DOI: 10.1111/ajag.12157

Research How do general practitioners engage with allied health practitioners to prevent falls in older people? An exploratory qualitative study Alasdair Grant Injury Treatment: Occupational Injury Management, Sydney, New South Wales, Australia

Lynette Mackenzie Discipline of Occupational Therapy, Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia

Lindy Clemson Ageing Work and Health Research Unit, Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia

Aim: To explore general practitioners’ (GPs’) perceptions about their use of Chronic Disease Management (CDM) items to access allied health interventions, in particular occupational therapy and physiotherapy, with the purpose of preventing falls, as well as to identify GP support needs with regard to development of partnerships with local allied health practitioners. Method: A qualitative study was conducted in the Sydney metropolitan area through individual semistructured interviews with eight GPs, which were recorded, transcribed and analysed thematically. Results: Themes included (i) difficulties and opportunities associated with multidisciplinary care; (ii) potential for CDM items to be used to support falls prevention strategies; and (iii) the user-friendliness of the CDM items. Conclusion: Effective coordination of multidisciplinary care between GPs and allied health professionals was desired but difficult to achieve through the CDM system, making translation of falls prevention evidence into clinical practice challenging. Further education on falls prevention and CDM item modification is needed to bridge this gap. Key words: accidental falls, chronic disease management, occupational therapy, physiotherapy.

Introduction Falls are the key cause of injury for older people over the age of 65 [1]. As Australia’s population continues to age, the medical and economic costs associated with falls and fallrelated injuries are growing [2]. Falls are extremely common in communities, with 30% of older people aged 65 and over and 50% of those aged 80 and over expected to fall at least once each year [3]. While around 10% of falls may result in Correspondence to: Associate Professor Lynette Mackenzie, Discipline of Occupational Therapy, Faculty of Health Sciences, University of Sydney. Email: [email protected] Australasian Journal on Ageing, Vol 34 No 3 September 2015, 149–154 © 2014 ACOTA

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an injury requiring medical attention or follow-up, other serious consequences of falls include reduction in activity, loss of confidence and increased social isolation [4]. Unless they result in admission to hospital, many fall events may go unreported and unattended to by any health professionals. To help address the increasing burden of falls, effective falls prevention interventions are available, such as home safety interventions and balance and strength exercise programs [5–7]. However, falls prevention programs in Australia are typically only accessed after an individual has experienced multiple falls [8]. General practitioners (GPs) are the key referral agents for older people in the community. However, to be referred to allied health practitioners, older people have to be identified as at risk of falls [9]. The establishment of Medicare Locals provided the possibility to bring allied health and GP practices together to facilitate greater collaboration between GPs and allied health practitioners in falls prevention [3,10]. One way that GPs in Australia can access subsidised allied health services for patients is through the Chronic Disease Management (CDM) system; however, the uptake of CDM items for occupational therapy and physiotherapy in particular is very low for people over the age of 65 [11]. Studies indicate that there are barriers to the uptake of CDM items in primary health-care practice [11,12], but few studies address community falls prevention. Similar issues have also been reported from the perspective of allied health practitioners [13,14]. Therefore, this qualitative study aimed to explore GPs’ perceptions about their use of CDM items to access allied health interventions to prevent falls, in particular occupational therapy and physiotherapy, and to identify GP support needs in order to facilitate the development of partnerships with local allied health practitioners.

Methods Ethical approval for this study was granted by the University of Sydney Human Research Ethics Committee. A qualitative design was selected, as the study was exploratory. GPs across the Sydney metropolitan area were invited to participate via email or mail, with addresses obtained using publicly available online practice directories and databases. Purposive sampling was used to ensure participants came from socioeconomically diverse locations. For the purpose of this study, the Prevention 149

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of Falls Network Europe (ProFANE) fall definition was employed: ‘an unexpected event in which the participants come to rest on the ground, floor, or lower level’ [15]. Data were collected from July to September 2010 using semistructured in-depth interviews, conducted by the first author, who had been trained in qualitative interview techniques. An interview schedule (see Table 1) was developed and piloted with two GPs prior to the study. Interviews lasted between 30 and 65 minutes and were recorded and transcribed verbatim. Each interview transcript was analysed prior to the next interview. Analysis took a grounded-theory approach using constant comparison and involved line-byline open coding and organising codes into categories. Axial coding was used to find relationships between the categories. Finally, selective coding was performed to incorporate the categories into a tentative framework [16]. Data analysis continued until themes became repetitive, which indicated theoretical saturation. Memos and diagrams were used throughout data analysis [16].

