
ect
ron
ic c
lien
t lis
t -
str
ateg
ies
in p
lace
to
rea
ch c
lien
t gr
ou
ps
par
t o
f ro
uti
ne
pra
ctic
e
AH
T 0
A
HT
7
2.2
i
Evid
en
ce b
ased
gu
idel
ine
s –
stra
tegi
c ap
pro
ach
to
sp
ecia
list-
gen
eral
ist
colla
bo
rati
on
A
HT
2
AH
T 6
3 S
elf-
man
age
men
t Su
pp
ort
3.1
ii
Ass
essm
ent
and
do
cum
en
tati
on
-ro
uti
ne
asse
ssm
ent
and
sta
nd
ard
do
cum
enta
tio
n o
f se
lf
–man
agem
ent
nee
ds
of
clie
nts
A
HT
0
AH
T 4
3.2
i
Ro
uti
ne
pro
visi
on
of
self
-man
age
men
t ed
uca
tio
n b
y st
aff
wit
h r
eco
gniz
ed t
rain
ing
and
sk
ills
in s
elf
– m
anag
em
ent
sup
po
rt
AH
T 0
A
HT
10
3.2
ii
Ro
uti
ne
invo
lvem
ent
of
fam
ilies
in s
elf-
man
age
men
t ed
uca
tio
n
AH
T 2
A
HT
9
3.2
iii
Syst
emat
ic a
pp
roac
h t
o b
ehav
ior
chan
ge in
terv
enti
on
s fo
r ri
sk r
edu
ctio
n
AH
T 0
A
HT
2
3.2
iv R
ou
tin
e u
se o
f go
od
qu
alit
y ed
uca
tio
n r
eso
urc
es u
sed
fo
r cl
ien
ts a
nd
fam
ilies
to
su
pp
ort
b
ehav
iou
ral r
isk
red
uct
ion
in s
elf-
man
age
men
t A
HT
0
AH
T 3
4 L
inks
wit
h t
he
co
mm
un
ity,
oth
er h
ealt
h s
ervi
ces,
an
d o
ther
ser
vice
s an
d r
eso
urc
es
34
8
4.1
i.–
Co
mm
un
ity
inp
ut
to h
ealt
h s
ervi
ce g
ove
rnan
ce
AH
T 0
A
HT
0
4.1
ii
Co
mm
un
icat
ion
an
d c
oo
per
atio
n o
n g
ove
rnan
ce a
nd
op
erat
ion
of
the
hea
lth
ser
vice
an
d
oth
er c
om
mu
nit
y b
ased
org
anis
atio
ns
and
pro
gram
s –
invo
lvem
ent
of
serv
ice
po
pu
lati
on
A
HT
0
AH
T 0
4.1
iv F
orm
al a
gree
men
ts b
etw
een
hea
lth
ser
vice
an
d
m
ain
stre
am p
rim
ary
care
ser
vice
s A
HT
0
AH
T 3
4.1
vi
Hea
lth
ori
enta
tio
n in
co
mm
un
ity,
so
cial
, ed
uca
tio
n a
nd
oth
er p
rogr
ams
AH
T 0
A
HT
3
4.2
ii
Reg
ula
rly
up
dat
ed, a
cce
ssib
le a
nd
wid
ely
use
d r
eso
urc
e d
irec
tory
A
HT
0
AH
T 0
4.2
iii
Lin
kage
arr
ange
men
ts in
tegr
atin
g re
sou
rces
into
sta
ff o
rien
tati
on
an
d in
serv
ice
trai
nin
g p
rogr
ams
AH
T 0
A
HT
4
4.3
i
Staf
f en
gage
men
t in
co
mm
un
ity
he
alth
pro
mo
tio
n d
eve
lop
men
t ac
tivi
ties
A
HT
1
AH
T 1
0
4.3
iii
Inte
grat
ion
of
com
mu
nit
y ac
tivi
ties
in h
ealt
h s
ervi
ce p
rogr
am
AH
T 0
A
HT
0
4.4
i
Hea
lth
ser
vice
sta
ff a
ctiv
ely
enga
ged
in a
nd
pro
mo
tin
g re
gio
nal
pla
nn
ing
AH
T 0
A
HT
0
4.4
ii
Hea
lth
ser
vice
sta
ff a
ctiv
ely
con
trib
ute
to
th
e d
evel
op
men
t an
d p
rom
oti
on
of
stan
dar
d
reso
urc
es f
or
hea
lth
ser
vice
s w
ith
reg
ion
-wid
e re
leva
nce
. A
HT
0
AH
T 0
4.5
iii L
oca
l co
mm
un
ity
pla
ns
syst
emat
ical
ly u
sed
to
info
rm r
egi
on
al p
lan
nin
g p
roce
sses
an
d
allo
cati
on
of
reso
urc
es
AH
T 0
A
HT
0
5 O
rgan
isat
ion
al in
flu
ence
an
d in
tegr
atio
n
5.1
i R
efle
ctio
n o
f co
mm
itm
en
t to
clie
nt
gro
up
in s
trat
egic
an
d b
usi
nes
s p
lan
s A
HT
1
AH
T 7
5.1
ii S
pec
ific
ad
eq
uat
e an
d lo
ng
term
fu
nd
ing
for
this
are
a
AH
T 0
A
HT
1
5.2
ii Q
ual
ity
imp
rove
men
t p
roce
sses
sys
tem
atic
A
HT
0
AH
T 1
0
5.2
iii E
lect
ron
ic c
lien
t in
form
atio
n u
sed
ro
uti
nel
y fo
r h
ealt
h s
ervi
ce p
erfo
rman
ce r
epo
rtin
g A
HT
0
AH
T 1
5.3
iv
Syst
emat
ic p
roce
sses
fo
r d
ealin
g w
ith
err
ors
an
d p
rob
lem
s A
HT
0
AH
T 4
K
EY: 0
-2 N
o o
r Li
mit
ed S
up
po
rt
3
-5 B
asic
Su
pp
ort
6-8
Go
od
Su
pp
ort
9-1
1 F
ully
Dev
elo
ped
Su
pp
ort
2
01
3 R
esu
lts
in R
ed
20
14
Re
sult
s in
Bla
ck
34
9
Tab
le o
f Id
en
tifi
ed
We
akn
ess
Are
as
20
13
We
akn
ess
es
(No
or
Lim
ite
d S
up
po
rt):
2
01
4 W
eak
ne
sse
s (N
o o
r Li
mit
ed
Su
pp
ort
):
Ab
sen
ce o
f cl
inic
al le
ader
ship
Lack
of
cult
ura
l acc
ess
com
pet
ence
in a
vaila
bili
ty o
f In
dig
eno
us
hea
lth
wo
rke
rs
Ab
sen
ce o
f se
lf-m
anag
em
ent
trai
nin
g fo
r st
aff.
Lack
of
sup
po
rt f
or
self
-man
agem
ent
ne
eds
of
clie
nts
rea
lly n
eed
ing
sup
po
rt.
Lim
ite
d s
up
po
rt f
or
self
-man
agem
ent
ed
uca
tio
n, s
up
po
rt,
invo
lvem
ent
of
fam
ily, b
ehav
iou
ral r
isk
red
uct
ion
res
ou
rces
.
Ab
sen
ce o
f h
ealt
h p
rogr
am p
rovi
sio
n w
ith
str
on
g h
ealt
h
ori
enta
tio
n.
Lack
of
com
mu
nit
y h
ealt
h p
rom
oti
on
/dev
elo
pm
en
t ac
tivi
ties
an
d
inte
grat
ion
into
hea
lth
ser
vice
’s p
rogr
am.
Ab
sen
ce o
f re
gula
rly
up
dat
ed r
eso
urc
e d
irec
tory
an
d in
tegr
atio
n in
st
aff
ori
enta
tio
n a
nd
inse
rvic
e p
rogr
ams.
Ab
sen
ce o
f co
mm
un
ity
inp
ut
to h
ealt
h s
ervi
ce g
ove
rnan
ce,
invo
lvem
ent
of
serv
ice
po
pu
lati
on
fo
rmal
agr
eem
ents
bet
wee
n
hea
lth
ser
vice
an
d m
ain
stre
am p
rim
ary
care
ser
vice
s
Ab
sen
ce o
f in
pu
t o
f h
ealt
h s
ervi
ce o
n r
egi
on
– w
ide
pla
nn
ing
and
al
loca
tio
n o
f re
sou
rces
.
Lim
ite
d o
rgan
isat
ion
al c
om
mit
men
t to
ser
vice
s fo
r cl
ien
t gr
ou
p in
st
rate
gic
and
bu
sin
ess
pla
ns.
Ab
sen
ce o
f fu
nd
ing
serv
ice
s fo
r cl
ien
t gr
ou
p in
str
ate
gic
and
b
usi
nes
s p
lan
s.
Ite
ms
on
20
13
on
ly
Ab
sen
ce o
f cl
inic
al le
ader
ship
Lack
of
team
ro
les
and
lin
es
of
rep
ort
ing
in P
T.
Lack
of
exp
erie
nce
wo
rkin
g w
ith
sta
ff w
ith
cu
ltu
ral k
no
wle
dge
(A
LOs,
AH
Ws)
.
Ab
sen
ce o
f se
lf-m
anag
em
ent
trai
nin
g fo
r st
aff
Lim
ite
d u
se o
f re
sou
rces
to
su
pp
ort
sel
f-m
anag
emen
t
Lim
ite
d s
up
po
rt f
or
self
-man
agem
ent
ed
uca
tio
n, s
up
po
rt,
beh
avio
ura
l ris
k re
du
ctio
n r
eso
urc
es.
Lack
of
com
mu
nit
y h
ealt
h p
rom
oti
on
/dev
elo
pm
en
t ac
tivi
ties
an
d
inte
grat
ion
into
hea
lth
ser
vice
’s p
rogr
am.
Ab
sen
ce o
f re
gula
rly
up
dat
ed r
eso
urc
e d
irec
tory
an
d in
tegr
atio
n in
st
aff
ori
enta
tio
n a
nd
inse
rvic
e p
rogr
ams
Ab
sen
ce o
f co
mm
un
ity
inp
ut
to h
ealt
h s
ervi
ce g
ove
rnan
ce,
invo
lvem
ent
of
serv
ice
po
pu
lati
on
fo
rmal
agr
eem
ents
bet
wee
n
hea
lth
ser
vice
an
d m
ain
stre
am p
rim
ary
care
ser
vice
s
Ab
sen
ce o
f in
pu
t o
f h
ealt
h s
ervi
ce o
n r
egi
on
– w
ide
pla
nn
ing
and
al
loca
tio
n o
f re
sou
rces
.
