What do private practice referrers value about neuropsychology assessment?

ABSTRACT

Objective

For optimal clinical utility of neuropsychological assessment (NPA), we need to understand what aspects referrers value. We aimed to use quantitative and qualitative methods to evaluate the value of NPA for a diverse range of Australian private practice referrers.

Method

Forty-nine referrers to Australian private neuropsychology practices completed a 25-item online survey evaluating referrer satisfaction, report preferences, barriers to referral, and views on the most beneficial outcome(s) of NPA. Sixteen referrers participated in individual online semi-structured interviews to provide richer accounts of these issues.

Results

Referrers’ survey responses indicated high satisfaction, and that NPA was considered valuable for diagnostic clarification, management planning, and access to support. Participants valued individualised reports with user-friendly explanations of findings and tailored recommendations. Interview data revealed four themes: (1) neuropsychologists possess unique expertise which carries weight amongst referrers and services, (2) neuropsychology enhances understanding of the person and problem, (3) neuropsychology guides healthcare and support, (4) financial, structural, and geographical barriers occur in accessing NPA and implementing supports.

Conclusions

Referrers’ perspectives can inform neuropsychologists’ approach to their work and optimise clinical utility. Future clinical trials should measure the reported useful outcomes of NPA to demonstrate more rigorously the evidence for the value of NPA.

Key Point

What is already known about this topic:

1. There are barriers to accessing NPA services within Australian youth mental health settings.

2. Although multiple systematic reviews support the usefulness of NPA, some trials have not, which may relate to outcome measures not reflecting the most valuable outcomes of NPA.

3. Prior surveys evaluating referrers’ perspectives in the US and Australian youth mental health settings found referrers were satisfied and found NPA useful for treatment planning, diagnostic clarification, and service access.

What this topic adds:

1. Australian referrers from a diverse range of professional backgrounds are satisfied with NPA services, finding NPA valuable for diagnostic clarification, management planning, and access to support services and funding.

2. Referrers reported NPA benefited clients’ and families’ understanding of their condition and how to manage it, via comprehensive case formulation and individualised recommendations.

3. Referrers perceive that neuropsychologists’ unique expertise improves the understanding of the person and presenting problem, which guides healthcare and support. Logistical, financial, and systemic barriers to access of NPA and implementation of recommendations were identified.

KEYWORDS:

• Neuropsychology assessment
• clinical neuropsychology
• barriers
• accessibility
• referrers
• neuropsychological report

Neuropsychology assessments (NPAs) are beneficial for individuals with neurological, psychological, degenerative, and neurodevelopmental conditions, and serve a range of purposes, including clarifying diagnoses, characterising baseline cognitive functioning, guiding management, determining capacity for specific roles, and predicting prognosis (Gruters et al., 2021; Harvey, 2012). Individuals commonly encounter neuropsychology services after referral from medical practitioners, allied health clinicians, legal service providers, and support coordinators, among others. It is crucial to establish the value of NPA empirically, especially given the unmet need for NPA services (Delagneau, Bowden, van der-el, et al., 2021; E. Fisher et al., 2022). Systematic reviews support the usefulness of NPA in enhancing diagnostic accuracy and healthcare (Belleville et al., 2017; Donders, 2020; Watt & Crowe, 2018), however, two frequently cited randomised controlled trials (RCTs) (Lincoln et al., 2002; McKinney et al., 2002), did not find NPA was beneficial for people with multiple sclerosis and stroke. Potential explanations for these discrepancies include trainees conducting the NPA, and the lack of feedback provided to participants (Gruters et al., 2022). Perhaps more critically, the outcomes measured may not represent the most valuable outcomes of NPA. Implications from these studies may hinder the utilisation and perception of the profession’s value, emphasising the need for studies that accurately reflect neuropsychology’s impact. Identifying what referrers perceive to be the most useful impacts of NPA is an important step in ensuring future RCTs measure the most appropriate outcomes when appraising neuropsychology’s value.

Neuropsychologists in Australia mainly conduct assessments in the public health system; in rehabilitation hospitals, memory clinics, or psychiatric services (Ponsford, 2016). Although the lack of Medicare rebate poses a substantial constraint for private neuropsychologists, a large number of private practitioners work with self-funded clients, such as children with possible neurodevelopmental or learning difficulties, or adult clients referred by private medical practitioners to investigate cognitive changes (Ponsford, 2016). This cohort of clients who are ineligible for a public NPA are most impacted by the current lack of subsidisation. Moreover, this financial barrier is particularly likely to affect people from low socioeconomic backgrounds, who are at higher risk for brain conditions (Resende et al., 2019). Previous Australian studies of youth mental health services report that NPA would benefit a third of clients, yet only 12% can access it (Allott et al., 2019). Additionally, limited accessibility reduces referral rates (Delagneau, Bowden, van der-el, et al., 2021). Increasing the understanding of the value of private practice neuropsychology and how barriers impact the provision of optimal care by referrers is crucial. This will inform policymakers and support advocacy for private sector funding.

Past studies investigating referrers’ perceptions of neuropsychology have focused on physicians (public and private) in the US, finding they are highly satisfied with neuropsychological services and perceive them as useful for their practice (Postal et al., 2017; Temple et al., 2006). Two more US-based studies expanded these findings to include non-medical referrers (Hilsabeck et al., 2014; Mahoney et al., 2017). Within a Veterans Administration Medical Centre, shorter wait times for the NPA and report, and increased communication with neuropsychologists influenced the perceived value of NPA for referrers (Hilsabeck et al., 2014). Mahoney et al. (2017) recruited referrers from a range of professional backgrounds through professional listservs and email lists, finding they appreciated the thoroughness and integration of the NPA, and that they were least comfortable with recommendations for laboratory work, medication, and neuroimaging. In the Australian context, studies of referrers in youth mental health settings report several useful outcomes of NPA, including treatment planning modifications, diagnostic changes, improved clinical assessment, and increased access to services (Allott et al., 2011; Delagneau, Bowden, Bryce, et al., 2020; C. Fisher et al., 2017). It is important to expand these findings within other contexts in Australia.

The neuropsychologist’s report is often the main communication to referrers, so it is important that it is written effectively. Previous studies have reported inconsistencies between how NPA reports are written and what referrers value the most (Postal et al., 2017). Referrers found the recommendations and diagnostic impressions most useful, and the history section least useful, consistent with Mahoney et al.’s (2017) study. Hilsabeck et al. (2014) found the length and detail of NPA reports influenced their value for referrers, with the “summary and impressions” section rated as most useful. Further understanding of referrers’ preferences regarding reports is critical to optimise their impact and inform neuropsychologists’ practice.