Table 1: Interview schedule Can you tell me about what your experience is of the Chronic Disease Management system? • Purpose of the CDM system? • Personal feelings about the CDM system? • How did you first come to know about the CDM system? • Previous experiences with the CDM system? What do you see as barriers and supports to your use of the CDM items? • Barriers/limitations to your use of the CDM items? • Access to allied health providers? • Supporting factors that have helped you use the CDM items? • Factors that would help you use the CDM items? Can you tell me more specifically about your use of the allied health initiatives of the CDM system? • Explain your current use of these items. • Diagnosis/age/particular allied health professions used? • Use of team care arrangements with allied health providers? • Barriers/limitations to your use of allied health initiatives? • Supporting factors that have helped you use the allied health initiatives? Can you tell me about your use of the CDM system with older people? • Broad estimate of your CDM usage? • Type of usage? • Barriers/limitations to your use of the CDM initiative? • Supporting factors to help you use the CDM system? Can you tell me about how the CDM items contribute to multidisciplinary care teams? • What do you think your role is in the multidisciplinary team? • What do you consider the other team member roles are? • How often are you involved in multidisciplinary care? • Barriers/supports to your involvement in multidisciplinary care? Do you think a CDM multidisciplinary team could be effective for falls prevention? • What do you perceive your role to be in community falls prevention? • Explain your understanding of what each team member can offer in community falls prevention. • Do you think your role is understood by the other team members? • How often would you typically interact with other multidisciplinary team members? • What would you do within this team for falls prevention? Do you have any other comments to make about the CDM system in general or using the CDM system for falls prevention interventions? 150

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The trustworthiness of the data analysis was addressed though consensus coding (where the first and second authors coded the interview transcripts separately and then discussed the results) [17] and member checking (where interview transcripts were summarised with preliminary codes and returned to participants for comment), and field notes were taken prior to and after interviews. All authors approached the study analysis from an occupational therapy background.

Results Eight GPs were interviewed. Participants had between seven and 32 years of practice experience with a mean of 24 years. There was an equal gender split. Each participant had previously used CDM items for various allied health referrals, but only half had used them for falls prevention interventions, with varying success and frequency. Three major themes were identified from the analysis: (i) difficulties and opportunities associated with multidisciplinary care; (ii) potential for CDM items to be used to support falls prevention strategies; and (iii) the user-friendliness of the CDM items. Theme 1: Difficulties and opportunities associated with multidisciplinary care Referrals to physiotherapists, podiatrists and dieticians but not occupational therapists Referrals were often related to management of diabetes, osteoporosis, osteoarthritis and chronic respiratory problems; therefore, GPs regularly engaged the services of podiatrists, physiotherapists and dietitians. The services of private occupational therapists were infrequently accessed by GPs, except for the few GPs from socioeconomically privileged areas. Half of the GPs described having little knowledge of the availability of private occupational therapy services and instead referred patients to public health services or the Department of Veterans’ Affairs. According to Participant 1: It would be good to have an [occupational therapist] doing that but we don’t have one. . . . We would have to get an [Aged Care Assessment Team] to do it and that would take 6 months. Some GPs suggested that older people enquired about physiotherapy services but not occupational therapy. Therefore, occupational therapy could be overlooked by both GPs and patients. A small number of GPs believed that occupational therapy services were more appropriate for people who had been hospitalised or those requiring rehabilitation. Communication between general practitioners and allied health provider critical but challenging GPs identified communication with allied health providers and the patient as critical to quality of care, although it was also difficult. Some GPs noted that the complexity of organising CDM plans added to communication challenges, Australasian Journal on Ageing, Vol 34 No 3 September 2015, 149–154 © 2014 ACOTA

