Goal Attainment and Outcomes of Physiotherapy Participants Funded by an Individualised Government Package’


 Purpose: To determine goal attainment and change in physical outcomes of individuals participating in a community Physiotherapy program funded by a new government funding package, the National Disability Insurance Scheme (NDIS). Additionally, to describe the alignment of NDIS goals with Physiotherapy goals and the impact of the NDIS on access to Physiotherapy.Methods: A consecutive case series was conducted involving 12 participants attending NDIS-funded Physiotherapy at a private clinic in Sydney, Australia. Outcome measures were recorded upon entry to the study and again after 6 months or at discharge, whichever occurred first. The primary outcome was goal attainment measured by the Goal Attainment Scale. Secondary outcomes included the 5-metre walk test, Motor Assessment Scale, World Health Organisation Quality of Life questionnaire and Exercise Self Efficacy Scale.Results: Forty-one percent of goals were fully attained and for 53% performance was equal to baseline, however, this was not reflected in concurrently measured outcomes where small changes occurred. Physiotherapy goals focused on mobility whilst NDIS goals varied. Changes in outcome measures differed between individuals. NDIS funding provided all participants access to more frequent or otherwise inaccessible Physiotherapy.Conclusion: Physiotherapy participants funded by an individualised government package had improved access to Physiotherapy where participants attained individualised goals.


Introduction
Physiotherapy (Barker et al. 2017, Allen et al. 2019, Ertekin et al. 2012, Spencer et al. 2018, Baque et al. 2016, Pollock et al. 2007, Dorsch, Ada and Alloggia 2018, Latimer-Cheung et al. 2013. As NDIS has prompted a shift in Australian Physiotherapy services, it is important to understand the outcomes experienced by this unique population to guide continued development of private sector services. This study documents goal attainment, physical outcomes, self-efficacy, quality of life (QoL) and satisfaction of a series of individuals with disability over a six-month period.
The specific research questions were: • What Physiotherapy goals are set by individuals with NDIS funding and are they achieved as measured by Goal Attainment Scaling?
• What NDIS goals are set by individuals with NDIS funding and do they align with Physiotherapy goals?
• Does participation in NDIS funded Physiotherapy alter physical function of individuals with permeant and significant disability as measured by the Motor Assessment Scale (MAS) and 5-meter walk test?
• Does NDIS funding improve access to private community Physiotherapy for individuals with permeant and significant disability?

Methods
A consecutive case series was conducted with individuals attending a private clinic in Sydney Australia between April 2019 and November 2019. Ethics approval was obtained from Macquarie University Human Research Ethics Committee (5201952888188). Written informed consent was obtained from all participants. This study was conducted alongside another larger survey-based study investigating experience of Physiotherapy participants funded by NDIS.
Primary outcomes were collected during the Physiotherapy appointment.
Questionnaires were collected outside participants' appointments, at a location of their choice, including in the clinic waiting room or at their home. Questionnaires were completed independently unless the participant requested or was identified as requiring support. Need for support was determined by a research team member, based on factors including cognition, physical function (e.g. unable to write responses), English-language, visual or speech limitations. Support was provided by a research team member or a participant's family member and was recorded.
Participant inability to complete questionnaires was recorded. Participants were given one week to complete and return the questionnaires. A follow up telephone call was conducted if the questionnaires had not been returned.

Primary Outcomes
Goal Attainment Scaling (GAS) The Goal Attainment Scale (GAS) was used to score the degree to which a selected goal or goals were attained (Turner-Stokes 2009). It is a criterion-referenced assessment that is responsive to minimal clinically significant change (Palisano 1993). Implementation and scoring of GAS followed the practical guidelines outlined by Turner-Stokes (Turner-Stokes 2009). Upon initial assessment, participants rated the relative importance and anticipated difficulty of achieving their goals. Baseline function was then scored as -1, unless function for a goal was as bad as it could be, resulting in a score of -2. At final assessment, attainment of each goal was rated and given an outcome score. Attainment of goals "as expected", "a little better than expected" or "much better than expected" was indicated by an outcome score of 0, +1 or +2 respectively. Attainment of goals "a little less than expected" and "a lot less than expected" corresponded with outcome scores of -1 and -2 respectively. A final GAS change t-score was then calculated using a formula and automated spreadsheet, to determine degree of change (i.e. improvement, no change, deterioration) (Turner-Stokes 2009).