Past studies examining the value of NPA have primarily used survey methodology, which is useful for capturing common opinions, but does not allow for in-depth exploration of different experiences and novel or nuanced ideas about the value of NPA. One exception analysed qualitative data but focused on a single open-ended question derived from a cross-sectional survey (Delagneau, Bowden, Bryce, et al., 2020), limiting in-depth exploration. Qualitative data gleaned from semi-structured interviews provides richer perspectives, and the opportunity to pursue participants’ responses to explore new or unexpected ideas (Nalder et al., 2017).

Although existing research provides support for the value of neuropsychology, the perceptions of a professionally diverse range of referrers to private practice neuropsychologists in Australia are important to further understand how best to maximise the utility of NPA. Our objective was to address this gap with an initial survey that aimed to evaluate a) referrers’ satisfaction with NPA services; b) their preferences for the report; c) the barriers they face to referring clients; and d) their views on the most beneficial outcome(s) of neuropsychology. These same topics were then followed up qualitatively through semi-structured interviews to enable a deeper investigation of referrers’ experiences and opinions regarding NPA.

Methods

Participants

This study was approved by the La Trobe University Human Research Ethics Committee (HEC21127). Eligibility criteria comprised of those: a) living in Australia, b) aged 18 years or above, c) had referred at least one client who completed an NPA, and d) identified as a referrer by an Australian private practice neuropsychologist. Recruitment occurred exclusively through private practice neuropsychologists who were contacted via researchers’ professional networks and email listservs to which most Australian neuropsychologists belong (NPinOz; BRAINSPaN). Referrers were recruited during July and August 2021.

Procedure and materials

Participants followed a link in an email received from the neuropsychologist who identified them as a referrer. This link presented the information and consent form, followed by a 25-item online QuestionPro survey (https://www.questionpro.com/au/) (Appendix A). This survey was adapted from previous studies (Allott et al., 2011; Mahoney et al., 2017; Temple et al., 2006) with additional questions suitable for the Australian private practice context. Questions covered: demographic information, how and why responders refer clients for NPA, referrers’ opinions on the neuropsychological report and process, the usefulness of NPA and its outcomes for referrers’ practice and clients. Most responses were indicated on a 4- or 5-point Likert scale with an N/A option to enhance accuracy. Open-ended questions were included to prompt further detail. The survey was piloted with one referrer to ensure it was well-understood, and no changes were required.

On the “Thank you” page after survey completion, participants were invited to fill out an expression of interest for participation in interviews. Interviews were conducted via videoconferencing (Zoom) with a mean length of 35 minutes (standard deviation = 10 minutes). Interviews were conducted by a psychology undergraduate female student (RA) as part of her Honours thesis, and this information was related to participants. RA had no prior relationship with any of the participants. One of the student’s supervisors (DW) (PhD; Clinical Neuropsychologist and experienced qualitative researcher) was also present for the first interview. A 16-question interview guide (Appendix B) was used to expand on the survey questions and obtain richer perspectives from referrers. Comments relevant to the research question were further explored with follow-up questions. Interview audio files were saved and professionally transcribed through “GoTranscript”.

Data analysis

This was a mixed methods cross-sectional observational study consisting of an online survey and videoconference qualitative interviews with a subset of participants. Survey responses were exported into Excel and screened for missing data. Cases with > 50% missing data were excluded. Descriptive statistics were analysed in Excel for the survey questions and were grouped under the following main categories: a) demographic information, b) characteristics of the referral process, c) satisfaction with neuropsychology, d) report preferences, e) barriers to referral and f) NPA’s useful outcomes. Content analysis; a process of identifying and quantifying repeated concepts, was employed for open-ended survey questions (Neuendorf, 2017).

Qualitative interview data was analysed using Braun and Clarke’s (2006) six-stage approach to reflexive thematic analysis, and followed a data-driven approach within a critical realist framework. Initial codes were created by RA using NVivo (released in March 2018), and one interview was cross coded with an independent student researcher. Discrepancies were examined, and edits to the codebook were discussed with the student cross-coder and the research team. A further 20% of the interviews were cross coded, and themes were generated by the research team (KP, DW, and RA). A table of the themes, the key codes that explain them, and examples from the raw data, was developed. Themes were then conceptualised using a figure to describe the relationships between them. An email was sent to all interviewees to confirm that the themes reflected their opinions and experiences. No participants indicated any changes were needed.

Results

Participants

Fifty-eight neuropsychologists were sent a unique survey code to share with their referrers. Of these, 23 neuropsychologists reported sharing the survey with a total of 1,117 referrers. A total of 55 survey responses were received. After excluding those with >50% missing data, the final sample consisted of 49 survey participants, 16 of whom agreed to participate in interviews. As Table 1 shows, most of the 49 referrers were aged above 40, female, and located in Victoria and New South Wales, with a diverse range of occupations which were also represented in the interview sample (Table 2).

Table 1. Survey participants’ demographic information.

Demographic category	Sub-category	Frequency	Percentage
Age	25–29	3	6.1%
	30–39	6	12.2%
	40–49	19	38.8%
	50–64	17	34.7%
	65 or above	4	8.2%
Gender	Male	15	30.6%
	Female	34	69.4%
State	VIC	19	38.8%
	NSW	25	51.0%
	QLD	3	6.1%
	WA	2	4.1%
Referrer’s location	Major city/Metropolitan suburb	36	75.0%
	Regional City e.g., Ballarat	10	20.8%
	Rural area	2	4.2%
Occupation	Psychologist	3	6.1%
	Allied health clinician	6	12.2%
	Psychiatrist	5	10.2%
	General Practitioner	6	12.2%
	Geriatrician	2	4.1%
	Neurologist	4	8.2%
	Social/Youth/Mental health Worker	3	6.1%
	Legal service providers	8	16.3%
	Case Manager/Support Coordinator	7	14.3%
	Teacher	1	2.0%
	Nursing/Nurse Consultant	3	6.1%
	Other	1	2.0%

Under the “General Practitioner” category there was: 1 Addiction Medical specialist, 1 Sports Physician and 1 General Paediatrician.

Table 2. Interview participants’ occupational information.

Female/Male/Non-binary	Occupation
M	School psychologist and private practice psychologist
F	Criminal Lawyer/Solicitor – Legal Aid
F	Neurologist
F	General Practitioner
M	Psychiatrist
F	Speech pathologist
F	NDIS Support coordinator
F	NDIS Support Coordinator
F	Case Manager
F	Team Leader at Corrective services
F	Director at law firm
F	Criminal Lawyer/Solicitor – Legal Aid
M	Geriatrician
F	Consultation-Liaison Nurse
F	Criminal Lawyer/Solicitor – Legal Aid
F	NDIS Support Coordinator

Characteristics of the referral process

As Table 3 shows, most survey participants reported they usually: refer to multiple neuropsychology services (51%), referred a client for NPA “a few times a year” (59.2%), and that clients’ NPA was usually self-funded (44.9%). Good past experience was the most common reason in choosing which neuropsychologist to refer to (87.8%). Diagnostic clarification was the most common reason for referral (79.6%), followed by management recommendations (69.4%), and assessment of cognitive strengths and weaknesses (67.4%).