Lim
ite
d o
rgan
isat
ion
al c
om
mit
men
t to
ser
vice
s fo
r cl
ien
t gr
ou
p in
st
rate
gic
and
bu
sin
ess
pla
ns.
Ab
sen
ce o
f fu
nd
ing
serv
ice
s fo
r cl
ien
t gr
ou
p in
str
ate
gic
and
b
usi
nes
s p
lan
s.
Ne
w it
em
s fo
r 2
01
4
Ph
ysic
al in
fras
tru
ctu
re o
utd
ated
, no
t ch
ild o
r fa
mily
fri
end
ly, a
ir c
on
to
o h
igh
wh
en
ass
essi
ng
bab
ies.
Equ
ipm
en
t su
ch a
s b
lock
s an
d t
oys
nee
d t
o b
e re
pla
ced
; mu
ch is
35
0
Lack
of
rou
tin
e p
lan
nin
g o
f ap
po
intm
ents
.
Lack
of
mai
nte
nan
ce a
nd
use
of
elec
tro
nic
clie
nt
list
to id
enti
fy
sup
po
rt p
lan
nin
g an
d d
eliv
ery
for
gen
era
l clie
nt
po
pu
lati
on
an
d
tho
se w
ith
sp
ecia
l nee
ds.
Lack
of
use
of
elec
tro
nic
clie
nt
list
to r
each
sp
ecif
ic c
lien
t gr
ou
ps
Lack
of
stra
tegi
c ap
pro
ach
to
sp
ecia
list
gen
eral
ist
colla
bo
rati
on
to
p
rovi
de
evid
ence
-bas
ed
gu
idel
ines
old
, bro
ken
an
d g
naw
ed.
No
str
ateg
y fo
r d
evel
op
ing
team
me
mb
ers
role
s an
d s
kills
.
KEY
: 2
01
3 it
ems
rep
eate
d in
20
14
are
mar
ked
in b
lue.
des
ign
ates
an
are
a w
her
e im
pro
vem
ent
no
ted
in 2
01
4
35
1
Ex
am
ple
s o
f S
AT
Co
mp
on
en
t a
nd
Ite
m d
iscu
ssio
ns:
Sco
res
an
d C
om
me
nts
fo
r 2
01
4
De
live
ry S
yste
m D
esi
gn
Ite
m 1
.1:
Team
str
uct
ure
an
d f
un
ctio
n
AH
T 8
.6
P
T 5
.6 5
“O
VER
ALL
LO
OK
ING
AT
ALL
5 A
REA
S(O
F D
ELIV
ERY
SY
STEM
DES
IGN
) I W
OU
LD G
IVE
[al
lied
he
alth
te
am]
a 1
0 a
nd
PT
a 1
0”
ii Le
ade
rsh
ip –
is it
def
ine
d a
nd
re
cogn
ized
? D
oes
th
e le
ader
h
ave
an a
pp
rop
riat
e le
vel o
f fo
rmal
au
tho
rity
wit
hin
th
e p
ract
ice
team
?
AH
T 1
0 9
P
T
0 0
A
HT:
10
FU
LLY
DEV
ELO
PED
P
T: 0
NO
SU
PP
OR
T I t
hin
k th
at t
he
team
is f
ully
dev
elo
pe
d…
I am
no
t go
od
at
givi
ng
11
s gi
ve it
a 1
0
PT
we
do
n’t
off
icia
lly h
ave
a se
nio
r p
hys
io…
P
hys
io i
s n
ot
app
licab
le -
it is
a 0
v.
De
velo
pin
g te
am
me
mb
ers
’ ski
lls a
nd
ro
les
– is
th
ere
a st
rate
gic
app
roac
h?
AH
T 3
P
T
7
AH
T: 3
BA
SIC
- P
T: 7
GO
OD
Stra
tegy
…I d
on
’t t
hin
k it
is s
trat
egic
en
ou
gh-
no
n
ot
a st
rate
gic
app
roac
h b
ut
it is
incr
edib
ly w
ell s
up
po
rted
. O
rien
tati
on
has
hu
ge g
aps
and
res
ult
s in
a lo
t o
f in
con
sist
enci
es w
ith
ho
w p
eop
le d
o t
hin
gs. F
or
exam
ple
, fili
ng,
rec
ord
kee
pin
g, C
CIS
, eve
ryb
od
y d
oes
dif
fere
nt
inta
ke p
roce
du
res.
Def
init
ely
no
t w
ell
dev
elo
ped
.”
“ …
Th
e p
rob
lem
it is
cal
led
su
pp
ort
… t
her
e’s
hea
ps
of
sup
po
rt…
the
sup
po
rt w
ou
ld b
e re
ally
hig
h…
” Fo
r st
rate
gy m
ake
it b
asic
…. h
ave
atte
mp
ted
to
imp
rove
ori
enta
tio
n a
nd
up
skill
peo
ple
W
e n
o lo
nge
r h
ave
skill
s m
atri
x
PT
bas
ic I
wo
uld
rat
e it
hig
her
I h
ave
pu
t a
lot
of
tim
e in
to t
rain
ing
[PT
staf
f]…
hav
e
“Su
pp
ort
: ver
y h
igh
fo
r A
HT
and
PT”
Su
pp
ort
is 1
1 f
ully
dev
elo
ped
“S
trat
egy
– m
ake
it b
asic
…”
Dir
ect
qu
ota
tio
ns
fro
m p
art
icip
an
ts d
esig
na
ted
by q
uo
tati
on
mark
s
APPENDIX 4:
QUALITATIVE STUDY SUPPLEMENT
352
4.1 CONSENT FORM FOR CHILDREN AND CARERS
CONSENT FORM FOR CARER OR CHILD INTERVIEW
A research project about physiotherapy services for children
Before you sign this form please make sure that you understand what it means to participate in this research project. Please read the Information Sheet. Please contact me to answer any questions you might have.
It is important that you understand: You do not have to take part in this research. You can stop at any time.
This means you can say NO
☐ the research project about physiotherapy services for children has been explained to me.
☐ I have read and understand the Interview Information Sheet.
☐ I agree to taking part in the interview.
☐ I agree to my child taking part in the interview
☐ if I participate in the interview with him/her.
OR
☐ without help from me (although I or another caregiver that I choose will be in the
room).
☐ I agree that some of my words but not my name may be used in reports and publications.
☐ I agree to the interview being voice recorded.
☐ I understand that I am free to pullout from the project at any time.
☐ I understand that I own the stories that I tell, including any about Aboriginal
culture and this will be acknowledged by the researchers.
Participant’s Name___________________________________________________ Signature_____________________________________________Date__________ Carer’s Name (if giving permission for child to participate) _____________________ Signature_____________________________________________Date__________ Independent Witness _________________________________________________
Signature_____________________________________________Date___________
353
Contact Details: For more information about the research project:
Caroline Greenstein- Ph: 08 XXXXXXXX or XXXXXXXX Email: caroline.greenstein@XXXXXX
For more information about ethical conduct of the research project:
The Secretary, Human Research Ethics Committee of NT Department of Health and Menzies School of Health Research,
phone 08 89227922
Did an interpreter assist with the consent process? ☐Yes ☐No
If yes, Interpreter’s name: _________________________________________________ Signed:__________________________________________ Date: __________________
354
4.2 INFORMATION SHEET FOR CHILDREN/YOUTH
Research Project Information for Children/Young Adults This is for you to keep
You are invited to participate in a research project about physiotherapy services to Indigenous children with movement problems
What is this project about?
Movement problems such as difficulty with sitting, standing, walking, jumping, hopping or playing sports with the other kids are common problems children have. Doctors often send children with their parents to see physiotherapists to help with weak muscles, balance, walking and help getting around with equipment such as wheelchairs and sticks. Physiotherapists do activities or exercises to help children get stronger and move around to their best ability. They might teach these skills in a lot of different ways at school, home or office visits.
I want to understand how young people and their families feel about any physiotherapy they have had, what they like and dislike about physiotherapy. I would like to know what has been good and bad and what skills and activities are most important to you.
What does it involve? I want to talk to young people with their parents (or those looking after them such as grandparents). All talks will be private - they will only involve you and your parents (or carer) and me. I will ask general questions about things that are important to you, things you liked or disliked about physiotherapy and a little bit about your life.
If you are over 18, you can choose not to have your parent/carer around. It is up to you.
Frequently asked questions What happens to all the information you have collected from young people and their parents/guardians?
Information collected directly from young people and their parents/carers will only be used by me on this project.
How long does it take? The interview will generally take up to 1-2 hours but can be shorter too. More than one interview can be done if you and your parents would like.
Do young people have to answer all the questions asked? NO. Young people can choose to answer only those questions that they are comfortable with. THEY CAN STOP AT ANY TIME.
What do I need to do?
355
Young people interested in participating will need to sign a consent form to take part. If under 18 years old, their parents/guardians will need to sign the consent form too.
How will the information be collected? If young people agree, the one-on-one interviews will be audio-taped so that I get their words straight, but young people can say no to having their words taped.
Is my information confidential (private)? All the information given by young people and their parents/guardians will be kept private. A number will be used instead of names.
All the information will be protected in locked files in my locked home. It is only available to me and my research supervisors overseeing the project. We would only give it to someone else if the young person and their parents/guardians gave us permission to do so beforehand. However, if they tell us about something against the law (like robbing a bank), there is no law that protects this information if it is requested by the Police or court.
I will use the information to make a report to tell other researchers, physiotherapists and program planners what I have found. No names will be used and any information that could identify people contributing will be removed.
Are there benefits? There is no money involved. A family pass to a movie or to the waterfront will be provided as a thank you for your time.
In the long term, I hope the information collected will make physiotherapy more fun and better for more Indigenous youths who come to see physiotherapists.
Are there any risks? There is little risk from taking part. I do not think any questions I ask will cause distress. But if you do get upset or talk to me about something that is upsetting you, I can organize extra help and support for you.
Where can I find out more?? You can call me on xxxxxxxxxx or email Caroline Greenstein on: caroline.greenstein@xxxxx
Or my supervisor David Thomas on 8922 7610 or [email protected]
If you have any concerns about the conduct of this study, or would like to make a complaint, please contact:
HREC Ethics Administration Human Research Ethics Committee of the NT Department of Health, and Menzies School of Health Research Phone: 08 89227922 Email: [email protected]
356
4.3 INFORMATION SHEET FOR CARERS
Research Project Information Brochure for Parent/Carer This is for you to keep
You are invited to participate in a research project about physiotherapy services to Indigenous children with movement problems
What is this project about? Movement problems such as difficulty with sitting, standing, walking, jumping, hopping or playing sports with the other kids are common problems children have. Doctors often send children with their parents to see physiotherapists to help with weak muscles, balance, walking and help getting around with equipment such as wheelchairs and sticks.