Metre Walk Test
The 5-metre walk test (5mWT) measured walking speed of participants able to walk (Peters, Fritz and Krotish 2013). Participants were asked to walk as quickly and safely as possible along a marked 7-metre track. Timing commenced once the participant crossed the 1-metre mark and ceased once crossing the 6-metre mark.
Two trials were performed, recorded and averaged for each participant. The time to complete the 5-metres was converted into walking speed reported in metres per second (m/s). The need for physical assistance or assistive devices was recorded.

Motor Assessment Scale
The Motor Assessment Scale (MAS) described participant motor function.
Participant performance on the eight MAS items was documented with scores ranging from zero to six with higher scores indicating better performance. The MAS has excellent test-rest reliability for individuals with chronic stroke (Carr et al. 1985).
As the MAS is designed specifically for individuals after stroke and scores the affected side, both sides were assessed for participants with other neurological conditions, and the poorer performing side recorded.

Secondary Outcomes
The World Health Organisation Quality of Life-Brief Version (WHO QOL-BREF) The WHOQOL-BREF assessed participant QoL. The participant rates 26 items based on their self-perceived QoL. Two items assess overall self-perceived QoL and satisfaction with general health. The remaining 24 items assess satisfaction of four domains: physical health (7 items), psychological health (6 items), social relationships (3 items) and environmental health (8 items). Raw scores were calculated and interpreted per domain with higher scores indicating higher perceived QoL (Gholami et al. 2013).

Exercise Self Efficacy Scale
The Exercise Self Efficacy Scale (ESES) gauged participant confidence in performing regular exercise. Responses to each of the 10-items were scored on a 4point scale, with a maximum score of 40. Higher scores indicate higher selfefficacy.
The ESES is a reliable questionnaire with high internal consistency (Kroll et al. 2007).

Data Analysis
Excel was used to analyse data, generate descriptive statistics and graphs. A deductive approach was used to thematically analyse goals obtained from the GAS and participant NDIS plans (Braun and Clarke 2006). Goals were categorised into themes based on the ICF model (WHO 2001b). As NDIS funds Physiotherapy and both NDIS and Physiotherapy aim to be centred around goals, alignment of such goals was determined by comparing participant NDIS goals with their corresponding Physiotherapy goals. Two members of the research team separately examined the goals and their alignment.
Each participant's baseline and latest recorded primary and secondary outcomes were used for data analysis. This was a pre-determined decision prior to data analysis to ensure data was present for participants who were discharged from Physiotherapy prior to the 6-month study timeframe.
Participant condition and diagnosis data was categorised from raw extracted data for analysis purposes. Participants were categorised on their condition (e.g. neurological) and more specifically based on their diagnosis (e.g. progressive) irrespective of time post diagnosis or injury.

Flow of participants
Thirty-eight percent of individuals attending the clinic at the time of the study were utilising NDIS funding. Nineteen individuals were eligible for the study, and 13 (68%) consented to participate. One participant withdrew, prior to baseline assessment, so 12 individuals participated in the study. Outcome measures were recorded at 2-and 6-months for 25% and 75% of participants respectively.

Participants and Physiotherapy treatment
Participant demographics are presented in Table 1. Participants attended a median of 19 individual (range = 0 to 41) and 0 (range = 0 to 17) group Physiotherapy sessions over 6 months. Median time in Physiotherapy over 6 months was 1185 minutes (range = 180 to 2460 minutes). One participant received Physiotherapy at home, whilst the remainder at the clinic. Five participants received both musculoskeletal and exercise intervention, six solely exercise while one received only musculoskeletal. Exercise interventions were individualised and included strengthening, mobility (e.g. walking, transfers, sit to stand), cardiovascular (e.g. bike, boxing), balance (e.g. stepping, weight shift) and stretching/ range of motion exercises (e.g. spine mobility, limb stretching). NDIS funding fully covered the cost for ten participants. Two participants also utilised private funding (private health insurance) to attend additional sessions, which for one participant occurred when NDIS funding for Physiotherapy ended. Eleven (92%) participants were able to access Physiotherapy who were otherwise unable with the remaining participant able to access more frequent Physiotherapy due to of NDIS funding. [Insert Table 1 near here]