Table 3. Information about the referral process and measures of referrers’ satisfaction with neuropsychology.

Question	Response Options	%	N
The Referral Process
1) Refer to the same or multiple neuropsychologists?	Usually the same clinic	49%	24
	Usually multiple	51%	25
2) Why do you refer to a particular neuropsychologist?	Good past experience with them	87.8%	43
	They have the relevant expertise	55.1%	27
	They are available/quick turnaround	40.8%	20
	Recommended by a colleague	28.6%	14
	They charge reasonable fees	24.5%	12
	Their location	4.1%	2
	Institutional affiliation	16.3%	8
3) How often do you refer a client for NPA?	Weekly	2%	1
	Fortnightly	8.2%	4
	Once a month	22.5%	11
	A few times a year	59.2%	29
	Once a year or less often	8.2%	4
4) Most clients you referred for NPA were funded through?	Self-funded	44.9%	22
	NDIS	26.5%	13
	Legal Aid	22.5%	11
	Transport incident insurance	12.2%	6
	Housing related funding	6.1%	3
	Workplace insurance	8.2%	4
5) Indicate the most common reason(s) for you to refer someone for NPA	Diagnostic clarification	79.6%	39
	Guidance/recommendations for management or treatment	69.4%	34
	To assess cognitive strengths and weaknesses	67.4%	33
	To determine decision-making capacity	51%	25
	To establish baseline functioning prior to an intervention/procedure	36.7%	18
	For a medicolegal opinion	28.6%	14
	To find out if they are eligible for funding or support services	28.6%	14
Referrers’ Satisfaction with Neuropsychology
6) How often is the referral question answered to your satisfaction?	Always	30.6%	15
	Usually	61.2%	30
	Sometimes	6.1%	3
	Rarely	2%	1
7) On average, how useful/valuable do you find the diagnostic impressions made by the neuropsychologist?	Very valuable	57.1%	28
	Valuable	36.7%	18
	Somewhat valuable	6.1%	3
	Not very valuable	0%	0
	Not at all valuable	0%	0
8) How likely are you to refer a client for neuropsychological assessment again in the future?	Very likely	89.8%	44
	Likely	6.1%	3
	Somewhat likely	2%	1
	Unlikely	2%	1
	Not at all likely	0%	0
9) How satisfied or dissatisfied are you with the time between referring a client and receiving the neuropsychology report?	Very dissatisfied	2%	1
	Slightly dissatisfied	4.1%	2
	Neutral	8.2%	4
	Satisfied	51%	25
	Very satisfied	34.7%	17
10) How satisfied or dissatisfied are you with the quality of written and verbal communication with the neuropsychologist?	Very dissatisfied	0%	0
	Slightly dissatisfied	4.1%	2
	Neutral	2%	1
	Satisfied	36.7%	18
	Very satisfied	57.1%	28
11) How satisfied or dissatisfied are you with the length of the neuropsychology report?	Very dissatisfied	0%	0
	Slightly dissatisfied	6.1%	3
	Neutral	2%	1
	Satisfied	34.7%	17
	Very satisfied	57.1%	28

Questions 2, 4, and 5 allowed referrers to choose more than one response and therefore, percentages do not total 100%.

Referrers’ satisfaction with neuropsychology

Approximately 90% of referrers reported their referral question was “usually” or “always” answered satisfactorily and reported being “very likely” to refer a client for NPA again (Table 3). Most referrers found the neuropsychologist’s diagnostic impressions “very valuable” (57.1%). Over 90% of referrers were satisfied or very satisfied with the quality of their communication with the neuropsychologist and the length of the report, while over 85% were satisfied or very satisfied with the turnaround time (see Table 3).

How can neuropsychological assessment improve?

Responses to an open-ended question regarding suggested changes to NPA indicated issues with long waitlists and lack of availability, especially in public hospitals and forensic contexts (n = 10). Increasing affordability was considered important (n = 12), with many referrers suggesting Medicare subsidisation (n = 7). Referrers also mentioned requiring more specific guidance for client management (n = 4), faster turnaround times (n = 2), development of multi-cultural norms (n = 1) and telehealth NPA (n = 2), having multidisciplinary clinics that function as a “comprehensive one-stop shop” (n = 2), and the increased recognition of NPA as part of the National Disability Insurance Scheme (NDIS) mainstream service (n = 2). Other points mentioned by one participant each included: greater cultural awareness when working with Indigenous people, improved referral pathways, more consistent provision of feedback sessions, the need for neuropsychologists to focus on and clarify the boundaries of their expertise, and improving the limitations of symptom-based diagnostic criteria.

Preferences regarding the report

As demonstrated in Figure 1, most referrers reported finding all sections of the report to be somewhat or very useful, and most frequently reported the summary/conclusion section to be “very useful”. Regarding the reporting style, most referrers indicated they prefer that the neuropsychologist includes information and recommendations beyond the referral question (71.4%), rather than a concise report focused solely on answering the referral question (28.6%).

Figure 1. Usefulness of neuropsychological report sections for referrers.

For all items above, n = 49.

During interviews, referrers identified the following features of good reports: 1) accessible and well-organised, 2) detailed and comprehensive, 3) include a summary/conclusion section, 4) include user-friendly explanations of test results, 5) written in a targeted way that addresses the referral question, and 6) specific and concise. These features are detailed further in Table 4.

Table 4. Preferences regarding the neuropsychological report as identified in interviews.