Physiotherapists teach these skills in a lot of different ways at school, home or in office visits. There is a lot of physiotherapy research on what non-Indigenous children and their parents/carers want or need from physiotherapy services but nothing involving Indigenous children or their families.
I want to understand how young people and their families feel about any physiotherapy they have had, what they like about physiotherapy and dislike about physiotherapy. I would like to know what has been good and bad and what skills are most important to you.
What does it involve? I want to talk to young people with their parents (or those looking after them such as grandparents). All talks will be private. Children will only be involved in the talks if they are 8 years and older and have their parents (or carers) present.
I would also like to talk with the parents or carers without their child. I will ask general questions about things that are important to you, things you liked or disliked about your child’s physiotherapy and a little bit about your child’s life or your experiences as a parent or carer.
Some Frequently asked questions
What happens from all the information you have collected from young people and their parents/guardians? Information collected directly from young people and their parents/guardians will only be used by me on this project.
How long does it take? The interview will generally be around 1-2 hours. More than one interview can be done if you and your parents would like.
Do young people have to answer all the questions asked? NO. Young people or their parents/carers can choose to answer only those questions that they are comfortable with. THEY CAN STOP AT ANY TIME.
357
What do I need to do? Parents/carers interested in participating will need to sign a consent form to take part. If their child is old enough to participate but under 18 years old, the parents/guardians also need to sign their child’s consent form before the child can take part.
How will the information be collected? If parents/carers agree, the one-on-one interviews will be audio-taped so that I get their words straight, but the parent /guardian can say no to having their words taped.
Is my information confidential (private)? All the information given by young people and their parents/carers will be kept private. A number will be used instead of names.
All the information will be protected in locked files in my locked home. It is only available to me and my research supervisors overseeing the project. We would only give it to someone else if the young person and their parents/carers gave us permission to do so beforehand. However, if they tell us about something against the law (like robbing a bank), there is no law that protects this information if it is requested by the Police or court.
I will use the information to make a report to tell other researchers, physiotherapists and program planners what I have found. No names will be used and any information that could identify people contributing will be removed.
Are there benefits? There is no money involved. A family pass to a movie or to the waterfront will be provided as a thank you for your time.
In the long term, I hope the information collected will make physiotherapy more fun and better for more Indigenous children and their parents/carers who come to see physiotherapists.
Are there any risks? There is little risk from taking part. I do not think any questions I ask will cause distress. But if you do get upset or talk to me about something that is upsetting you, I can organize extra help and support for you.
Where can I find out more information? You can call me on xxxxxxxxxx or email Caroline Greenstein on: caroline.greenstein@xxxxxxxx.
Or my supervisor David Thomas on 8922 7610 or email: [email protected]
If you have any concerns about the conduct of this study, or would like to make a complaint, please contact:
HREC Ethics Administration Human Research Ethics Committee of the NT Department of Health, and Menzies School of Health Research Phone: 08 89227922 Email: [email protected]
358
4.4 CHILD/YOUTH INTERVIEW GUIDE
Interview Guide Topics and Possible Questions
Structure
1. Go over reason for interview
2. Choose some activities to play before the interview if needed.
3. Go over “Ground rules”
If I ask you a question and you don’t want to answer, that’s OK.
If you don’t know the answer to a question , don’t understand the question, or don’t
remember, just tell me that.
4. Begin with non-threatening questions
The first questions are to tell me a little about yourself
How old are you?
Were you born in xxxx?
If not, where were you born? (where’s your country)
When did you come to xxxx?
Do you have any brothers or sisters?
Any details?
Where do you go to school?
Do you like school?
What sort of stuff do you like?
What sort of stuff do you dislike?
Personal Story/How you became involved with physio
When did you start seeing a physio?
Why did you start seeing a physio?
Some kids see a physio because they have trouble walking
Some kids have trouble moving their arms or legs or balancing
Do you remember when you started seeing a physio? How did you feel?
Was he or she scary? Mean? Confusing? Nice?
What sort of stuff have you done with the physio?
What have been the things you liked about physio?
What have been the things you disliked about physio?
Have you had more than one physio?
Was that confusing or was it okay?
Have there been times that you have seen a physio but really did not want to?
What happened?
Participation
Do you understand why you see a physio?
Do you feel comfortable asking your physio questions? What happens?
359
Do you understand his or her answers?/Do you understand what your physio tells you?
Does it ever seem confusing?
Do you ever get asked what you would like to work on(for example throwing a ball or jumping
on a trampoline)?
Do you ever get given a choice of activities?
Do you prefer to see the physio at his or her office, at school or at home?
Does this ever depend on what you are working on?
Do you like it when the physio and you pick things to work on and set goals?
Do you prefer for the physio to tell you what to do?
Specific Events relating to the clients care
e.g. wearing AFOs
using a wheelchair/walking device
going swimming
doing gym or groups
visiting the doctor
Follow up
Do you prefer the physio to ring and remind you about your apt
Do you prefer for him or her to leave you alone?
360
4.5 CARER INTERVIEW GUIDE Interview Guide Topics and Possible Questions
Prompt questions that may be used to encourage people to use their own words. As this is not a
survey, the order of topics, phrasing of questions and questions included may vary with the
interview and participant. Note that it is unlikely that all the prompt questions will be asked in
any single interview, with question order and which questions to include determined by the flow
of the interview, what has been said by that participant and previous participants.
Similarly, these issues will be approached sensitively with participants based on the factors such
as the level of familiarity the participant has with the interviewer or PT service, the participant’s
age and personality.
Client/Primary Carer Story
(The story of how you became involved with CDT physiotherapy services)
Example prompt questions:
How did you become involved with CDT Physiotherapy
How did you hear about the CDT service?
What reason were you referred?
What sort of stuff has your physio done with your child?
What was your impression/what was it like the first time you saw a physiotherapist?
What have been the good things about the physiotherapy services your child /you have
received?
What have been the bad things?
Reflecting on Access to Care
Example prompt questions:
Did you have to wait long to see a physio?
Was it difficult to travel in to see the CDT physiotherapist?
What has been the biggest problem (transport, getting time off, waitlist)
Can you get seen when you want to be seen?
Can your child get seen where you want him or her to be seen (for instance, the home or
school)?
Can you talk to a physio on the phone or in person when you need to?
Are the physios you have seen friendly and welcoming?
Are the physios you have seen helpful?
If you have had to come into[the office]have you found the office staff friendly and
welcoming?
Do you think the personality of the physio makes a difference in terms of your child’s
involvement?
Reflecting on Participation in Care
Example prompt questions:
Have you required any help from your physio to understand your child’s physical
issues?
361
Did the physiotherapists give you information that you understand about your child’s
issues and treatment options?
Did you get asked about your concerns for your child?
Did you get asked what areas you would like the physio treatment to work on?
Did the physiotherapist ask you about your goals when developing your child’s
treatment plan? How do you feel about that?
Did you get to have a say in what type of physio treatment you have for your child? For
instance, have you been given a choice of whether your child has exercise in a group or
individually? Have you been asked whether you would prefer home or school activities?
Did the treatment plan suit the way you live your life?
If the physio provided activities to do at home or school, were these explained how they
would help?
Did you feel like you got to participate in your child’s physio program?
Did you feel like you were given all the information and tools to manage your child’s
condition?
Respectful Care
Example prompt questions:
Did the physiotherapist ask you about your language, culture and beliefs when
providing care for your child?
How do you feel about this?
Were you offered an interpreter?
Did you feel you needed an interpreter?
Did you feel the staff responded to your needs as an Indigenous person?
Did the physiotherapist ask you about your home and your family when they planned
your care?
Did you feel comfortable asking questions if you needed to?
Was any information presented in a way that you understood?
-Did the physiotherapists use pictures, posters, models or demonstration (on the
child’s or the physiotherapist’s body) when they were talking to you about your
child’s condition? Would this have been helpful?
Were there posters and people in the physio office that you can relate to?
Did you ever feel shame when your child got seen by a physio?
-If so, would this change if you could pick where the child saw his or her physio?
Care Providers
Example prompt questions:
Do you feel that your care is well organized?
Have you had different physiotherapists involved?
-If so, do you get the same messages about your condition and physio advice
regardless of which physio you see?
Did you ever get linked in with other care providers (for example OTs, doctors,
disability case managers)?
-If so, was this helpful or overwhelming?
-If not, was this a problem?
Follow Up
Example prompt questions:
362
Did the physio or the physio office remind you when your child next physio
appointment was?
-If so, was this helpful?
-If not, was this a problem? When would and how would it be best
to be contacted?
Do the physiotherapists contact you when you have not been able to attend an apt?
Do the physiotherapists help you get appointments to see the specialist if you need help?
Advice
Example prompt questions:
If you were talking to a physiotherapist who was just starting to work with children,
what advice would you give them (or what would you like them to know)?
We are coming to the end of the interview. Are there questions you would like to ask?
Are there any comments you would like to make?
At the completion of each interview I will thank the participants for their time and
attention and tell them that I greatly appreciate and value all their time and perspective
and that once this interview is put on paper I will contact them to make sure the
information I have recorded is true to their perspective. Once the research is completed I
will also contact them and if they are interested, I will share with them the results of the
project.
I will also tell them that although this interview was voluntary as required under the
guidelines for the research, I will provide them and their family with a family pass to the
cinemas to thank them for all their time and effort.