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whereas others thought that communication was enhanced by using CDM items. According to Participant 7: With the CDM items . . . we’ve got much better communication because we’ve set some goals, they know what we are looking for . . . and the fact that they actually have to report back . . . ensures that you’re going to get good two-way communication. GPs recognised strategies that made communication easier, such as being familiar and knowledgeable about allied health providers. Most indicated their preference to use allied health providers that they knew and had worked with previously, as they were more confident about the care being provided and were more aware of the allied health provider’s specialist skills. According to Participant 3: But once you have got a group of people that you know and that you work with regularly it becomes easy and quite good . . . and you tend to target the ones that have helped you in the past. Case conferencing incompatible with practice demands None of the participants regularly used CDM case conferencing items, as they were seen as ‘awkward’ and took up too much time. GPs preferred to contact allied health providers individually outside of the system. Some GPs acknowledged that case conferencing items could enhance the quality of patient care, although they would have to change work practices to use them. Participant 1 stated: My dream would be to have a couple of hours a week set aside for team consultations . . . and we could identify where there were gaps and overlaps. Everyone could pool their ideas about what would be best. I’m sure that would be much more beneficial to the patients. Theme 2: Potential for CDM items to be used to support falls prevention strategies Falls as a significant issue All the GPs recognised that falls were a significant issue because of the ageing population and the consequences a fall can have for an older person, including hospitalisation, admission to a nursing home and death. According to Participant 7: Hopefully we can prevent injury from falls by making their bones stronger and their muscles stronger so that they don’t damage themselves quite as much. Despite having considerable knowledge of falls prevention and reduction strategies, many GPs were not implementing these with older patients, as falls were viewed as ‘inevitable’. This led many GPs to maintain a focus on treating the consequences of falls rather than adopting preventative strategies. Many suggested that falls prevention was needed, yet more than half did not address the issue until after an injurious fall had occurred. As Participant 6 stated: Australasian Journal on Ageing, Vol 34 No 3 September 2015, 149–154 © 2014 ACOTA

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I must admit that a lot of my falls prevention work has been probably done after people have had a fall and after people have fractured something. GPs perceived that patients were resistant to falls prevention, and this was attributed to older people not wanting to lose their autonomy or independence. They suggested that older people were only receptive to falls prevention once a fall occurred resulting in a hip fracture. According to Participant 5: It has taken me years to convince [one of my patients] that she just really couldn’t live at home, and she had to fall several times before she finally accepted that. GPs as gatekeepers to access falls prevention services from other team members GPs often referred to themselves as ‘coordinators’ or ‘gatekeepers’ and felt that this was the primary purpose of the CDM system. They recognised the need to effectively assess patients’ health conditions, identify the appropriate treatment and coordinate the appropriate care services for the patient. GPs regarded their roles in falls prevention as follows: My main role would be to detect, identify those patients and if there are obvious medical issues that I can help them with to improve their general mobility and so on. But beyond that, identify specific people to help patients in their physical environment. (Participant 3) GPs consistently indicated that they would employ the services of occupational therapy and physiotherapy providers as they had specialist knowledge in falls prevention. GPs perceived the occupational therapy role to include home assessment and modification, while the physiotherapist addressed muscle function, balance and coordination. Potential of CDM items yet to be realised for falls prevention strategies Every GP recognised the potential for the CDM items to be used as an avenue for falls prevention. One GP stated they were ‘lucky’ and benefited from practising in areas that were well serviced by private allied health providers specialising in falls prevention, which made falls prevention using CDM items readily available. Two GPs described their preference to use existing community health services and programs instead of using the CDM items to access private allied health providers. They felt that community health services offered sufficient falls prevention programs, and they preferred to use the CDM items for other purposes such as diabetic care. Theme 3: User-friendliness of the CDM items CDM items can be beneficial All the GPs perceived the CDM items as beneficial to older people, as they opened up services that were not previously 151