Code Name	Frequency	Description	Examples
Accessible and well-organised.	n = 3, 7 instances	Referrers mention they prefer the report to be organised in a clear way that makes it more accessible and easier to read.	“It’s really good when they can separate that out in the report, deal with one major issue first, second issue, and then tie it all together at the end with the final opinion … They’re easy to understand. They’re set out in paragraphs”. (R2)
Detailed and comprehensive.	n = 8, 12 instances	The referrers prefer that the NPA report is detailed, comprehensive and doesn’t leave things out. Some referrers mentioned they enjoy the complexity and jargon included.	“The reports are really thorough”. (R2) “They’re pretty comprehensive and yes, I don’t know that I would change them”. (R4)
Including a summary/conclusion section.	n = 5, 12 instances	Referrers often express that a summary at the end or start of the report that includes the main conclusions is necessary. This can also be used to forward to other relevant practitioners or services, or given to the client.	“That summary of the raw data in the main body of the report is necessary and helpful”. (R5). “If there was maybe a bit more of a summary, that didn’t have all the person’s gory details in there. Some of the things they find out can be quite personal, or things that maybe you wouldn’t want someone’s employer, or someone that you need to really know about, they don’t really need to disclose those things in those environments”.(R9)
User-friendly explanations of the test results.	n = 8, 9 instances	Referrers mention the value is in being able to describe the test results in layman’s English (less jargon), and clarifying impact on daily life.	“Every now and then, we get one that’s a little bit too jargonistic or too technical. A few times we’ve had to ring up, we’ve got a really good report, but we’ve had to have a conference with the neuropsychologists and just say, “Can you explain this to us because we don’t understand it”. Then we’ll say, “Look, could you just add that explanation to your report?” (R12)
Written in a targeted way that addresses the referral question.	n = 4, 8 instances	Referrers describe that it is important that the neuropsychological reports are worded in a way that will achieve their required purpose, and sometimes will have to work with the neuropsychologist to ensure the report is suitable.	“If you’re doing a report for an NDIS participant it’s completely different to health, do you know what I mean?”(R16)“We have to be very creative with our reports around the way the wording is. It needs to focus on someone’s capacity, their everyday functioning and how their disability impacts that. When we focus on the health, we do a health-based report, they don’t care, it’s not their job, not their responsibility”.(R7)“If I think it’s too focused on something like offending and juvenile justice, I need that to be reworded so that it reads to disability”. (R7)
Specific and concise.	n = 5, 14 instances	Referrers state that reports that are vague are not useful and that reports should be very specific to a client, by using specific observations of them for example. Also, reports should not be longer than they need to be.	“I don’t know how well you know the WISC, but you can actually do a WISC, and put it in, and it can write a summary report for you … They’re really bad because they’re actually not about the person”. (R1) “It’s that sense of sometimes you get an assessment that’s 15 pages long. Who’s ever going to read 15 pages of stuff that just doesn’t go to the point?” (R1)“The only bad ones that I’ve had have been where they’ve just obviously not left themselves enough time, haven’t read the briefing material properly, have made all sorts of assumptions that they shouldn’t have, and have just answered questions in a very generic way”. (R15)

Barriers to referring clients for NPA

Cost was the most common barrier to referring clients (42.9% indicating encountering this “often” or “very often”), closely followed by long waitlists. Figure 2 represents barriers to referring clients for NPA, with greener blocks indicating the barrier was experienced less often than redder blocks.

Figure 2. Frequency of barriers to NPA referral.

n = 48 for “Location” and “Ambiguous Referral Pathway”, and n = 49 for “long waitlist” and “cost”.

Useful outcomes of NPA

Most referrers (93.9%) indicated they find the NPA and report to be “very useful” or “useful” for their practice. Figure 3 highlights that referrers find almost all types of recommendations somewhat or very valuable. Suggestions for support services and cognitive strategies were most frequently perceived as “very valuable” (over 70%), while suggestions for neurodiagnostic procedures were least frequently rated as “very valuable” (32.7%).

Figure 3. Referrers’ perceived value of different recommendations.

For all items above, n = 49. Percentages for response options were calculated after removing participants who selected N/A.

Referrers reported that NPA can lead to a wide range of beneficial outcomes, as evident in Figure 4. Diagnostic clarification, influence on management plan, access to support services, and access to funding were reported as outcomes occurring often or very often by over 50% of referrers. Most referrers (87.8%) said they usually discuss the NPA results and experience with their clients. Of these, over 60% reported that clients and their families benefit to a large or very large extent from understanding their cognitive strengths and weaknesses and the causes of their presenting problem, improved coping, access to support or treatment, and guidance with planning for their future (see Figure 4).

Figure 4. Reported useful outcomes of NPA.

For the first set of items, referrers were asked how frequently these outcomes occurred and n = 49. For the second set of items, referrers were first asked whether they discussed feedback with their clients and their families, and if they reported they did they were then asked the extent to which they perceive them to benefit from the outcomes listed. For the second set of items n = 43.

In-depth exploration of referrers’ opinions regarding NPA’s value

Forty codes were generated from thematic analysis of the qualitative interview data. From these, four main themes were generated, representing the value referrers perceive in neuropsychology (Table 5). The first theme (neuropsychologists possess unique expertise which carries weight with referrers and services), highlights interviewees’ appreciation of neuropsychologists’ specific expertise, and the impact and influence of NPA reports in legal settings and in enabling access to NDIS and other support services. A subtheme (being in safe hands) refers to how the neuropsychologist’s expertise and approach influences the client’s experience of the NPA process. As one referrer explained; “One of the reasons I keep working with the person I work with is that she’s got a warm, friendly personality, and she’s very good at putting people at their ease” (R5). The second theme (neuropsychology engenders and enhances the understanding of the person and the problem) encapsulates interviewees’ perspective on NPA’s value through its ability to provide a comprehensive case formulation for the referrer and the client, which is a holistic process. One referrer described this process: “’join[ing] the dots’ is where neuropsychologists write a report and finally, we see the picture because the way that they work shows us the history, shows us the current deficits, and gives us the recommendations. That for us is premium”. (R6). The third theme (neuropsychology guides healthcare and support) describes referrers valuing that the NPA empowers the referrer and the client regarding their future healthcare; “recommendations that are really targeted” (R1); “I think it just allowed me to better understand how I approach a client”. (R7). The final theme (barriers in accessing NPA and implementing supports) covered factors that hinder the utilisation of NPA, such as the family’s unwillingness or lack of awareness about NPA, the cost, the unavailability, and inadequate support to implement recommendations. Many interviewees highlighted the significance of reducing access barriers; “a lot of people just fall through the cracks … if it ended up being more accessible, it could be very helpful because you’re going to save yourself a lot of pain and suffering down the track as a society, actually”. (R4)

Table 5. Main Themes generated from interviews.