363
4.6 EMERGING CODES FROM INTERVIEWS ACCESS
Access to paediatricians
Access to physio -child
student interests
Access to services
Advice to other families
Entering CDT process
FIFOs (Fly in, Fly out therapy services)
Hearing about AHT
Moving to Darwin
CARERS EXPERIENCE MULTIPLE DEMANDS
Afraid to seek support/they’re the ones with the helmets on
Attending appointments
Being a carer
being a parent
being listened too
Childcare
Consumer Questions - handling and activities
Consumer questions -communication with PT
criticism in general
Lack of attention to how child is feeling
Criticism of AHT
Criticism of PT
Depression
Discovering when trouble started
Finances
Good experiences of carer
Hospital appointments
Interstate hospital
Lack of Family Support
Lack of Support
Ongoing grief
Raising a child with a disability
Respite
Staff Turnover
Surgery
Transport
Visiting Paediatric Service appointments
What happened to cause need of physio- child perspective
What is not said –diagnosis
What parents want
parent attitude to physio
personality of PT
Child Experience – best thing about therapy
Child experience of team’s physiotherapy
Child attitude towards physiotherapy
Child experience of doctors’ visits
Child experience first experiences with any physiotherapy
Child experience hanging out with wrong kids
364
Issues for the child
Child experience participation
Child experience – school
Child experience – self esteem
Child experiences – therapists should ask about family
Child defines physiotherapy
Good experiences of child or student
Too many therapists at once-child
Consumers Questions
AHT service pathway
Linking with other services
Getting timely appointments
Respectful Care
Well organized care
Facilities
Front Office
Handling and activities
Communication with PT
Location of Sessions
Hearing about AHT
CULTURE
Asking about culture
Bad experiences
Explaining the wide way
Interpreters
Judge mentality
Lack of communication
Language and family
Childs experience linking with culture
Living with a disability
Looking after all the kids
Orthotics
Parent Indigeneity
Racism
Skin Colour
Unpleasant experiences
Culture quotes
Discrimination
Childcare
Prejudice against disability
Racism
Familiarity with physiotherapist
FIFOs (Fly in Fly out staff)
GOALS
AHT PT Goals
COMMUNICATION
Importance of Communication
365
PT concerns asked
Communication with PT staff
Interpreters
Level of engagement
IMPORTANCE OF EQUIPMENT
Equipment
Orthotics
IMPORTANCE OF RELATIONSHIPS
Because we're all in it together
Physio- concerns asked
Characteristics of good PT – parent
Continuity
IMPORTANCE OF FAMILY
Family
Having parent support
Lack of family support
JUST ONE PHYSIO
Personality of PT
Familiarity with physiotherapist
Lots better than none but prefer one for a long time
Relationships
Rotate that person away from us
Things that make life easier
It may not be skin colour
LEISURE OF CHILD
Fun out of school
Leisure activities after school
Student interests
Exercises
Walking
What children want
LIVING WITH A DISABILITY
Living at home as a young adult
Living in care
living with a disability 2
Pain
Appreciating care services
Looking after the carer
Medications
Parent comments on child
pregnancy young adult
What makes a smart child
366
RECOMMENDATIONS AND GOOD EXPERIENCES
Advice to other families
Advice to physiotherapists
Because we're all in it together
Characteristics of good PT – parent
Continuity
She got us the right way
ROLE OF PHYSIO
Characteristics of good Physio – parent
Good experiences of carer
Physio as advocate
Things that are good
Things that are hard
Things that make life easier
What carers want
What we want in life
What children or students want
367
4.7
EL
AB
OR
AT
ED
QU
OT
ES
FR
OM
IN
TE
RV
IEW
S
Ela
bo
rate
d q
uo
tes
tha
t su
pp
ort
resu
lt t
hem
es
an
d r
ecom
men
dati
on
s
Th
eme
Su
bth
eme
Quo
te
Liv
es w
ith
mu
ltip
le
and
com
ple
x
dem
and
s
Mu
ltip
le a
pp
oin
tmen
ts
So
me
day
s w
e ju
st t
hin
k w
e’ve
had
four
ph
one
call
s th
is w
eek o
r w
e’ve
mad
e fo
ur
phon
e ca
lls
or
som
eon
e fo
rget
s to
tel
l us
that
th
ey’r
e on
lea
ve
and
th
e dep
artm
ent
do
n’t
let
…so
it’
s li
ke
we’
re w
aiti
ng
fo
r so
met
hin
g t
o h
appen
and
we’
re g
oin
g t
o r
un o
ut
of
tim
e bec
ause
ever
ybo
dy
else
has
tim
elin
es o
r dat
es t
o m
ake
and
ever
ybo
dy
is
a te
am,
wh
en
we’
ve g
ot
27
peo
ple
th
at
we
nee
d t
o w
ork
wit
h w
ell,
ou
t of
tha
t 27,
27
peo
ple
are
n’t
go
ing
to
com
e to
a m
eeti
ng
if
they
ha
ven
’t b
een
giv
en a
t le
ast
a f
ort
nig
ht’
s [n
oti
ce]
in a
dva
nce
. (F
ost
er M
oth
er o
f K
aty
, ag
e 16
)
Att
end
ing
appo
intm
ents
T
he
syst
em’s
tak
en a
lo
ng
tim
e bu
t w
hen
you g
o t
her
e y
ou
wait
a l
on
g t
ime
in t
he
clin
ic.
You
go
at
the
righ
t ti
me
an
d y
ou
en
d u
p g
oin
g h
ou
rs …
. (F
ost
er M
oth
er o
f S
teve,
age
21)
Att
end
ing
appo
intm
ents
I
alw
ays
ha
ve
this
sort
of
un
cert
ain
ty o
ver
wh
at
is g
oin
g t
o h
appen
. W
e hav
e to
do
a l
ot
of
con
ver
sati
ons
ov
er,
“We’
re g
oin
g t
o t
he
do
ctor.
T
his
is
what
th
ey’r
e go
ing t
o d
o.
Th
ey w
on’t
be
do
ing
this
” an
d l
ots
of
con
ver
sati
ons
just
in t
he
car
on t
he
way
ther
e ju
st p
reppin
g.
(M
oth
er
of
Bet
ty, ag
e 1
2)
Att
end
ing
appo
intm
ents
Bal
anci
ng
ch
ild
’s n
eeds
So
you
nev
er k
now
ho
w t
he
med
ical
syst
em
is
go
ing
to
work
. H
e co
uld
be
in t
he
lin
e fo
r
som
ethin
g [
surg
ical
pro
cedu
re]
and
th
en,
ban
g,
[th
e pro
cedu
re w
ou
ld b
e sc
hed
ule
d].
..an
d t
hat
wou
ld b
e w
ould
bugg
er o
ur
trip
...th
ere’
s 17 p
eople
. It
’s l
ike
a fu
ll f
amil
y a
ffai
r bec
ause
th
is i
s
the
last
tri
p w
ith
th
eir
gra
nd
fath
er,
ever
yon
e w
ants
to g
et t
his
on
e ou
t th
e w
ay …
( M
oth
er o
f
Noah
, ag
e 13)
368
Att
end
ing
appo
intm
ents
Rel
atio
nsh
ips
Oh,
she
was
lik
e it
– l
ike
I use
d t
o l
ook a
t li
ke
as i
f sh
e w
as
a l
ittl
e gu
inea
pig
. Y
ou
kn
ow
,
she
alw
ays
had
med
ical
per
son
nel
aro
und
her
, y
ou k
now
, dif
fere
nt
kin
ds.
…Y
eah.
It
was
ju
st
so o
ver
whel
min
g s
om
etim
es.
Lik
e, w
hen
you
go
to
see
a d
oct
or,
you
ha
ve,
you
kn
ow
, li
ke
fou
r o
r fi
ve o
f th
em j
ust
all
sta
nd
ing
aro
un
d. (M
oth
er o
f E
llen
, ag
e 1
9)
Str
ess
I kn
ow
wit
h a
lo
t of
spec
ial
nee
ds
kid
s in
gen
eral
, a
dia
gn
osi
s is
alw
ays
go
ing t
o b
e a
loss
an
d
a ver
y t
raum
atic
th
ing f
or
any
fam
ily
, but
it's
pro
bab
ly d
iffe
rent
to a
dea
th i
n a
sen
se t
hat
it's
kin
d o
f co
nti
nu
ou
s in
som
e w
ays.
T
he
mil
esto
nes
wil
l pop u
p a
nd t
hen
you
com
e to
rea
lise
tha
t th
at'
s pro
ba
bly
not
goin
g t
o h
appen
fo
r yo
ur
chil
d s
o t
hen
yo
u m
ight
go b
ack i
nto
that
gri
ef I
su
pp
ose
. …
I'v
e n
eve
r cr
ied s
o m
uch
in
my
life
. A
nsw
ers,
th
at'
s a
lwa
ys b
een
a r
eall
y
ha
rd o
ne,
th
e an
swer
to
"H
ow
do
we
get
her
to
rea
d,
ho
w d
o w
e get
her
to
do
th
is,
ho
w d
o
we
get
her
to d
o t
ha
t?
Wh
y is
sh
e do
ing
th
at,
wh
y is
sh
e st
ill
no
t to
ilet
ing
?"
All
th
ose
sort
s
of
thin
gs,
try
ing
to
fin
d o
ut
yo
urs
elf
what
is
the
secr
et,
what
's t
he
pro
gra
m t
hat
I c
an u
se o
r
what
's t
he
ther
apy
that
I c
an u
se t
hat
's g
oin
g t
o f
ix t
his
? (M
oth
er o
f B
etty
, ag
e 12)
Str
ess
Ell
en’s
ow
n f
ather
had
a d
isab
ilit
y,
so I
was
car
ing
fo
r him
as
wel
l [a
s E
llen
].(M
oth
er o
f E
llen
,
age
19)
Str
ess
Just
a s
imple
th
ing l
ike
when
I'm
at
ho
me
and
I g
o t
o s
tart
coo
kin
g d
inn
er a
nd I
nee
d a
n o
nio
n
or
I nee
d a
gar
lic
or
a po
tato
. I
cou
ld j
ust
get
in
a c
ar a
nd
ju
st z
ip u
p t
o t
he
sho
p a
nd
go
get
th
at
thin
g,
get
in t
he
car,
co
me
bac
k a
nd
cut
it u
p a
nd
som
eon
e's
at h
om
e w
ith
chil
dre
n.
Sim
ple
thin
g l
ike
that
. E
ven
if
I've
go
t to
du
ck o
ut
an
d g
o t
o a
n a
ppo
intm
ent,
mys
elf
fo
r a p
riva
te
thin
g,
to s
it d
ow
n w
ith
th
e d
oct
or,
I'v
e go
t to
ha
ve m
y ch
ild
ren
th
ere
talk
ing
, dis
cuss
ing
my
pri
vate
bu
sin
ess
an
d t
hat.
I'm
try
ing
to
kee
p t
ho
se k
ids
stil
l. (
Moth
er o
f N
oah
, ag
e 13
)
On
go
ing
su
pport
dem
and
s-st
ress
Th
en a
no
ther
tim
e has
bee
n w
ith
Noah
’s f
irst
ele
ctri
c w
hee
lchai
r, i
t ju
st s
tart
ed t
o f
ail
on h
im,
a go
od
coup
le o
f y
ears
th
roug
h.
So
the
con
tro
ller
ju
st k
ept
stopp
ing,
what
ever
- a
ny
lit
tle
bu
mp i
t w
ou
ld j
ust
sto
p.
So I
ha
d r
an
g i
n a
th
ird
tim
e fo
r it
to
be
fix
ed,
an
d t
his
was
in a
mon
th,
pro
ba
bly
sli
gh
tly
ove
r a m
on
th.