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available, improved the quality of care, provided access to private allied health professionals and reduced reliance on public health services. Several GPs commented on the positive aspects of being able to treat older people with complex, chronic health conditions in the community rather than using institutions. It is much more satisfactory from a cost–benefit point of view and for the patient. . . . Most people have got multisystem pathology and we are managing them far more at home rather than institutions. (Participant 4) You take away expenses and they don’t have to travel to and from the public hospitals. . . . So it’s beneficial for them but it makes little difference for me really. (Participant 2) Identified barriers to CDM utilisation Despite patient benefits, the CDM items were not viewed as valuable by all of the GPs and their peers. GPs described a range of practice barriers to using CDM items, caused by busy workloads and a shortage of GPs. Several commented that the time required to organise a CDM care plan for one patient resulted in other patients missing out on care. According to Participant 2: Let’s say that I do a care plan every day – well, that’s four or five patients that I can’t see. It’s a backlog and either I’ve got to work more hours, which I can’t, or some of the patients end up missing out. GPs labelled the items as a ‘hassle’ and ‘inconvenience’ due to time demands created by excessive paperwork and longer consultations. One participant reported that they were aware some GPs refuse to use the CDM items. Participant 2 stated: But I would rather not use the care plan or have a very shortened version of it. . . . It’s all rubbish. It’s the kind of rubbish produced by bureaucrats. GPs expressed frustration with allied health services being limited to five sessions per calendar year through the CDM system, as this was considered to hinder the quality of care that they could provide. They suggested that 10 allied health referrals per calendar year, or having separate CDM items for falls prevention similar to mental health and dental care claims, would be more appropriate to improve their utilisation.

Practice nurses as a link to CDM utilisation Several GPs viewed practice nurses as significant in facilitating their use of CDM items. They commented on how essential nurses were in reducing paperwork, negating the need for long consultations, enhancing multidisciplinary communication and reducing their time commitment. A few GPs stated that without the practice nurse they would not utilise the CDM items. Other GPs highlighted technological supports 152

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such as electronic reminders and automatic patient updates as valuable time-saving resources for CDM utilisation.

Discussion Findings indicated that the GPs in this study were not consistently facilitating falls prevention interventions in the community. Despite the high prevalence and adverse effects of falls among older adults living in the community, prevention appeared to receive limited attention in everyday GP practice. However, GPs considered that using the CDM items for falls prevention could be a workable solution in the future. Multidisciplinary care GPs actively used CDM items to manage other chronic conditions, particularly diabetes, hypertension and osteoporosis, yet multidisciplinary care in the community was a barrier for GPs [18]. GPs indicated that multidisciplinary care in the community often yielded disappointing results due to poor communication and referral links between health providers. This would account for difficulties reported by participants in coordinating with allied health providers to implement falls prevention. Familiarity with local allied health providers meant smoother communication processes and a superior level of care [19]. Consistently with previous research [20], GPs recognised the benefits of multidisciplinary care for patients with complex care requirements and understood the specialist skills of allied health professionals. Falls risk is one such complex requirement. However, a greater awareness of occupational therapy services on the part of both GPs and community members is needed to make multidisciplinary care available to those needing falls prevention interventions [9]. Although there is evidence to support using occupational therapy services in the community with older people [21], findings indicated that GPs viewed occupational therapy services as properly limited to hospital or rehabilitation settings. Multidisciplinary care in the community depended on strong referral and communication links between health providers; however, referral alone has been shown to be ineffective for complex falls prevention interventions [22,23]. Relying on referral alone often leads to lack of coordination and communication between health providers and to ineffective service provision or no service provision at all [24]. Falls prevention requires the coordination of several health providers with complementary skills and evidence-based knowledge, including GPs, practice nurses, occupational therapists and physiotherapists. Translation of evidence about preventative care into practice Evidence-based interventions implemented by GPs are a key resource for reducing the impact of falls in older people, yet the study findings indicate that GPs do not commonly translate research evidence for falls prevention into their practice Australasian Journal on Ageing, Vol 34 No 3 September 2015, 149–154 © 2014 ACOTA

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[22,24]. Our findings have shown that despite GPs often being aware of suitable falls prevention strategies such as strength and balance exercises and home safety interventions, these were not routinely employed. The focus of care appeared to be medical treatment rather than preventative interventions. Further professional education may be required to help GPs adopt falls prevention interventions in their clinical practice [25].