THEME	KEY CODES	EXAMPLE QUOTES
Neuropsychologists possess unique expertise which carries weight.	Neuropsychologist has expertise in a specific area	“It’s their expertise in that narrow area that we’re relying on.” (R1)
	Provides a diagnosis/ capacity assessment, or clarifies client’s strengths and weaknesses	“What’s useful is the neuropsychologist’s opinion about the diagnosis or the presenting syndrome.” (R5)
	The report is evidence that fast-tracks support and enables access to NDIS and other funding and support services	“It’s quite life-changing for them because they can use those reports to get NDIS funding.” (R12) “They’re [neuropsychology reports] very useful in getting things you need. They’re recognized out there by the powers as being valid.” (R4)
	Ensures justice and equity for clients in criminal cases	“He was charged with murder, and we got a report from a neuropsychologist that said he had a defense to the charge of murder, of what’s called a substantial impairment.” (R2)
Subtheme: Being in safe hands.	The neuropsychologist’s warmth, sensitivity, and flexibility	“One of the reasons I keep working with the person I work with is that she’s got a warm, friendly personality, and she’s very good at putting people at their ease. Early in my career, I worked with a neuropsychologist mainly in research activities who, whatever else he may have been was not very good at, reassuring, engaging with subjects. I had more people who saw him had negative experiences.” (R5) “We’re fortunate in that often our assessors will break up the sessions, so they’re not really long, and stressful for our patients.” (R14)
	Clients often have negative emotions, and less commonly, positive emotions, during the actual assessment process due to how confronting and/or laborious the process is.	“They find it intrusive or overwhelming, the experience of failure distresses them.” (R5) “They feel that it’s a positive experience, they’ve been listened to, it’s not too grueling.” (R1)
Understanding the person and the problem.	Provides clarity about the case formulation to help the referrer manage the client.	“You get to stop there and say, “Okay, that is bad news, but the silver lining is at this point, we don’t have to do any more medical tests whatsoever. We can just focus on how best to support you” (R3) “It’s very helpful for me because we’ve got clients that present with all these issues, and we have no idea what they are and it’s really good to get a report that just clarifies all of that and gives us tips about where to go and what’s happening for them”(R2)
	Neuropsychology assessment is a holistic and objective assessment.	“So ‘join the dots’ is where neuropsychologists write a report and finally, we see the picture because the way that they work shows us the history, shows us the current deficits, and gives us the recommendations. That for us is premium.” (R6)
		“I feel like you can respect what they’ve come up with, because it’s mostly objective.”(R9)
	Client feels validated and reassured, or empowered due to access to services.	“Most people are relieved to get some explanation that validates what they’ve always thought.”(R12)
	Increases family’s understanding of and empathy towards the client.	“Some of them feel like it’s a bit of an explanation of like, “Oh, so that’s why he keeps on doing that.” It gives them a bit more understanding, a bit more tolerance of what the person’s doing.” (R9)
	Validating and reassuring experience for the family.	“A similar thing about validating; often a lot of my clients come from circumstances of intergenerational disadvantage. Having some recognition that it wasn’t just that I was a bad parent, but there’s all this stuff that’s going on with my child, who’s probably now an adult, can be quite validating for them I find.” (R15)
	Neuropsychologist enriches client and family’s understanding through the feedback they provide. Client or family experience negative emotions due to the assessment outcome.	“Families don’t always understand, so the neuropsychologists are good at linking in and interviewing with families and reporting on the main idea in reports.”(R6) “Families will often grieve.” (R14) “The outcome of NPA is quite negative; people are faced with information about their impairment…implications on their freedom, freedom of movement, freedom having a choice where to live.” (R10)
Neuropsychology guides support and health care.	Enhances communication with the client.	“I think it just allowed me to better understand how I approach a client.” (R7)
	Clarifies which support services or treatments the client needs.	“Recommendations about possible service providers who could assist. I love it when we get reports where they’re really specific about who and where we should go, who we should call, what the services might be.”(R12)
	Provides practical cognitive or behavioural strategies.	“For example, try to have a centre in your house where you keep all your keys and the things that you lose together. Practical recommendations for the patient and their family are very useful, I think, and sometimes allow them to cope better with the situation they’re in.” (R5)
	Specific recommendations tailored to the client that are also user friendly.	“It’s [recommendations] that are really targeted … this is an intervention that we think might work for that child, those ones.” (R1)
	Guides parents/family on how to deal with the client moving forward.	“This grandmother went from feeling not only not heard but feeling disempowered to knowing what to do, to feeling fully empowered.”(R6)
	Neuropsychological Intervention.	“Neuropsychologists being involved with some degree of management or management advice, that may get more important in the future.” (R5)
	Leads to further investigations or assessments of the client.	“Sometimes there’s recommendations for perhaps going on to do further assessments and that can be helpful, and it also can be leveraged to try and move on to those things.”(R4)
Barriers associated with accessing neuropsychology assessment and implementing supports.	Client or family are unwilling.	“Sometimes you have these discussions around maybe medication or something. Sometimes people don’t want to do that, which is fair enough.” (R4)
	Cost of neuropsychology assessment.	“Where there’s no financial barriers, it’s incredibly helpful. Where there are financial barriers, and that stretches out to long waitlists for neuropsychology in the public system, then a useful tool is drastically underutilised.” (R3)
	Lack of availability/lengthy waitlists for neuropsychology.	“In the public system, the waitlist is simply astronomical.” (R7)
	Structural barriers to accessing assessment or to implementing recommendations.	“NDIS would push back to get a GP care plan for mental health supports for psychology, not necessarily understanding what neuropsychology is on top of generalised psychology, that they’re two very different strains … Our biggest challenge is NDIS.” (R7)
	Inadequate support or resources to implementing the neuropsychologist’s recommendations.	“The biggest one would have to be the capacity of the carer to expedite the recommendations. I think the saddest part is if it’s crystal clear, but it just doesn’t happen because there’s no capacity.” (R6)
	Lack of awareness or understanding on what neuropsychology is.	“There’s only one barrier, and that is ignorance. The barrier is, “what is a neuropsychologist? What do they do? I’ve never heard of them.” That would be the only one.” (R6)
	Location barriers. Gaps in relevance of NPA techniques	“For example, I do a lot of work in (regional city), and so, for clients in regional New South Wales, it’s even more complicated.” (R2) “To get more norms for people who are from different cultural or linguistic backgrounds… So that it doesn’t need as much interpretation from the neuropsychologist or interpreter.” (R9) “If there’s overlays of anxiety and post-traumatic stress, and then how does that impact the young person’s ability to do the testing? I don’t really see it as a carved-in-stone situation.” (R4)

Figure 5 illustrates the interactions between themes, and how they can be understood in an ordered manner; with neuropsychologists’ unique expertise (1) leading to the understanding of the person and presenting problem (2) which then allows for confident future management (3). The figure also reflects how barriers (4) have an influence on achieving the benefits of neuropsychology throughout, with barriers to accessing NPA at the beginning of the process, followed by barriers to implementing the recommendations of the neuropsychologist, which may inhibit useful outcomes.

Figure 5. Relationships between themes.

Discussion

This mixed-methods study aimed to investigate the value and clinical utility of NPA services from the perspectives of medical and non-medical referrers to neuropsychologists in Australian private practices. Overall, referrers were highly satisfied with NPA, highlighting its value for diagnostic clarification, management planning, and access to support services and funding. Importantly, referrers described benefits to clients and their families’ understanding of their neuropsychological problems and how to manage them with individualised recommendations based on a comprehensive case formulation. They valued recommendations for feasible, relevant cognitive strategies and support services more than recommendations for additional diagnostic investigations (e.g., neuroimaging). Referrers also preferred detailed, targeted reports with user-friendly explanations of findings and recommendations. Four inter-related themes were generated from qualitative interviews, whereby neuropsychologists’ unique expertise (theme 1) leads to enhanced understanding of the person and presenting problem (theme 2). This enhanced understanding guides healthcare and support (theme 3), although logistical, financial, and systemic barriers prevent access to NPA and implementation of recommendations (theme 4). Our findings highlight the unique value that NPA offers referrers, and the need to address access barriers.

