Re: Central intake to improve access to physiotherapy for children with complex needs: A mixed methods case report (BHSR-D )

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1 Author s response to reviews Title: Central intake to improve access to physiotherapy for children with complex needs: A mixed methods case report Authors: Kristy Wittmeier (kwittmeier@hsc.mb.ca) Gayle Restall (Gayle.Restall@umanitoba.ca) Kathy Mulder (kmulder@hsc.mb.ca) Brenden Dufault (brenden.dufault@umanitoba.ca) Marie Paterson (Mpaterson@hsc.mb.ca) Matthew Thiessen (mthiessen2@exchange.hsc.mb.ca) Lisa Lix (lisa.lix@umanitoba.ca) Version: 1 Date: 22 Jun 2016 Author s response to reviews: June BMC Research Editorial Office Dear Dr. Ounpraseuth, Re: Central intake to improve access to physiotherapy for children with complex needs: A mixed methods case report (BHSR-D ) Thank you for the review of our above-mentioned study, we appreciate the reviewers comments. The responses to the review are detailed below (responses in bold), including a reference to the page numbers on which changes were made in the manuscript where applicable. Please note that minor editorial changes were also made (e.g., spaces added where they had been missing). These

2 and all other changes have been tracked / highlighted in a revised version of the manuscript. We look forward to the next steps toward publication. Sincerely, Kristy Wittmeier, on behalf of the authors Reviewer #1: This is a well written case report describing the evaluation of the process and implementation of a central implementation system and its efficacy for managing a access to services for a population that face barriers in accessing services in a timely and appropriate manner. The process described appear thorough and robust. The methods are well described and context for the study is provided which assists the reader in understanding the pertinent issues. It helps provide justification for the study. Just a few comments on particular detail: 1. A relatively small number of participants were interviewed (n=9) which is study limitation. Who conducted the interviews? Information has been added to address this in Line 183: All interviews were conducted by the same study team member (KM), a physiotherapist with over 40 years experience in child health, to maintain consistency. 2. Data collection undertaken between what has happened in the 4 years since study undertaken.

3 Thank you for this important question. Since the time frame included in this study, the services at the centre used in the case study have continued to evolve in alignment with the Specialized Services for Children and Youth mandate of service integration and co-location (SSCY; see line 131 (original text)). The outpatient pediatric physiotherapy service has moved from Health Sciences Centre to a new site in May of 2016, along with other pediatric therapy services providers from across the city. The study of the process and impact of co-location and integration of pediatric outpatient rehabilitation services in our province goes beyond the scope of this study, and will be evaluated in the future with guidance from the SSCY Research and Evaluation Committee. A sentence in the discussion which addresses this point is highlighted in the discussion (line 442) and we look forward using the data from the present study as part of the baseline to monitor and evaluate the impact of the co-location. 3. What informed the design of the caregiver satisfaction survey as I note they were non validated. Starting at line 216, wording has been changed to reflect this as follows: A satisfaction survey (non-validated) was conducted annually as part of ongoing quality of care monitoring. The survey was developed by physiotherapy managers and clinicians to assess client (in this case, caregiver) satisfaction. The survey was developed in a way that key questions could be used on an annual basis, across multiple areas of physiotherapy practice within the centre, to provide common satisfaction measures for quality monitoring and improvement purposes. 4. Generalisability of the case study model. The following statement and 2 references were added to address this point: Line 171: Case studies use a specific case to understand an issue or phenomenon in greater depth. They have value in both generating theory as well as generalizing understanding of existing theories and frameworks relative to specific contexts.

4 Stake, R. (2005). Qualitative case studies. In N. K. Denzin & Y. S. Lincoln (Eds.) The Sage handbook of qualitative research (3rd ed.) (pp ). Los Angeles: Sage. Flyvberg, B. (2011). Case study. In N. K. Denzin & Y. S. Lincoln (Eds.) The Sage handbook of qualitative research (4th ed.) (pp ). Los Angeles: Sage. 5. May benefit from more discussion of the wider literature in the discussion. The following sections have been added to the discussion: Line 414: Interestingly, the above stages and perspectives align well with the 5 Rs of Reorganization which were developed and used by Phoenix and colleagues in a 2016 case report detailing change in an Ontario pediatric rehabilitation setting. Briefly, with the 5Rs Phoenix et al provide the following 5 steps to guide planning for service delivery change in pediatric rehabilitation: 1. Recognize need for change, 2. Reallocate resources, 3. Review reality, 4. Reconstruct reality and 5. Report results. Reference added: Phys Occup Ther Pediatr May;36(2): doi: / Epub 2015 Jan 8. The "5Rs of Reorganization": A Case Report on Service Delivery Reorganization within a Pediatric Rehabilitation Organization. Phoenix M1,2,3, Rosenbaum P1,2,4, Watson D3, Camden C1,5,6.

5 Line 425: Similarly, a perception of responding to families needs, project funding and leadership were among the facilitators identified within a study of service model reorganization in pediatric rehabilitation by Camden and colleagues. Reference added: Dev Neurorehabil. 2011;14(4): doi: / Going beyond the identification of change facilitators to effectively implement a new model of services: lessons learned from a case example in paediatric rehabilitation. Camden C1, Swaine B, Tétreault S, Carrière M. Reviewer #2: Dear Authors, You have conducted an interesting and important study about the processes and impact of health care reorganisation for children with complex needs. Your study addresses important issues relating to equity in health care and highlights problems in the health care organisation for children with complex needs. You have clearly addressed the limitations of your study. Thank you. No response required.

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