Conclusion Effective falls prevention strategies are well known, and to be effectively implemented, these need to be available in the community, where GPs can identify older people at risk and coordinate services to mitigate their risk. This study has demonstrated that there is a gap in the evidence-based services offered by allied health practitioners in primary care Australasian Journal on Ageing, Vol 34 No 3 September 2015, 149–154 © 2014 ACOTA

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Key Points • Effective falls prevention strategies are available in the community from allied health professionals. • GPs tend not to incorporate falls prevention into their clinical practice with older people. • Current systems need to be adapted to make the translation of falls prevention evidence into general practice possible to achieve.

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Limitations of the study The applicability of the study findings across Australia is limited as the participants were all from metropolitan Sydney, and some GPs may have agreed to participate because they had strong opinions relating to the CDM items and/or falls prevention. It is unknown if these findings would be replicated in other locations, so future research should include the perceptions of GPs from regional, rural and interstate areas, and address a larger sample.

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settings, largely due to barriers in GP practice. Practice change is needed for falls prevention to be effectively implemented in primary care. This should involve education of GPs and other health professionals, along with the establishment and adequate funding of effective multidisciplinary teams working in cooperation. Sustainable pathways for falls prevention are essential and must be developed in the primary care setting.

The need for older people in the community to understand the benefits of falls prevention interventions was also identified. GPs’ framing recommendations for referral to falls prevention services as improving performance with daily living tasks may be greeted positively by older people [26]. Older people may prompt the GP to incorporate falls prevention interventions into practice [25]. Limitations of the CDM system Findings indicated that the CDM system needs modification if health providers are to provide the most effective service. Competing demands and time limitations often restricted GPs’ ability to address falls prior to an injurious fall. Other studies have identified the limitations of the current system with regard to provision of adequate care as seen by allied health providers [13,14]. GPs struggled with the bureaucratic requirements of the CDM system, which led to low uptake of the items [12,18]. GPs commonly felt that the CDM items were insufficient for dealing with complex, chronic health conditions due to the limited availability of allied health services and restrictions on the eligibility and number of services being provided. GPs further suggested that the CDM items were more suited to basic assessment and brief intervention tasks rather than sophisticated multidisciplinary care [27]. Nonetheless, GPs who utilised practice nurses and IT support were able to more efficiently utilise the CDM items. Community falls prevention utilising these items is an opportunity for GPs to expand their practice of preventative care in the community, but if the barriers to the items’ use remain in place, they may continue to be underutilised in the future.

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Bradley C. Hospitalisations due to falls by older people, Australia 20092010. Injury Research Statistics Series no. 70. Cat no. INJCAT 146. Adelaide: Australian Institute of Health & Welfare, 2013. Watson W, Clapperton A, Mitchell R. The incidence and cost of falls injury among older people in New South Wales 2006–2007. Sydney: NSW Dept of Health, 2010. Australian Commission on Safety and Quality in Healthcare. Falls prevention best practice guidelines (community). Canberra: Commonwealth of Australia, 2009. [Cited 14 March 2014.] Available from URL: http:// www.cec.health.nsw.gov.au/programs/falls-prevention#resources Monagle S. Reducing falls in community dwelling elderly. The role of GP care planning. Australian Family Physician 2002; 31: 1111–1115. Clemson L, Mackenzie L, Ballinger C, Close JC, Cumming RG. Environmental interventions to prevent falls in community-dwelling older people: A meta-analysis of randomized trials. Journal of Aging and Health 2008; 20: 954–971. Gillespie L, Robertson C, Gillespie W et al. Interventions for preventing falls in older people living in the community. [Systematic review]. Cochrane Database of Systematic Reviews 2012; (9): CD007146. Sherrington C, Whitney J, Lord S, Herbert RD, Cumming RG, Close JC. Effective approaches to exercise in the prevention of falls: A systematic review and meta-analysis. Journal of the American Geriatrics Society 2008; 56: 2234–2243. Hill K, Moore K, Dorevitch M, Day LM. Effectiveness of falls clinics: An evaluation of outcomes and client adherence to recommended interventions. Journal of the American Geriatrics Society 2008; 56: 600–608. Mackenzie L, Clemson L, Roberts C. Occupational therapists partnering with general practitioners to prevent falls: Seizing opportunities in primary health care. Australian Occupational Therapy Journal 2013; 60: 66–70. Medicare Locals Commonwealth of Australia. Improving primary health care for all Australians. Canberra: Commonwealth of Australia, 2011. [Cited 14 March 2014.] Available from URL: http://www.yourhealth .gov.au/internet/yourhealth/publishing.nsf/content/improving-primary -health-care-for-all-australians-toc Blakeman TM, Harris MF, Comino EJ, Zwar NA. Evaluating general practitioners' views about the implementation of the Enhanced Primary Care Medicare items. The Medical Journal of Australia 2001; 175: 95–98. Oldroyd J, Proudfoot J, Infante F et al. Providing healthcare for people with chronic illness: The views of Australian GPs. The Medical Journal of Australia 2003; 179: 30–33. Middlebrook S, Mackenzie L. The Enhanced Primary Care program and falls prevention: Perceptions of private occupational therapists and physiotherapists. Australasian Journal on Ageing 2011; 31: 72–77. Cant R, Aroni R. Melbourne dietitians' experience of Medicare policy on allied health services in the first 12 months. Nutrition and Dietetics 2007; 64: 43–49. 153