So
th
at
was
thre
e t
imes
it h
ad t
o b
e fi
xed
. A
lad
y
from
an
oth
er r
ecep
tio
n a
t [M
edic
al
Su
ppli
er],
ha
d s
aid
. th
at
she
ha
d a
go a
t m
e a
bo
ut
that
com
e on
th
at’s
th
e th
ird t
ime
they
're
hav
ing t
o f
ix t
his
key
pad
. It
mad
e m
e fe
el b
ad f
or
ask
ing
to h
ave
it d
one…
. B
ecau
se I
had
to
get
on
to
it
bec
ause
wh
en t
hey
to
ok
it
the
thir
d t
ime,
th
ey
369
sat
wit
h i
t. S
o t
hey
wer
e m
ore
or
less
wer
e ta
kin
g t
hei
r ti
me
to d
o i
t…(M
oth
er o
f N
oah
, ag
e
13
)
Str
ess
Wel
l fo
r m
e, w
hen
Noah
was
sm
alle
r, I
did
no
t re
ali
se h
ow
ph
ysic
al
an
d m
enta
l it
was
go
ing
to g
et t
hro
ugh t
he
yea
rs, as
his
dis
abil
ity
det
erio
rate
d.
(Moth
er o
f N
oah
, ag
e 13)
On
go
ing
su
pport
dem
and
s-st
ress
All
I w
ante
d t
o d
o,
all
I re
ally
wan
t, I
don't w
ant
to b
e co
unse
lled
, I
just
wan
t su
pp
ort
wit
h m
y
chil
dre
n t
o h
ave
a b
reak
fro
m t
hem
. (M
oth
er o
f N
oah
, ag
e 1
3)
Bal
anci
ng
ch
ild
’s
exp
erie
nce
(N
ego
tiat
ing
the
soci
al a
nd p
hy
sica
l
env
iro
nm
ent)
Bec
ause
it’
s har
d –
it
would
be
har
d f
or
the
kid
, I
mea
n,
a ch
ild
wit
h a
dis
abil
ity t
oo,
bec
ause
in a
mai
nst
ream
cla
ss,
they
’re
just
go
ing t
o h
ear
what
is
gen
eral
ised
. I
t’s
no
t oft
en l
ike
that
wit
h a
chil
d w
ith
a d
isab
ilit
y.
So,
yo
u k
now
, it
’s a
ctu
all
y cr
uel
, I
thin
k,
for
a c
hil
d w
ith
a
dis
ab
ilit
y to
hea
r all
th
ese
no
rmal
stori
es
wh
en i
t’s
no
t re
all
y li
ke
tha
t.
(Mo
ther
of
Ell
en,
age
19
)
Bal
anci
ng
ch
ild
’s
exp
erie
nce
(N
ego
tiat
ing
the
soci
al a
nd p
hy
sica
l
env
iro
nm
ent)
…I
get
off
ended
by c
hil
dre
n,
I know
that
th
ey’r
e on
ly c
hil
dre
n,
but
to m
e an
adu
lt -
inst
ead o
f
a ch
ild
bei
ng r
ude.
So
me
of
my
fri
end
s w
ill
sit
ther
e an
d t
hey
won’t
tu
rn a
round
and c
orr
ect
the
chil
dre
n.
I al
way
s sa
y,
“I
wan
t yo
u t
o e
xp
lain
to
you
r ch
ild
wh
at’
s w
ron
g w
ith
Noa
h a
nd
wh
y h
e’s
lik
e th
is,
I do
n’t
wan
t th
e ch
ild
to
rea
ct t
ha
t w
ay.
” S
o t
ha
t w
hen
th
ey r
eact
th
at
way
I fe
el b
ad
fo
r m
y ch
ild
ren
, bec
au
se t
hey
feel
ou
t of
pla
ce,
so I
do
n't
go a
nyw
her
e. I
kee
p t
hem
aw
ay
from
th
at.
(M
oth
er o
f N
oah
, ag
e 1
3)
Bal
anci
ng
ch
ild
’s
exp
erie
nce
(N
ego
tiat
ing
the
soci
al a
nd p
hy
sica
l
env
iro
nm
ent)
Rec
om
men
dat
ions
Ano
ther
th
ing I
gu
ess,
wh
at I
was
goin
g t
o s
ay, it
wil
l hel
p –
wel
l w
hen
I g
rew
up,
bec
au
se o
f
my
dis
ab
ilit
y, a
lo
t of
chil
dre
n, b
ecau
se k
ids
did
n't
kn
ow
ab
ou
t it
, I
was
just
weir
d a
nd i
t w
as
the
sam
e q
uest
ion
“W
hat’
s w
ron
g w
ith
you
?”,
“W
hat’
s w
ron
g w
ith
you
?” a
nd t
hen
bec
ause
they
had
n't
hea
rd o
f st
uff
lik
e th
at b
efore
, I
was
alw
ays
get
tin
g t
ease
d. M
ayb
e th
ere
sho
uld
be
som
ethin
g p
ut
or
mad
e to
war
ds
also
aw
are
nes
s to
peo
ple
wit
hou
t it
als
o.
Lik
e aw
are
nes
s o
f a
ll
the
typ
es o
f dis
ab
ilit
ies
that
are
lin
ked
wit
h t
his
typ
e o
f jo
b a
nd
stu
ff,
so t
hat
in t
he
futu
re n
ot
all
ch
ildre
n a
re h
avi
ng
to
gro
w u
p w
ith
th
e sa
me,
havi
ng e
very
on
e el
se b
ein
g “
Wh
at’
s th
is?”
At
leas
t h
op
efull
y i
f th
ere'
s m
ore
aw
aren
ess,
then
oth
er c
hil
dre
n w
ould
be
like
“Th
at k
ids
got
this
, b
ut
it’s
okay
. I
know
abo
ut
it, w
e ca
n g
o p
lay
wit
h t
hem
” an
d s
tuff
. (E
llen
, ag
e 1
9)
Bal
anci
ng
ch
ild
’s
…O
ne
was
lik
e hav
ing o
ther
kid
s st
are
bec
ause
she
was
wea
ring
spli
nts
or
in a
whee
lchai
r.
370
exp
erie
nce
(N
ego
tiat
ing
the
soci
al a
nd p
hy
sica
l
env
iro
nm
ent)
So
met
imes
, w
hen
th
ey’r
e do
ing
a r
eall
y lo
ng
sta
re,
you
ju
st f
eel
lik
e tu
rnin
g a
rou
nd
an
d
sayi
ng
, w
ha
t’s
you
r pro
ble
m,
kin
d o
f th
ing
. I
gu
ess
they
’re
just
curi
ous
as t
o w
hy
is
she
lik
e
that
…(M
oth
er o
f E
llen
, ag
e 1
9)
Bal
anci
ng
ch
ild
’s
exp
erie
nce
(N
ego
tiat
ing
the
soci
al a
nd p
hy
sica
l
env
iro
nm
ent)
We
wer
e at
a s
ho
p o
nce
at
Cas
uar
ina
for
Chri
stm
as a
nd t
her
e w
ere
tw
o y
ou
ng g
irls
up
at
the
cou
nte
r an
d t
hey
tu
rned
aro
un
d a
nd t
hey
wer
e co
nst
an
tly
stari
ng
at
Katy
an
d K
aty
cam
e
ove
r to
me
an
d s
aid
, “A
un
tie
th
at
gir
l w
ho
’s l
ookin
g a
t m
e an
d i
s pu
llin
g a
fu
nn
y fa
ce.”
…(F
ost
er M
oth
er o
f K
aty
, ag
e 1
6)
Bal
anci
ng
ch
ild
’s
exp
erie
nce
(N
ego
tiat
ing
the
soci
al a
nd p
hy
sica
l
env
iro
nm
ent)
Sta
irs,
no
t ev
ery
sch
oo
l is
equ
ipp
ed w
ith
ele
vato
rs…
.don
't, s
o t
hat
was
kin
d o
f har
d.
I en
ded
up
act
ua
lly
dro
ppin
g o
ut
of
sch
oo
l a
nd
th
en t
hey
beg
ged
for
me
to c
om
e b
ack
an
d I
agre
ed
to b
e in
on
e cl
ass
wh
ere
we
did
n't
ch
an
ge
cla
sses
, ju
st s
o t
hat
I w
ould
go
to s
cho
ol
bec
ause
I
stop
ped
goin
g b
ecau
se o
f th
e fa
ct t
hat
I d
idn't l
ike
hav
ing
to w
alk a
roun
d t
he
wh
ole
sch
ool,
up
and
dow
n f
lights
of
stai
rs a
ll d
ay e
ver
y d
ay, it
was
to
o h
ard
. (E
llen
, A
ge
9)
Rel
atio
nsh
ips:
Rel
atio
nsh
ips:
G
et t
o k
no
w c
hil
d a
nd
fam
ily
Rec
om
men
dat
ions
It’s
nic
e to
get
to
know
th
e kid
s fi
rst
inst
ead o
f ju
st l
aunch
ing s
trai
gh
t in
to e
xer
cise
s. Y
ou
cou
ld p
lay
wit
h t
hem
a l
ittl
e bit
an
d t
alk t
o t
hem
and
th
en w
hen
they
get
to
kn
ow
you
a b
it a
nd
tru
st y
ou
, th
en y
ou l
aunch
into
yo
ur
exer
cise
s. (
Fo
ster
Moth
er o
f T
iana,
age
9)
Get
to
kn
ow
ch
ild
and
fam
ily
, C
om
mun
icat
ion
Rec
om
men
dat
ions
I su
ppo
se r
igh
t ba
ck t
o b
asi
cs a
s in
th
em
kn
ow
ing
her
wh
ole
his
tory
, h
ow
lo
ng
we’
ve b
een
a
pa
rt o
f th
e se
rvic
e, w
ha
t h
as
work
ed a
nd w
ha
t h
asn
’t w
ork
ed a
nd t
akin
g i
t fr
om
th
ere I
sup
po
se, so
rt o
f tr
ial
and
err
or.
(F
ost
er M
oth
er o
f K
aty
, ag
e 16
)
Get
to
kn
ow
ch
ild
and
fam
ily
, ca
rin
g,
To
me
I th
ink t
hat
is
a big
th
ing,
bec
ause
yo
u'r
e n
ot
just
dea
lin
g w
ith
my
chil
d,
you
’re
dea
lin
g w
ith
my
bes
t in
tere
st a
nd m
y oth
er t
wo
ch
ild
ren
’s b
est
in
tere
st.
Th
at’
s w
ha
t I
lik
e.