Goals and goal attainment scaling
Ten (83%) NDIS plans and corresponding NDIS goals were accessible, with an average of 2 short-term goals per participant. Many NDIS goals covered several ICF domains and subdomains, reflecting the broad nature of such goals. Upon exploring alignment of NDIS goals and Physiotherapy goals, it was apparent that Physiotherapy goals were a subset of NDIS goals. Most participants accessed Physiotherapy to work towards mobility goals. (e.g. walking further or with reduced assistance) with 78% of goals classified under mobility subdomain (see Figure 7 and Appendix 1). Seventeen Physiotherapy goals were set at baseline and reassessed at study completion. At baseline 15 goals were rated at -1 indicating some ability while two were rated at -2 indicating no ability. At study completion 41% (n=7) of goals were attained as indicated by an outcome score of 0, +1 or +2. Fifty-eight percent (n=10) of goals were not attained with outcome scores of -1 or -2, however function and scoring for nine of those goals was equal to baseline indicating maintained function. Only one goal scored worse than baseline indicating functional decline. Five participants displayed positive change in goal attainment (positive t-score) while three participants had no change (t-score 0). One participant had a negative t-score, however improved 'more than expected' in one of his three goals. He did not achieve

Case Study number one-Participant Three
Participant three sustained a spinal cord injury over 20 years ago, is wheelchair dependent and community dwelling with external support for personal care. She accessed weekly home-based NDIS fully funded Physiotherapy (floor or seated strength and mobility exercises) from the clinic for 11 months. She reported recent decline in strength, transfer ability and writing requiring home modifications, assistive technology and greater assistance with ADLs.
During the study she received 21 Physiotherapy sessions. Her two goals were to maintain independent transfers from her bed and toilet to her wheelchair. Her baseline function for both goals were rated as -1. Participant three stated these goals were vitally important to her as "if I can't manage the transfers any longer, I will be completely immobile and totally dependent".

Goal achievement and outcome measure results
Upon 6-month goal review, she achieved positive change in GAS (t-score 8), attaining her goal of maintaining transfers to and from her bed "as expected" (correlating to a score of 0). However, her wheelchair to toilet transfer goal attainment was "less than expected", correlating to a score of -1. There was a slight increase in her physical and social relationships QoL. Scores on ESES, environmental and psychological QoL decreased. NDIS enabled her to access supports, equipment and remain community dwelling.

Case Study number two-Participant 9
Participant nine sustained a right sided hemiplegia post stroke over 10 years ago and lives in the community with family support for ADLs. Support workers accompany him to external activities (e.g. hydrotherapy). He has accessed individual and group NDIS fully funded Physiotherapy (manual therapy and lower limb strengthening, cardiovascular, mobility and balance exercises) from the clinic for 11 months.
During the study he received 19 individual sessions (ranging from 30 to 60 minutes) and 13 group sessions (1-hour). His two goals were to independently walk 500 metres with his walking stick outdoors and ascend 4 steps holding a railing. At baseline, function for these goals was rated as -1 and -2 respectively. Participant 9 expressed the importance of goal setting, stating "having many smaller goals has given me more sense of accomplishment" and "I have a feeling of accomplishment when I can do things that were not possible before".

Goal achievement and outcome measure results
Within the 6-month period he sustained a fall reducing confidence mobilising outdoors. Subsequently, there was no change in function scoring, attaining improved outdoor walking "less than expected" (correlating to a score of -1) and stair ascent "much less than expected" (correlating to a score of -2). His GAS t-score was zero, indicating function was equal to baseline. Furthermore, his walking speed decreased slightly. Due to the fall, his treatment was adjusted to include manual therapy. His scores remained unchanged or slightly decreased on the MAS, ESES and social relationships QoL. Physical, psychological and environmental QoL scores increased.
NDIS enabled access to supports and the community.