G r a n t

15

16 17 18 19

20

21

154

Lamb SE, Jorstad-Stein EC, Hauer K, Becker C; Prevention of Falls Network Europe and Outcomes Consensus Group. Development of a common outcome data set for fall injury prevention trials: The Prevention of Falls Network Europe consensus. Journal of the American Geriatrics Society 2005; 53: 1618–1622. Strauss A, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage, 1990. Miles M, Huberman A, eds. Qualitative Data Analysis, 2nd edn. Thousand Oaks, CA: Sage, 1994. Harris M, Zwar N. Care of patients with chronic disease: The challenge for general practice. The Medical Journal of Australia 2007; 187: 104– 107. Powell Davies G, Harris M, Perkins D et al. Coordination of care within primary health care and with other sectors: A systematic review. Sydney: Research Centre for Primary Health Care and Equity, School of Public Health and Community Medicine, University of New South Wales, 2006. Tieman J, Mitchell G, Shelby-James T et al. Integration, co-ordination and multidisciplinary care: What can these approaches offer to Australian primary health care? Australian Journal of Primary Health 2007; 13: 56–65. Matteliano M, Mann W, Tomita M. Comparison of home based older patients who received occupational therapy with patients not receiving

A ,

22 23

24 25

26 27

M a c k e n z i e

L ,

C l e m s o n

L

occupational therapy. Physical and Occupational Therapy in Geriatrics 2002; 21: 21–33. Clemson L. Prevention of falls in the community. British Medical Journal 2010; 340: 1042–1043. Gates S, Lamb SE, Fisher JD, Cooke MW, Carter TH. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency care settings: Systematic review and meta-analysis. British Medical Journal 2008; 336: 130– 133. Tinetti M. Multifactorial fall-prevention strategies: Time to retreat or advance. Journal of the American Geriatrics Society 2008; 56: 1563– 1565. Baker D, King M, Fortinsky R et al. Dissemination of an evidence-based multicomponent fall risk-assessment and -management strategy throughout a geographic area. Journal of the American Geriatrics Society 2005; 53: 675–680. Yardley L, Donovan-Hall M, Francis K, Todd C. Older people's views of advice about falls prevention: A qualitative study. Health Education Research 2006; 21: 508–517. Foster MM, Mitchell G, Haines T, Tweedy S, Cornwell P, Fleming J. Does Enhanced Primary Care enhance primary care? Policy-induced dilemmas for allied health professionals. The Medical Journal of Australia 2008; 188: 29–32.

Australasian Journal on Ageing, Vol 34 No 3 September 2015, 149–154 © 2014 ACOTA

How do general practitioners engage with allied health practitioners to prevent falls in older people? An exploratory qualitative study.

To explore general practitioners' (GPs') perceptions about their use of Chronic Disease Management (CDM) items to access allied health interventions, ...
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