371
Rec
om
men
dat
ions
(Mo
ther
of
No
ah,
age
13
Get
to
kn
ow
ch
ild
and
fam
ily
, C
arin
g,
Rec
om
men
dat
ions
…it
’s l
ike
you j
ust
don
't sh
ow
in
volv
emen
t to
the
chil
dre
n,
you
mak
e su
re t
hat
it’
s okay
fo
r m
e
to -
lik
e w
hen
I'm
tra
vel
ling
to
an a
ppoin
tmen
t, i
t’s
go
od
fo
r ev
ery
body
wit
h m
e an
d m
y
dau
gh
ters
, as
wel
l as
my
son
. W
hen
I c
om
e to
th
e in
terv
iew
, yo
u m
ake
sure
th
at m
y d
augh
ters
are
- I
can d
o s
om
ethin
g w
ith
my
chil
dre
n,
my
oth
er t
wo a
nd
get
them
ou
t of
the
way
. T
hen
we
go
an
d w
e st
art
sort
ing
ou
t ou
r oth
er bu
sines
s. I
lik
e th
at,
yea
h it
m
akes
m
e fe
el re
ally
com
fort
able
(M
oth
er o
f N
oah
, ag
e 1
3)
Co
llab
ora
tio
n
Rec
om
men
dat
ions
I th
ink
th
at
it w
as
an
all
-rou
nd
tea
m e
ffort
th
at I
co
uld
see
what
she
was
str
ugg
lin
g w
ith
,
talk
ing
about
it,
wher
e sh
e sa
id s
he
was
hav
ing h
er p
ain,
how
much
her
fo
ot
had
gro
wn
th
at w
e
no
w h
ave
ort
ho
tics
fro
m o
ver
seas
, th
at s
he
has
tw
o d
iffe
rent
size
fee
t, h
ow
much
her
fee
t hav
e
gro
wn
. I
thin
k i
t w
as
a w
on
der
ful
effo
rt. (F
ost
er M
oth
er o
f K
aty
, ag
e 1
6)
Co
llab
ora
tio
n
Rec
om
men
dat
ions
…th
e w
ho
le c
on
sist
ency
of
thes
e ch
ild
ren t
o n
ever
fee
l th
at t
hey
are
chil
dre
n i
n c
are
…
the
mo
st i
mpo
rtan
t th
ing i
s th
at t
he
rig
hts
of
a ch
ild
is
what
nee
ds
to b
e hea
rd a
nd I
’ll
do
what
I
can t
o m
ak
e su
re t
ha
t th
at’
s go
ing
to b
e ach
ieva
ble
an
d w
ith
th
e h
elp o
f ev
eryb
ody
else
thin
gs
do
happ
en. (F
ost
er M
oth
er o
f K
aty
)
Co
nsi
sten
cy
Rec
om
men
dat
ions
But
yea
h,
I th
ink
th
e w
ho
le k
eepin
g t
he
on
e, l
ike
the
chil
d w
ith
th
e sa
me
per
son
ove
r th
e ti
me
mak
es i
t a l
ot
more
easi
er f
or
the
kid
bec
au
se t
hen
th
ey s
tart
to
get
to k
now
th
e per
son
.
Th
ey'r
e li
ke
“Y
eah
, th
is p
erso
n d
id i
t fo
r m
e bef
ore
, I
kn
ow
th
ey'r
e go
ing
to
do i
t fo
r m
e th
is
tim
e ag
ain
”(E
llen
, ag
e 1
9)
Co
nsi
sten
cy
Rec
om
men
dat
ions
I w
ou
ldn
't w
an
t to
see
dif
fere
nt
peo
ple
in
bet
wee
n b
ecau
se y
ou
'd h
ave
to
kee
p r
epea
tin
g t
he
story
an
d t
hat
get
s ve
ry t
irin
g a
fter
you
've
bee
n t
o t
he
op
tom
etri
st a
nd
th
e pae
dia
tric
ian a
nd
repea
ted t
he
sto
ry t
o e
ver
y o
ther
med
ical
pro
fess
ion t
her
e is
. N
ot
on
ly t
hat
bu
t it
ju
st w
ou
ldn't
be
a go
od s
ervic
e in
th
at s
ense
th
at y
ou'd
be
seei
ng
lots
of
dif
fere
nt
peo
ple
. (M
oth
er o
f B
etty
,
age
12)
Co
nsi
sten
cy
it's
bee
n r
eall
y g
ood
hav
ing
yo
u f
or
a lo
ng
per
iod o
f ti
me
too,
over
th
e la
st,
what
has
it
bee
n
pro
bab
ly a
cou
ple
of
yea
rs m
aybe,
so h
ave
that
lo
ngev
ity
in
the
serv
ice.
Y
ou
kn
ow
wh
ere
we'
ve s
tart
ed f
rom
th
e ti
me
tha
t yo
u'v
e pic
ked
her
up u
nti
l n
ow
an
d b
ecau
se w
e do
see
you
372
on
a r
egula
r bas
is. T
hat
's a
good t
hin
g.
(Mo
ther
of
Bet
ty, ag
e 12
)
Co
nsi
sten
cy,
Co
mm
un
icat
ion
An
d I
th
ink t
ha
t w
hen
ch
ild
ren
ha
ve b
een
in
care
for
a l
on
g t
ime
an
d t
hey
’ve
bee
n w
ith
th
e
sam
e peo
ple
or
the
com
mu
nic
ati
on
is
go
od,
they
un
der
sta
nd
, ev
ery
bo
dy’s
too
bu
sy t
oday
acce
ss c
an’t
hap
pen
, hopef
ull
y i
t m
ight
be
do
ne
on a
no
ther
day
, ju
st t
ake
each
day
as
it c
om
es,
that
’s a
ll t
her
e is
to
it.
(F
ost
er M
oth
er o
f K
aty
, ag
e 1
6)
Co
nsi
sten
cy
I ju
st t
hin
k t
he
who
le t
hin
g o
f hav
ing c
han
ges
wit
hin
tea
m l
ead
ers
and
stu
ff l
ike
that
. T
he
chil
dre
n j
ust
get
th
at
rapport
wit
h p
ick
-up
s an
d d
rop o
ffs
for
acc
ess,
we
fin
d i
t un
avai
lable
to
go
to
a d
oct
or’
s ap
poin
tmen
t bec
au
se so
met
hin
g’s
h
app
ened
in
m
y li
fe or
I’m
aw
ay on
resp
ite,
th
e c
hil
dre
n f
eel
at
ease
an
d c
alm
th
at
they
can
to
th
eir
app
oin
tmen
ts a
nd
th
at
wh
o’s
takin
g t
hem
kn
ow
s so
met
hin
g a
bou
t th
is c
hil
d (
Fo
ster
Mo
ther
of
Kat
y, ag
e 16
)
Co
nsi
sten
cy -
neg
ativ
e
exp
erie
nce
s
Yea
h.
Lik
e w
hen
I h
ad i
t [t
her
apy
] w
ith
you
, b
ecau
se I
've
had
oth
er p
eople
co
me
too,
lik
e
som
e of
the
oth
er p
eople
I d
idn
't r
eall
y kn
ow
th
em,
they
wer
e th
e ra
ndo
m o
nes
th
at
ha
d t
o
com
e, it
w
as
kin
d of
wei
rd w
ith
th
em bec
au
se I
did
n't
fe
el th
at
they
kn
ew w
ha
t I
was
sup
po
sed t
o b
e do
ing
. It
was
lik
e th
ey d
idn
't re
ally
kn
ow
what
they
wer
e do
ing,
what
th
ey
wer
e su
pp
ose
d t
o b
e do
ing w
ith
me.
..(E
llen
, ag
e 1
9)
Co
nsi
sten
cy-
Th
e ex
cep
tio
n
Wh
en t
hey
’re
chan
gin
g w
ork
ers,
at
that
tim
e, I
co
uld
fee
l if
th
at w
ork
er d
id n
ot
wan
t to
rea
lly -
she’
s no
t bei
ng
ru
de
bec
ause
she’
s on
ly d
oin
g h
er j
ob,
to h
er t
hat
’s t
hat
jo
b.
So
if
she
do
esn
’t
wan
t to
do i
t an
ymore
, I'
m h
app
y fo
r an
oth
er w
ork
er t
o c
om
e on
th
at’
s h
app
y to
do
it,
and
to
mak
e m
e fe
el h
appy
and
com
fort
able
and
my
chil
d f
eel
com
fort
able
. I'
m h
appy
for
that
, so
it
do
es n
ot
both
er m
e, I
wan
t th
at
to b
e ro
tate
d,
to r
ota
te t
ha
t per
son
aw
ay
from
us.
(M
oth
er o
f
Noah
, ag
e 13)
Car
ing
- p
osi
tiv
e
exp
erie
nce
s
…[T
he
Th
erap
ist]
cam
e in
wit
h a
n o
pen
hea
rt,
[th
e th
erap
ist
was
] so
eag
er.
I li
ked
th
at.
(Mo
ther
of
No
ah,
age
19)
Car
ing
-
Go
od
ex
per
ience
s
wh
en I
've
go
t a g
ood
tea
m b
ehin
d m
e…
th
at
an
d a
re j
ust
th
inkin
g a
bou
t th
e bes
t in
tere
st o
f
my
son
, I'
m h
app
y w
ith
th
at.
I d
on't w
orr
y a
bo
ut
smal
l peo
ple
no
more
. S
o a
s lo
ng
as
we’
ve
go
t our
good
tea
m t
hat
’s w
hat
I'm
hap
py w
ith
(M
oth
er o
f N
oah
, ag
e 1
3)
373
Car
ing
-
Lac
k o
f ca
ring
But
any
way
, th
ey h
ad t
o f
ind s
om
eon
e to
tak
e her
[T
iana]
, w
hil
e al
l th
is [
dra
ma
was
occ
urr
ing
]… i
t w
as
lik
e K
eyst
on
e co
ps,
we
ha
d a
bou
t 2
0 p
oli
ce c
ars
...
det
ecti
ves,
you
na
me
it,
they
wer
e all
her
e… n
o o
ne
from
[D
isa
bil
ity
Su
ppo
rt S
ervi
ce c
am
e]
- an
d I
con
tact
ed t
hem
firs
t. (
Fo
ster
Mo
ther
of
Tia
na,
age
9)
Car
ing
-
Lac
k o
f ca
ring
Pre
tty
much
fro
m t
her
e I
thin
k t
hey
clo
sed h
er f
ile,
you
kn
ow
ho
w t
hey
do
. (M
oth
er o
f B
etty
,
age
12)
Car
ing
-
Lac
k o
f ca
ring
Wel
l, I
co
uld
n’t
poss
ibly
say
anyth
ing a
bou
t it
bec
ause
th
ey’v
e go
t th
e ru
lebo
ok
an
d t
ha
t’s
all
ther
e is
abo
ut
it.