Discussion
This is the first known study to investigate outcomes in individuals accessing NDIS funded community-based Physiotherapy. As NDIS has prompted a shift in Australian Physiotherapy services, it is important to understand the outcomes experienced by this unique population to guide continued development of such services. Within this study, all participants improved or maintained function of at least one Physiotherapy goal. However, this was not reflected in physical and subjective measures, resonating with previous research (Barker et al. 2017, Rannisto et al. 2015  It is important to use formal goal setting tools in conjunction with standardised measures which commonly have normative values to compare with a study population (Turner-Stokes 2009). Literature demonstrates benefits of goal setting as a person-centred outcome measure (Hurn et al. 2006). Yet a person-centred approach is rarely used during hospital-based rehabilitation goal setting despite being associated with better functional outcomes and improved goal attainment in neurorehabilitation (Rosewilliam et al. 2011, Turner-Stokes et al. 2015. NDIS plans and Physiotherapy aim to be centred around individualised goals. Within the current study, it was apparent that Physiotherapy goals were a subset of short term NDIS goals. Physiotherapy goals focused on mobility while NDIS goals were broad, including improving mobility, accessing accommodation and therapy. The broad nature of NDIS goals within the current study may have been a result of the complex needs of individuals accessing NDIS funding.
Change in participant outcome measures varied, with improvement, deterioration and maintenance observed, the latter of which should not be overlooked. NDIS seeks to provide long term support for individuals with permanent and significant disability (May et al. 2018). Without ongoing Physiotherapy, individuals with chronic disability can deteriorate, and become vulnerable to the consequences of inactivity (Allen et al. 2019, Ertekin et al. 2012. Moreover, this population tends to have more comorbidities further predisposing them to increased health risks and reduced QoL (ABoS 2016). To promote optimal function, reduced social isolation and associated risks of inactivity, on-going Physiotherapy is required (Allen et al. 2019, Ertekin et al. 2012. Within this study, NDIS funding provided participants access to more frequent and otherwise inaccessible Physiotherapy. Physiotherapy benefits motor and nonmotor symptoms and has the ability to reduce disease progression in individuals with neurodegenerative conditions (Barker et al. 2017, Allen et al. 2019, Ertekin et al. 2012, Spencer et al. 2018, Baque et al. 2016, Pollock et al. 2007, Dorsch et al. 2018, Latimer-Cheung et al. 2013. By funding individuals with chronic health conditions to access Physiotherapy, NDIS seeks to fulfil one of its insurance principals, "to invest in people with disability early to improve their outcomes later in life" (NDIA 2019section 4.3).
This study was strengthened by using GAS, a formal individualised goal attainment tool, which recognises progression towards attaining goals, as opposed to an all-or-nothing approach. To minimise bias, goal scoring levels were predefined in individualised follow-up guides prior to treatment commencement. However, study limitations need to be considered when interpreting data. Staff setting goals had minimal experience using GAS thus potentially impacting the reliability without the recommended 1-year of GAS implementation experience (King et al. 2000).
Furthermore, the study sample is not truly consecutive. Finally, those who consented to participating may not be representative of the entire population as they were accessing a service provider and may have been more motivated for therapy or had strong views about NDIS that they wished to express.
In conclusion, this study provides information on individuals with NDIS funding accessing private community Physiotherapy. It demonstrates goal attainment while supporting previous literature that goal setting and GAS capture changes not evident in standardised outcome measures. This study provides important information to physiotherapists treating individuals with NDIS funding. Further, larger scale longitudinal research, across multiple organisations, is recommended to explore longer term outcomes for such participants.

Ethics Approval and Consent to Participate
Ethics approval was obtained from Macquarie University Human Research Ethics Committee (5201952888188). Written informed consent was obtained from all participants.

Availability of Data and Materials
Not applicable • Figures 1a, 1b, 1c. NDIS goals as outlined in participant NDIS plans. Goals have been classified based on ICF framework domains and subdomains.
• Figure 2. Specific participant mobility goals as outlined in baseline assessment using Goal Attainment Scaling (GAS). •