Satisfaction with neuropsychology services

Compared to previous studies, fewer referrers in this study reported their referral question was “always” answered to their satisfaction; 30.6% in this study compared to around 60% in two previous studies (Allott et al., 2011; Mahoney et al., 2017). This may reflect the variety of different neuropsychologists addressing a broader range of referral questions in this survey. Surprisingly, referrers were highly satisfied with report length, compared to 42% reporting it was too long in Mahoney et al. (2017) US-based study. This may indicate a difference in report length between countries, or in referrers’ preferences, as those who refer to private neuropsychologists may be more tolerant of longer reports.

Referrers reported being less satisfied with report turnaround time than other aspects of the NPA process. However, it should be noted that the exceptionally long waitlist for NPA was a more prominent concern than report-writing time, akin to another Australian study (Allott et al., 2011). Previous work suggests slow report turnaround times negatively affects patient care, which highlights the importance of ensuring optimal efficiency (Postal et al., 2017).

Consistent with previous research (Delagneau, Bowden, Bryce, et al., 2020; Howieson, 2019; Ponsford, 2016), suggested improvements included faster turnaround times, more specific recommendations, multidisciplinary care team integration, and increased client involvement through the direct provision of feedback and continuation of care. Referrers also highlighted the need for telehealth or remote NPA and improvement in assessing people from diverse cultural backgrounds, highlighting important directions for future research into best practice and service development (Hewitt et al., 2020; Page et al., 2022).

Report preferences

Over 75% of referrers rated the NPA test results as “very useful”, which contrasted with other studies reporting referrers do not strongly value test results (E. Fisher et al., 2022; Hilsabeck et al., 2014). This may relate to the high number of case managers in the current study, who, as some interviewees indicated, use objective data as evidence to justify supports or funding. Nevertheless, the importance of specific and user-friendly explanations of test results was also emphasised, consistent with past research (Postal et al., 2017).

Although it is often recommended that neuropsychological reports are brief and focus exclusively on the referral question (Donders, 2016), over 70% of this sample preferred reports that include information and recommendations beyond the referral question. This may be attributable to different approaches to NPA between the US and Australia, with US services being more diagnostic, and less focused on recommendations and management. Consistent with US studies reporting the background section was the least read (e.g., Mahoney et al., 2017; Postal et al., 2017), this study found this section was least often rated as very useful, likely due to referrers’ adequate familiarity with clients’ history. Nonetheless, referrers mostly indicated finding the background section useful and reading the full report. This suggests referrers to private practice neuropsychologists are more appreciative of a comprehensive report due to the multiple audiences and potential uses for the report. Some interviewees complained of the lack of standardised reporting, while others noted that different framing was critical depending on the purpose (e.g., a report for NDIS focuses on the impact of disability in everyday function, compared to a diagnostic report that focuses on patterns of findings related to various health conditions). Indeed, the importance of targeting reports to the referral question while being specific and concise, yet providing a comprehensive report and a conclusive summary, all arose as important themes in referrers’ reflections on NPA reports. It is important that neuropsychologists are flexible and work collaboratively with regular referrers to determine what is important within each referral context (Baum et al., 2018). This may manifest as providing different reports for various stakeholders, as noted by one interviewee, who conveyed gratitude for the neuropsychologist who writes separate reports with appropriate detail and language for the referrer, caregivers, and the child client.

Barriers to accessing neuropsychology

Confirming and expanding on past Australian research within youth mental health, we found that cost and availability pose significant barriers to NPA referrals across settings (Allott et al., 2019; Delagneau, Bowden, Bryce, et al., 2020). Many referrers mentioned their clients cannot afford private NPA, but public services are often inaccessible due to ineligibility or long waitlists. Subsidising NPA through the Medicare Benefits Schedule would improve accessibility. This has potential long-term benefits, as NPA is associated with cost reductions and economic benefit (Glen et al., 2020; Horner et al., 2014; Sieg et al., 2019; VanKirk et al., 2013). As the study’s sample was mostly metropolitan based, location barriers were reported to a lesser extent. Nevertheless, our participants noted the scarcity of neuropsychologists in regional areas, consistent with previous Australian research (Delagneau, Bowden, van der-el, et al., 2021). Lack of awareness of NPA was another commonly cited barrier, suggesting that education regarding the process and outcomes of NPA targeted within healthcare and NDIS settings may improve access.

Usefulness of neuropsychology

Referrers reported NPA was highly useful for their practice. The reported outcomes and preferred recommendations were consistent with past research (Mahoney et al., 2017; Tremont et al., 2002). Referrers expressed they perceived positive outcomes for clients and their families, including understanding their cognitive strengths and weaknesses. Interview data revealed that referrers rely on the unique expertise of neuropsychologists to achieve specific outcomes. Referrers conveyed that, due to this expertise, NPA reports are respected documents that fast-track desirable outcomes. Furthermore, NPA clarifies case formulation and improves the referrer’s, client’s, and family’s understanding of the client. Consistent with previous research, interviewees noted that although the NPA can be distressing for some clients, it often resulted in positive outcomes (Bennett-Levy et al., 1994; Gruters et al., 2021). This highlights the importance of clients feeling they are “in safe hands” with a neuropsychologist who is warm, and compassionately guides the client through the NPA. Moreover, an enhanced understanding for referrers and clients enables them to manage the presenting problem and move forward with more certainty.

Our results suggest that future RCTs evaluating the impact of neuropsychology should measure the outcomes referrers reported as valuable, i.e.: diagnostic clarity; characterisation of cognitive strengths and weaknesses; cultivating the client and family’s understanding of the presenting problem and how to manage it in their everyday lives; improving the referrer’s confidence in management planning; establishing functional and decision-making capacity; and enabling access to funding, treatment, and support services. Comparing these outcomes between people who have and have not undergone an NPA, as well as comparing the perspectives of their referrers and families will strengthen the current understanding of NPA’s unique utility.

Our findings also have several clinical practice implications regarding neuropsychologists’ approach to their work (such as being flexible and adapting the intensity of the assessment to the client’s needs); efficient and useful report-writing (such as including specific examples of how test results are reflected in the client’s daily functioning); and educational efforts to enhance consumers’ awareness of the service. Implications are summarised in Table 6.

Table 6. Clinical implications of the study findings.