… (
Fost
er F
ather
of
Tia
na,
ag
e 9)
Car
ing
-
Lac
k o
f ca
ring
…I
tho
ug
ht
tha
t w
as
a p
rett
y h
ars
h j
ud
gem
ent
beca
use
I w
as
the o
ne
tha
t h
ad g
on
e aro
un
d
an
d t
ried
to e
nga
ge
ever
ybo
dy t
o t
ry a
nd
get
som
ethin
g d
one,
I w
asn
't in
den
ial
abo
ut
what
was
go
ing o
n w
ith
her
I k
new
ver
y w
ell
ther
e w
as s
om
eth
ing w
ron
g.
It
all
cam
e ba
ck t
o t
he
[th
erap
y] r
eport
th
at
was
wri
tten
th
at
said
I'd
mis
sed a
cou
ple
of
ap
po
intm
ents
… (
Mo
ther
of
Bet
ty, ag
e 1
2)
Car
ing
Be
pat
ien
t
Rec
om
men
dat
ions
Be
pa
tien
t w
ith
you
r fa
mil
ies
bec
ause
they
've
pro
bab
ly g
ot
abo
ut
ten o
ther
spec
iali
sts
giv
ing
them
rec
om
men
dat
ion
s, t
hat
's m
y f
irst
th
ing…
(M
oth
er o
f B
etty
, ag
e 12
)
Car
ing
-
Rec
om
men
dat
ions
…I
sup
po
se i
t's
just
an
un
der
sta
nd
ing
fro
m o
ther
peo
ple
an
d j
ust
a w
illi
ngn
ess
to s
up
po
rt
you
, m
aybe
that
's b
een t
he
most
hel
pfu
l th
ing (
Moth
er o
f B
etty
, ag
e 12
)
Co
mm
un
icat
ion
-
Tal
k t
o t
he
chil
d
Wh
en y
ouse
[th
erap
ist
and c
arer
s] a
ctual
ly t
alk
– t
urn
ed t
o t
he
par
ent’
s, i
f th
e pa
ren
ts s
ay
“W
ell
wh
at'
s h
app
enin
g n
ow
?"
Ma
ybe
call
th
e ch
ild
in
to i
t to
o,
bec
ause
ano
ther
th
ing t
hat
I've
no
tice
d i
s th
at I
don't –
lik
e it
's m
y d
isab
ilit
y,
but
I do
n't r
eall
y k
now
th
at m
uch
abo
ut
it
bec
ause
of
the
fact
th
at –
lik
e w
hen
so
meo
ne
asks
me
"What
ab
ou
t th
is w
hen
you w
as l
ittl
e?"
Or
"What
's a
bo
ut
yo
ur
dis
abil
ity
?",
bu
t I
do
n't
rea
lly
kn
ow
ho
w t
o a
nsw
er p
eople
ha
lf t
he
tim
e bec
au
se i
t w
as
my
mu
m t
ha
t w
as
alw
ays
kn
ow
ing
wh
at'
s o
n (
Ell
en, ag
e 19
)
Tak
e so
me
tim
e …
.I t
hin
k t
he
ind
igen
ou
s m
ob
[o
ther
care
rs]
mig
ht
feel
a b
it t
hin
g,
som
etim
es t
hey
don
’t
un
der
sta
nd
an
d y
ou
’ve
got
to g
ive
them
a l
ot
of
un
der
stan
din
g t
oo
, th
en o
nce
th
ey k
no
w
374
what
’s g
oin
g o
n. (F
ost
er M
oth
er o
f S
teve,
age
21)
Tal
k
Wel
l as
an
in
div
idu
al
it’s
a g
ood
th
ing t
o s
ha
re o
ur
stori
es b
eca
use
if
you
do
n’t
ha
ve s
ha
red
stori
es h
ow
are
you
eve
r go
ing
to
lea
rn w
ha
t’s
righ
t an
d w
hat’
s w
ron
g a
nd b
ein
g a
ble
to
acce
pt
what
’s r
ight
and w
hat
’s w
ron
g,
and
wh
ere
do
yo
u g
o f
or
hel
p, w
hat
can
you
do
.
Co
mm
un
icat
ion
neg
ativ
e ex
per
ien
ces
Th
ere
are
tim
es w
hen
sh
e co
mes
ho
me
dis
trau
gh
t w
hen
som
eth
ing
’s h
app
ened
at
sch
ool-
and
th
is i
s w
hat
we’
ve
said
- w
e w
ill
no l
ong
er a
ccep
t a
tele
ph
on
e ca
ll, w
her
e th
e te
acher
or
the
Abo
rig
inal
Lia
ison
Off
icer
, ri
ngs
us
up a
nd
say
s, “
the
teac
her
wan
ts t
his
, an
d t
his
, an
d t
his
”.
It’s
not
acce
pta
ble
, th
ey e
ith
er w
rite
it
do
wn o
r… t
hat
’s w
hat
th
ey d
id,
all
of
last
yea
r…all
we
get
in
th
e [s
tuden
t co
mm
un
icati
on
] book
is
: pan
ts w
et t
wic
e. B
ow
el o
pen
. N
oth
ing
els
e.
Th
ey d
on’t
tel
l y
ou
th
e physi
oth
erap
ist
cam
e, s
he
had
dif
ficu
ltie
s w
ith
her
exer
cise
s, o
r sh
e
cou
ldn’t
sit
in t
he
chai
r p
roper
ly…
(F
ost
er M
oth
er o
f T
ian
a, a
ge
9)
I kn
ow
on
my
last
tri
p [
inte
rsta
te]
they s
aid
so
met
hin
g a
nd t
hey
ha
dn
't p
ut
it i
n t
he
repo
rt
and
th
en I
had
to
fee
d t
hat
bac
k t
o y
ou
so t
hat
lef
t y
ou p
rob
ably
a b
it c
on
fuse
d a
s to
"W
hat
do
they
rea
lly
mea
n t
her
e?"
I'm
no
t a m
edic
al
per
son
so f
or
me
to i
nte
rpre
t it
th
e w
ay t
ha
t th
ey
mea
nt
it p
robab
ly i
sn't
th
e sa
me. (M
oth
er o
f B
etty
, ag
e 12
)
At
the
star
t, l
ike
I sa
id i
t has
tak
en m
e a
whil
e to
get
an u
nder
stan
din
g o
f th
e sy
stem
. S
o
no
w
I'm
sort
of
awar
e of
it m
ore
, bu
t at
th
at t
ime
yes
th
ey w
ou
ld u
se w
ord
s an
d t
hin
gs
that
th
ey
had
to
com
e bac
k a
rou
nd
. I
wasn
’t s
ayi
ng
th
at
I did
n’t
un
der
sta
nd
it,
so I
was
just
go
ing
alo
ng w
ith
it.
So
I d
idn
't k
no
w a
nd
th
en I
had
to
tu
rn a
rou
nd
and
ask
. B
ecau
se t
hen
I'd
co
me
to a
no
ther
appo
intm
ent
and t
hey
’d s
ay t
hat
th
ey s
aid i
t to
me,
bu
t I
nev
er -
it
look
ed l
ike
I
was
n't
pay
ing at
tenti
on.
But
it w
as th
e w
ay th
at it
w
as
med
ical
ly sa
id.
…I'
m no
t bei
ng
off
end
ed,
they
’re
no
t bei
ng o
ffen
siv
e to
me,
bu
t I
just
th
ink t
hat
som
etim
es I
've
go
t to
be
told
and
exp
lain
ed t
o.
I f
eel
ba
d t
hat
if I
ha
ve t
o a
sk I
fee
l li
ke
I'm
du
mb,
bu
t bec
au
se t
hey
au
tom
ati
call
y th
ink,
ass
um
e th
at
I kn
ow
th
at b
ecau
se I
m
ight
be
bri
ght.
B
ut
they
do
n't
real
ise
and
I'm
no
t go
ing t
o p
ut
that
po
int
ou
t to
th
em s
om
etim
es,
bec
ause
I'm
em
bar
rass
ed b
y
it.
(Mo
ther
of
No
ah,
age
13)
Bec
au
se w
hen
sh
e ca
me
from
th
e ca
rers
bef
ore
han
d t
her
e w
as
no
med
ica
l fi
les,
no
no
thin
g
giv
en t
o m
e, w
ell
if s
he
was
to
lea
ve
tom
orr
ow
th
ere’
s a
med
ical
fil
e ov
er t
her
e th
at h
as s
ho
wn
375
ever
yth
ing
th
at’s
ev
er
hap
pen
ed
in
her
li
fe
and
I
thin
k
that
’s
impo
rtan
t bec
ause
I
kn
ew
no
thin
g.
I did
n’t
ev
en
hav
e ph
one
num
ber
s;
I did
n’t
kn
ow
w
ho
w
ork
ed
wit
h
her
an
d
wh
at.
(Fost
er M
oth
er o
f K
aty,
age
16)
No,
they
don’t
. T
hey
don
’t l
iste
n a
t a
ll.
Th
ey j
ust
open
up
th
e ru
lebo
ok a
nd
sa
y ri
gh
t th
at’
s it
–fi
nis
hed
(F
ost
er F
ath
er o
f T
iana,
ag
e 9)
Ask
fo
r [T
her
apis
t’s
off
ice]
, an
d 9
tim
es o
ut
of
10,
you
’ll
get
pu
t th
rou
gh
to
[dif
fere
nt]
Dis
ab
ilit
y S
ervi
ces.
(F
ost
er M
oth
er o
f T
iana,
age
9)
So
wh
en y
ou r
ing u
p a
nd
ask
fo
r [T
her
apis
t] o
r, [
they
say
] “
who
, w
ho?”
. [I
say
]“S
he’
s in
[nam
e o
f o
ffic
e]”
[Th
ey s
ay,
In o
ffic
ious
tone]
, “W
e hav
en’t
go
t her
nam
e?”
[I s
ay]
“Wel
l
she’
s th
ere!
” (F
ost
er M
oth
er o
f T
iana,
ag
e 9)
Th
e dep
art
men
t[s]
need
to k
now
th
at
som
eth
ing
is
ha
pp
enin
g,
this
per
son
is
in t
he
ha
rd
ba
sket
it’
s goin
g t
o t
ake
us
a l
ot
lon
ger
wit
h t
hem
, goin
g t
o a
cces
s fo
r th
e sc
hool
ho
lid
ays
or
liv
ing r
emote
it’
s no
t al
way
s th
ere,
no
t ev
ery
on
e ca
n g
et t
o a
cli
nic
, no
t ev
ery
on
e go
es t
o
scho
ol,
no
t ev
ery
bo
dy h
as s
up
po
rt p
eople
th
at a
re s
up
po
rtiv
e, t
hey
may
be
in a
ho
use
wit
h
som
eon
e, t
he
sup
po
rt’s
not
alw
ays
ther
e. (
Fo
ster
Mo
ther
, K
aty
age
16)
Bei
ng
In
dig
eno
us
Bei
ng
In
dig
eno
us
Imp
ort
ance
of
cult
ure
L
ike
I sa
id,
she
did
n’t
kn
ow
it
aft
er w
e w
ent
to S
ydn
ey.
