Evaluation of the inclusion of an allied health assistant within an adult cystic fibrosis centre : Their role, scope of practice, and impact on physiotherapy services

Cystic Fibrosis (CF) is a chronic, progressive disorder and the predominant genetic condition in Australia. The last few decades have seen a rise in the survival age and numbers of adults with Cystic Fibrosis attributable primarily to improved access to multidisciplinary care delivery via dedicated CF services and the impact of new medications, including, most recently, modulator therapies. These increased numbers and complexity of care delivery requirements have presented challenges for developing sustainable models of care delivery. Physiotherapy is a key component of the multidisciplinary care delivered to adults with CF. Several countries have developed clinical practice and standards of care guidelines, including physiotherapy clinical guidelines, that recommend requirements for care delivery, structure, staffing, and roles of the multidisciplinary team for adults with CF. However, it is not known if current physiotherapy services meet the recommended guidelines in terms of care delivery. Meeting service demands with growing numbers of patients will require innovative service redesigns to deliver efficiencies and services amenable to both staff and patients.

Implementing an allied health assistant (AHA) role into CF physiotherapy services may be feasible and sustainable for remodelling care delivery. Delegating clinical and non-clinical tasks to a specially trained AHA could improve physiotherapy care delivery and may change the scope of practice for CF physiotherapists. Currently, there is no published evidence on how a service redesign involving an AHA role may affect patient safety or the scope of practice of physiotherapists and AHAs in acute respiratory clinical settings, specifically in adult CF care. The overarching aim of this thesis was to establish current physiotherapy care delivery for adults with CF and then implement and evaluate a service redesign using an AHA role. Four studies were completed. The first study aimed to establish current CF physiotherapy care delivery and benchmark against current clinical guideline evidence. The second study examined the redesign of the CF physiotherapy service using a systematic workforce redesign system, the Calderdale Framework. Study three examined the changes to the remodelled CF physiotherapy care delivery for both physiotherapists and AHAs associated with implementing the AHA role. Finally, the fourth study examined changes in staff and patients' perceptions of the care delivery pre-and post-implementation of the AHA role.

Study 1 examined physiotherapy service provision, scope of practice, and skill mix in a large tertiary adult CF service using a cross-sectional observational study. Results showed that care was provided by 22 physiotherapists. Respiratory (n = 1058, 38%), and exercise treatments (n = 338, 12%) were provided frequently. However, other recommended activities, such as exercise testing (n = 20, 1%) and detailed treatment reviews (n = 79, 3%) occurred infrequently. Time for research was limited. Junior physiotherapists undertook more exercise treatments per day (p < 0.001), with senior physiotherapists attending outpatient clinics (p < 0.001). Findings from this study suggest that adherence to clinical practice recommendations could be improved. A redesign of services that would support and improve the existing staffing and skill mix within adult CF services to meet recommended standards of care was undertaken. Development and implementation of an AHA role were proposed as part of service redesign.

Study 2 examined the real-world application of the Calderdale Framework as a workforce redesign to implement an AHA role within an acute respiratory physiotherapy service. Staff perceptions were collected at four time points during the implementation to assess the Framework’s serviceability. Clinical and non-clinical delegation tasks were developed for acute respiratory physiotherapy care. In addition to AHA competency training, all staff received training in delegation procedures, emphasising risk mitigation. Six new comprehensive clinical task instructions, guidelines and other resources were created. Using the Calderdale Framework to support implementation was perceived by staff to be a positive experience. A positive change in the perceptions of the value and role of an AHA and increased confidence in the understanding of delegation procedures was perceived by staff.

Study 3 explored the changes to physiotherapy care delivery following the addition of an AHA into CF physiotherapy service in a pragmatic pre-post design study. This study describes care delivery in terms of the service provision, scope of practice, skill mix and any safety implications for patients with CF and staff associated with the new model of care. Overall, physiotherapy care delivery Increased. Physiotherapists conducted fewer respiratory (p<0.001) and exercise treatments (p < 0.001) but increased complex review of care for inpatients (p<0.001). Physiotherapists’ activity in multidisciplinary outpatient clinics increased (56% vs 76%, p<0.01). The AHA provided 20% of all service provision. The AHA delivered clinical care as delegated established respiratory (5%) and exercise treatments (10%) and completed the majority of all exercise tests (n = 25). Most AHA activity involved non-direct clinical care, such as managing equipment and patient-related administrative tasks. No adverse events were reported.

Study 4 examined patient and staff perceptions of, and satisfaction with, the physiotherapy care delivery pre-implementation of the AHA role and assessed any perceived change to care delivery post-implementation of a new AHA role in a pragmatic pre-post-study design. Pre/post response rates were similar: patients 35% (n = 63) vs 36% (n = 62), multidisciplinary team 51% (n = 18) vs 49% (n = 17). According to patients, physiotherapists provided good to excellent care (P1-87%, P2-88%, p=0.097) pre- and post-AHA implementation. Two-thirds of patients reported involvement with the AHA. Physiotherapy care delivery was perceived as effective by 72% of participants pre-implementation and increased to 87% post-implementation (p = 0.024). The multidisciplinary team acknowledged physiotherapy staff as valuable, despite 22% reporting that access to physiotherapy did not happen pre-implementation. As a result of the addition of the AHA, senior physiotherapists were more accessible for clinical discussion and clinical research, improving physiotherapy care delivery according to multidisciplinary team staff. Overall findings suggested that an AHA role did not change the perceived high quality of physiotherapy care but improved the care's perceived effectiveness.

Implementing an AHA role within an acute respiratory physiotherapy service has contributed new evidence regarding scope of practice and its impact on physiotherapy care delivery. It should be considered by physiotherapists and other allied health professionals to support remodelling care delivery. The development of AHA roles in other allied health professional services and other hospital and community settings should be supported by evidence demonstrating the scope of practice and acceptability of such roles. Other healthcare service delivery models can benefit from moving towards evidence-based care delivery recommendations, improving effectiveness and maintaining high quality. An evidence-based redesign system is recommended when redesigning a health service, particularly skill mix. An effective system must be comprehensive, systematic and engage all stakeholders, including comprehensive training for new and appropriate AHA activity, training for all staff in delegation procedures and ongoing mentoring and supervision for the role. Research is needed to provide robust data to support the effectiveness of these new models of care delivery, which extend the scope of practice for AHAs while enhancing the contributions of both junior and senior physiotherapists, demonstrating a better overall workforce delivery, as well as cost-effectiveness.