Clinical Implications
Implications for report-writing and communications:	Including a user-friendly standalone section or summary document that could be forwarded to relevant practitioners or given to the client/family Collaborating with expert stakeholders to create a clear report template/framework useful for particular settings Providing examples of how specific test results impact the client’s daily functioning Including recommendations that are realistic to the client/family’s capacity, and ensuring recommendations are as specific as possible, to enhance implementation Enhancing report readability (headings, clear structure, tabled results), ensuring the background/history contains the most essential information, which may improve report turnaround times
Advocacy for neuropsychology:	Efforts to enhance awareness of neuropsychology publicly, in the healthcare setting and within organisations of particular significance (such as NDIS), and education clarifying how neuropsychology differentiates from other services Enhancing efforts to develop telehealth NPA as this may enhance accessibility for clients in regional areas or clients difficult to assess (prison system/clients who require many sessions)
The assessment process:	Ensuring the neuropsychologist is flexible in adjusting the NPA length and intensity to individual clients’ needs, and has a warm and encouraging demeanour Neuropsychologists are ideally more involved in the provision of care; conduct direct feedback sessions; and follow up assessments with interventions to address areas of difficulty.

Limitations and future directions

This study had several limitations. First, the survey sample was smaller than the target sample size for a representative data set. This may partially be explained by the COVID-19 pandemic and the associated pressures on healthcare workers during the recruitment period. Secondly, although this study aimed to focus on referrers to private neuropsychologists (given the lack of research into this group who have different referral patterns and barriers), many participants had experience referring clients both publicly and privately. It may have been difficult to disentangle these when responding. Positive bias in the sample must also be considered, as neuropsychologists may have selectively shared the study with referrers whom they have a positive relationship. It is also possible that only referrers who appreciate neuropsychology were motivated to respond. Furthermore, since only those who have previously referred were included, this study cannot provide insights into why other professionals do not utilise NPA. Therefore, selection bias is a possibility for both the survey participants and those who chose to be interviewed, as they may have had more experience and passion regarding NPA and the barriers they face. It is important to consider the opinions of those who do not utilise NPA to draw comparisons on the outcomes NPA may impact. Another area currently lacking research is evaluating NPA from clients’ perspectives. Although patient satisfaction surveys have been previously conducted (e.g., Lanca et al., 2020; Rosado et al., 2018), there is a lack of qualitative research exploring client’s perspectives about the assessment feedback process in the Australian context. Additionally, high quality RCTs measuring key outcomes of NPA are urgently needed.

Conclusion

NPAs in Australian private practice are valuable for a diverse set of referrers, aiding case formulation and confident management planning, and enabling access to vital services and funding. Neuropsychologists are viewed as having unique expertise which is respected by referrers and services, including the legal system and support services. NPAs enhance understanding of the person and their problem – for the referrer, the client, and their family. They also guide healthcare and support. Future studies should develop validated measures of the outcomes referrers identified as most valuable. These can be utilised in future clinical trials to systemically build the evidence base for neuropsychology’s value, and aid advocacy for increased funding to help overcome financial, structural, and geographical barriers to accessing neuropsychology services.

Acknowledgements

We are grateful for the neuropsychologists who shared this study with their referrers and for the participants, both those who completed the survey and those who took time out of their busy schedule to share their ideas and experiences with us in interviews. We would also like to thank Jessie Hill for her help with the coding of the qualitative data. This work was supported by a La Trobe University Tracey Banivanua Mar Fellowship awarded to KP.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author, KP. The data are not publicly available due to their containing information that could compromise the privacy of research participants.

Additional information

Funding

The work was supported by the La Trobe University Tracey Banivanua Mar Fellowship.

APPENDICES Appendix A

Online Survey:

About You

What is your age?

1. Under 18

2. 18-24

3. 25-29

4. 30-39

5. 40-49

6. 50-64

7. 65 or above

What is your gender?

1. Male

2. Female

3. Non-binary

4. Prefer not to say

What is your state of practice?

1. VIC

2. NSW

3. QLD

4. NT

5. TAS

6. SA

7. WA

8. ACT

Where is your practice located?

1. Major city/Metropolitan suburb

2. Regional City

3. Rural area

Please select your occupation:

1. Psychologist

2. Psychiatrist

3. General Practitioner

4. Geriatrician

5. Neurologist

6. Rehabilitation Physician

7. Epileptologist

8. Allied health clinician (e.g., occupational therapist, speech and language therapist)

9. Social Worker

10. Legal service providers

11. Case Manager

12. Other (please specify):

Referring for Neuropsychological assessment:

Do you always refer to the same neuropsychology clinic or to multiple services/clinicians?

1. Usually the same clinic/neuropsychologist

2. Multiple

Which of the following best describes why you choose to refer to a particular neuropsychologist? Please choose all responses that apply to you:

1. Recommended by a colleague

2. Good experience with them in the past

3. They have the relevant expertise

4. Institutional affiliation

5. They charge reasonable fees

6. They are available/have a quick turnaround

7. Other

Approximately how often do you refer a client for neuropsychological assessment?

1. Weekly

2. Fortnightly

3. Once a month

4. A few times a year

5. Once a year or less often

On average, most of your clients that were referred for a neuropsychology assessment were funded through (please choose all that apply):

1. Self-funded

2. Transport accident insurance, e.g., the Transport Accident Commission (TAC) – VIC, NT Motor Accidents Compensation Commission (MACC), Motor Accident Insurance Commission – QLD, Motor Accident Injuries Commission (MAI) – ACT, State Insurance Regulatory Authority (SIRA) – NSW, Motor Accidents Insurance Board (MAIB) – TAS, The Motor Accident Commission (MAC) – SA, Insurance Commission of Western Australia (ICWA) – WA

3. Workplace insurance

4. NDIS

5. Department of Veterans’ Affairs (DVA)

6. Legal Aid

7. Other

How often have you encountered the following barriers to referring someone who needs neuropsychological assessment?

Table

	Never	Rarely	Sometimes	Often	Very often
Financial cost of assessment	❏	❏	❏	❏	❏
Geographical location too far	❏	❏	❏	❏	❏
Waiting list too long	❏	❏	❏	❏	❏
Ambiguous referral pathway	❏	❏	❏	❏	❏

Please indicate the most common reason(s) for you to refer someone for neuropsychological assessment (please choose all that apply):

1. For diagnostic clarification

2. To establish baseline functioning prior to an intervention/procedure

3. To assess their cognitive strengths and weaknesses

4. For guidance/recommendations for management or treatment

5. To find out if they are eligible for funding or support services

6. To determine their decision-making capacity

7. For a medicolegal opinion

8. Other

Characteristics of the neuropsychology report and process:

On average, how satisfied or dissatisfied are you with the following aspects of the neuropsychology process:

Table

	Very dissatisfied	Slightly dissatisfied	Neutral	Satisfied	Very satisfied
The time between referring a client and receiving the neuropsychology report	❏	❏	❏	❏	❏
The quality of written and verbal communication with the neuropsychologist	❏	❏	❏	❏	❏
The length of the neuropsychology report	❏	❏	❏	❏	❏

Please indicate the extent to which you find the following sections of the neuropsychology report useful:

Table

	Not at all useful	Not very useful	Undecided	Somewhat useful	Very useful
Background/history	❏	❏	❏	❏	❏
Observations/presenting features	❏	❏	❏	❏	❏
Neuropsychological test results	❏	❏	❏	❏	❏
Summary/conclusions	❏	❏	❏	❏	❏
Recommendations	❏	❏	❏	❏	❏

Please choose what you prefer in terms of the information included in neuropsychology reports:

1. That the report is concise and focuses on answering the referral question

2. That the neuropsychologist includes information, observations, and recommendations beyond the referral question

Please mention any other comments you have on neuropsychology reports (e.g. the style you find most efficient, what parts you find most useful, what you would change):

Usefulness and outcomes of the neuropsychological assessment:

How often is the referral question answered to your satisfaction?