Sh
e ju
st l
earn
t all
lik
e E
ng
lish
fro
m
ther
e, w
hen
we
com
e ba
ck,
an
d i
n s
choo
l.
Ju
st E
ng
lish
. B
ut
she’
s pic
kin
g u
p [
Ind
igen
ou
s
La
ng
ua
ge]
up n
ow
. S
he’
s aw
are
of
a l
ot
of
wh
o h
er f
am
ily
is n
ow
. B
efore
she’
s ju
st s
ee l
ike
abo
rig
inal
mob
. I
’d j
ust
say
ok
ay,
that
’s y
ou
r au
nty
, or
this
is
your
fam
ily
. B
ut
did
n’t
know
the
rela
tion
ship
to
her
. S
he’
s fi
ndin
g t
hat
ou
t fo
r her
self
no
w.
So
it’
s go
od.
(Mo
ther
of
Ell
en,
age
19)
Cu
ltu
ral
exp
ecta
tio
ns
Yea
h,
I th
ink s
o b
ecau
se i
t’s
stil
l an
im
port
ant
thin
g,
thro
ug
ho
ut
her
th
erap
y w
e’v
e alw
ays
ha
d f
emale
s w
hic
h i
s a g
ood
th
ing b
ecau
se I
don’t
know
whet
her
or
not
a m
an s
ho
uld
be
to
uch
ing h
er a
nd
I t
hin
k t
he
on
ly t
hin
g i
s th
at m
akin
g s
ure
th
at s
he’
s g
ot
app
ropri
ate
cloth
ing o
n,
if s
he
has
wom
en’s
bu
sin
ess
wh
eth
er
or
no
t w
e sh
ou
ld g
o t
o t
hes
e
ap
poin
tmen
ts o
r w
ith
dra
w b
ecau
se t
hat’
s so
met
hin
g e
lse…
(F
ost
er M
oth
er o
f K
aty
, ag
e
376
16
)
Cu
ltu
ral
exp
ecta
tio
ns
Wit
h S
teve
wh
en h
e had
to g
et h
is o
rthoti
cs d
one
it w
as a
man
that
was
th
ere
and
I d
idn’t
min
d i
t w
as a
man
wit
h h
im.
So
met
imes
lik
e S
all
y w
ith
Doct
or
Jan
e sh
e’s
wit
h a
wo
man
,
so t
ha
t’s
fin
e by
me
bu
t if
a b
loke
cam
e u
p f
or
ph
ysio
I’d
lik
e so
meb
ody
ther
e…
.. (
Fo
ster
Mo
ther
of
Ste
ve,
age
21)
Rac
ism
Y
ou
kn
ow
, <
sigh
s> y
ou
wan
t to
be
pro
ud
of
wh
o y
ou
are
an
d w
her
e yo
u’r
e fr
om
bu
t yo
u’r
e
go
ing
to c
op
it
lik
e, y
ou’l
l co
p i
t, y
ou k
now
, y
ou
get
pla
ced i
n t
hat
ste
reoty
pe
and p
eop
le t
hin
k
bec
ause
I’m
a l
ight
hea
rted
per
son t
hat
they
thin
k i
t’s
all
good t
o h
ave
a jo
ke
abo
ut
it a
nd s
tuff
and
it’
s n
ot
funny
to m
e, i
t’s
off
ensi
ve
and
, y
ou k
no
w, I
may
not
let
on b
ut
it’s
sti
ll –
th
at’s
who
I a
m, w
her
e I’
m f
rom
and
th
at’s
who
my
kid
s ar
e an
d t
hat
’s w
her
e th
ey’r
e fr
om
. A
nd
if
they
wan
t to
be
pro
ud o
f th
eir
bac
kg
round a
nd
, y
ou k
no
w, w
ho t
hey
are
, th
ey h
ave
ever
y r
igh
t
to b
e.
It’s
not
a j
oke,
it’
s n
ot,
you
kn
ow
, it
’s n
ot.
.. W
e’re
no
t a
ll b
loody
sitt
ing i
n t
he
park
dri
nkin
g,
som
e p
eop
le, y
ou
kno
w. I
t’s
a sh
ame
that
th
at i
s so
me
of
the
min
ori
ty a
nd
, y
ou
kn
ow
what
, th
e A
bori
gin
als
aren
’t t
he
only
peo
ple
that
do i
t.....W
hit
e fe
llas
ju
st s
it i
n t
hei
r
ho
use
an
d d
o t
he
sam
e th
ing, y
ou k
no
w (
Mo
ther
of
Ari
el,
age
4)
[Th
ey s
ay]
oh y
ou’r
e h
ere,
“w
hy
, you
tal
k l
ike
yo
u’r
e a
whit
e w
om
an.”
I'm
lik
e, “
Wel
l w
e’re
livi
ng
in
a w
hit
e so
ciet
y, b
ut
it’s
no
t ev
en a
wh
ite
soci
ety,
it’
s fo
r eve
ryon
e. I
t’s
just
wh
ite
peo
ple
ha
ve t
o r
un
th
ese c
ha
nn
els
an
d I
said
it
is a
fact
. B
ecau
se s
om
e o
f th
em a
re t
he
on
es
wit
h t
he
hel
met
s o
n y
ou
kn
ow
...
“(m
oth
er o
f N
oah
, ag
e 13
)
Rac
ism
…
. E
ven
th
ou
gh
I’m
a w
hit
e fe
lla
fro
m x
xx
xx
x [
laug
hs]
an
d p
eople
see
m t
o s
ee a
wh
ite
fell
a
pu
shin
g a
n A
bo
rigin
e a
nd t
hey
’ll
[th
ink
] “
wh
at’
s g
oin
g o
n h
ere?
”…
I’m
giv
en t
ha
t h
orr
ible
feel
ing
th
at,
wh
at
do y
ou
call
th
at
mob t
hat
live
in
th
e g
rass
?
(Fo
ster
Fat
her
of
Tia
na,
ag
e 9)
Inte
rvie
wer
: …
Th
ey t
hin
k y
ou’r
e a
long g
rass
er [
ho
mel
ess
per
son
]?
Fo
ster
Fat
her
: [a
ffir
ms
and
lau
ghs]
Sch
oo
l E
xp
ecta
tio
ns
Yes
In
dig
enou
s, b
ecau
se o
f th
e -
it d
id c
om
e do
wn
wit
h t
he
raci
al
thin
g,
a l
ot
of
peo
ple
did
n’t
wan
t to
take
the
tim
e to
sit
do
wn
wit
h I
nd
igen
ou
s ch
ild
ren
an
d t
each
th
em.
Th
ey m
ove
d
377
Rac
ism
th
em t
o t
he
nex
t le
vel
wit
hou
t fu
lly
edu
cati
ng
th
em. (
moth
er o
f N
oah
, ag
e 13
)
Sch
oo
l E
xp
ecta
tio
ns
Rac
ism
Wh
ere
in m
y s
cho
ol,
it
was
En
gli
sh [
spo
ken
], y
ou
know
th
at a
nd
we
did
wh
at s
he
[th
e te
acher
]
asked
of
us.
We
had
Eng
lish
fir
st a
nd t
hen
cult
ure
tim
e af
ter
scho
ol.
An
d I
sa
id t
o t
he
tea
ch
er
“Y
ou
’re
bei
ng
ra
cist
to
th
em. T
hey
do
n’t
kn
ow
En
gli
sh.…
th
ose
2 y
oung
gir
ls [
clas
smat
es]
wer
e fr
om
[R
emote
Sch
ool]
…”
Th
ey d
on’t
know
a s
ingle
word
of
En
gli
sh a
nd
they
go
t to
tal
k
En
gli
sh p
rop
erly
. W
her
e th
ey w
ere,
‘B
ilin
gual
’ w
as t
hei
r fi
rst
lang
uag
e”.
(Mo
ther
of
Mar
y,
age
17)
Rac
ism
an
d
dis
emp
ow
erm
ent,
str
ess
I st
ay
aw
ay
from
th
at,
bec
au
se i
f I
get
lin
ked
up
[to
sup
po
rt]
wit
h t
hat
it
cou
ld a
ffec
t m
e in
oth
er t
hin
gs
wit
h c
hil
d p
rote
ctiv
e se
rvic
es w
ill
see
tha
t I'
m s
tru
gg
lin
g.
I c
anno
t co
pe
and I
do
n't w
ant
to e
ver
in
vo
lve
that
, so
I d
o i
t m
yse
lf (
moth
er o
f N
oah
, ag
e 1
3)
Rac
ism
It
’s l
ike
a ji
gsa
w p
uzz
le,
I th
ink
th
at
on
ce [
the
con
cep
t of]
‘ra
cism
’ h
as
step
ped
in
it’
s li
ke
the
pu
zzle
beco
mes
bro
ken
, m
issi
ng
, d
am
aged
. (F
ost
er M
oth
er o
f K
aty
, a
ge
16)
378
4.8 THEME DIAGRAM
SERVICE DELIVERY
This diagram reflects the position of physiotherapy service delivery and underlying theme
of communication permeating the emerging themes.
Lives with Multiple and Complex
Demands
Being Indigenous
Relationships: Caring,
Consistency, Communication
379
4.9 ELABORATION ON OVERALL STUDY METHODOLOGY
Mixed Methods
Throughout my experience as a physiotherapist, an Australian and a public health student I have
noted the disparity between what the medical records and people in the community report about
care, the one-sided picture of Indigenous health through statistics, political news blips and health
documents.
While on a personal level I have been influenced by my undergraduate courses in anthropology
where one is taught to look at what is not obvious and to look at any social phenomenon in a
way to better understand those who experience it, or in turn to look at those who experience a
phenomenon to understand the event in itself. Professionally, I have trained in physiotherapy
whose most basic foundations focus on the natural sciences. One is taught to examine or search
for tangible signs of a disorder and avoid nebulous processes such as applying intuition.
Community-based physiotherapy service in the area of disability is placed in both the social and
physical sphere. Physiotherapy services and client experiences may be complicated by a
multitude of issues. The theoretical approach adopted could be considered one of pragmatism.
Pragmatism, as defined by the Merriam-Webster dictionary, is “a reasonable and logical way of
doing things or of thinking about problems that is based on dealing with specific situations
instead of on ideas and theories”(internet website).
Through conducting an examination of services provided, service provider perspectives and
service user perspectives, I hoped to develop a picture that was greater than any one approach
itself could provide.