1. Always

2. Usually

3. Sometimes

4. Rarely

On average, how valuable do you find the following types of recommendations when made in a neuropsychology report:

Table

	Not at all valuable	Not very valuable	Undecided	Somewhat valuable	Very valuable	N/A
Cognitive strategies (e.g., memory aids)	❏	❏	❏	❏	❏	❏
Psychological/Coping strategies (e.g., mindfulness, behavioural activation)	❏	❏	❏	❏	❏	❏
Management strategies for behaviours of concern (e.g., positive behaviour support plans)	❏	❏	❏	❏	❏	❏
Suggested referrals to other specialists (including medical, psychological, allied health)	❏	❏	❏	❏	❏	❏
Suggestions for neuroimaging/neurodiagnostic procedures	❏	❏	❏	❏	❏	❏
Suggestions for medication/medication review	❏	❏	❏	❏	❏	❏
Ideas for relevant supports in education/work settings	❏	❏	❏	❏	❏	❏
Suggestions for relevant support services	❏	❏	❏	❏	❏	❏
Recommendation for driving assessment	❏	❏	❏	❏	❏	❏

On average, how useful/valuable do you find the diagnostic impressions made by the neuropsychologist?

1. Not at all valuable

2. Not very valuable

3. Somewhat valuable

4. Valuable

5. Very valuable

Overall, how useful do you find the neuropsychological assessment and report to be for your practice in general?

1. Not at all useful

2. Not very useful

3. Somewhat useful

4. Useful

5. Very useful

How often has the neuropsychological assessment led to the following outcomes?

Table

	Never	Rarely	Sometimes	Often	Very often	N/A
Diagnostic clarification	❏	❏	❏	❏	❏	❏
Influenced a client’s management or treatment plan.	❏	❏	❏	❏	❏	❏
Access to support services (e.g., learning support services at university or TAFE, support groups, aged care services etc.)	❏	❏	❏	❏	❏	❏
Access to funding (e.g., NDIS, Centrelink or other funding)	❏	❏	❏	❏	❏	❏
Changes in educational or vocational pursuits (e.g., change to program of study, change of work duties/hours)	❏	❏	❏	❏	❏	❏
Change to living situation (e.g., supported accommodation, residential care)	❏	❏	❏	❏	❏	❏
Change to financial situation (e.g., appointment of power of attorney; received compensation payout)	❏	❏	❏	❏	❏	❏

How likely are you to refer a client for neuropsychological assessment again in the future?

1. Very likely

2. Likely

3. Somewhat likely

4. Unlikely

5. Not at all likely

Do you usually discuss with the client their experience of the neuropsychological assessment?

1. Yes

2. No

If yes, to what extent do clients and their family/support people generally appear to benefit from the following:

Table

	Do not benefit	Benefit to a small extent	Benefit to a moderate extent	Benefit to a large extent	Benefit to a very large extent	N/A
Understanding of their cognitive strengths and weaknesses	❏	❏	❏	❏	❏	❏
Understanding of the causes of their presenting concerns	❏	❏	❏	❏	❏	❏
Understanding of how to manage or cope with their presenting concerns	❏	❏	❏	❏	❏	❏
Change to the support services and treatment available to them	❏	❏	❏	❏	❏	❏
Guidance for work and/or study	❏	❏	❏	❏	❏	❏
Guidance in planning and making decisions about their future	❏	❏	❏	❏	❏	❏

If you could identify the biggest benefit of neuropsychology, what would it be?

What would you change about neuropsychological assessment services? In your opinion, how can the field of neuropsychology improve?

Please leave any final comments or suggestions you have here:

After you click ‘Done’, you will be invited to join the interview component of this research study. Please read the following page for more information and for the link to sign up!

Thank You Page:

We are also looking for referrers to participate in a short interview to explore your opinions and attitudes about the value of neuropsychology for your practice and how it can be improved.

Interviews will be over Zoom and should not take more than 15 minutes of your time. The Zoom call will be recorded, the video part will be deleted immediately after, while the audio recording will be deleted once it has been transcribed so that your responses cannot be linked to you. Your participation and responses will not affect your relationship with any neuropsychologists you have worked with or the researchers involved in this study.

If you consent to participating in this study, you will be contacted to arrange a suitable date and time for the interview. Please click on this link to provide your details to indicate your willingness to participate:

https://interviewsignup.questionpro.com

We thank you for your time and contribution to this research!

Appendix B

Interview Guide

Referral process:

• How do you usually decide to refer a client for neuropsychological assessment?

• Can you tell me about the process of referring a client for neuropsychology assessment in your area of practice?

• Have you faced any barriers to referring clients? What barriers are these and what do you believe is the cause for these barriers?

• What proportion of your clients do you think would benefit from neuropsychological assessment that did not end up being assessed?

Report:

• When you receive a neuropsychology report, how do you usually go about reading it? Is there a certain part that you jump to or focus on?

• What types of recommendations do you usually find useful in the report?

• What gets in the way of implementing those recommendations?

• Is there anything you would change about neuropsychology reports or wish was different?

Usefulness and outcomes:

• In what ways has the neuropsychology service been useful for your practice and for client care overall? In what ways does the neuropsychologist’s opinion on the client guide your own decision making and confidence when it comes to the client?

• Can you tell me about the process of discussing the neuropsychological assessment results with your client? Do you usually give feedback to your client based on the report or do you rely on the neuropsychologist’s feedback to the client?

• From your experience, what impact does the neuropsychological assessment have on the client?

• From your experience, what impact does the neuropsychological assessment have on the client’s family or loved ones?

• How satisfied have you been overall with the outcomes of the neuropsychology assessment in answering your referral questions?

• Have you had any negative experiences with any neuropsychology services? In your experience, do you suspect it has ever led to any unhelpful/negative outcomes?

• In what ways would you like to see the field of neuropsychology change in the future? Should anything change about the role of neuropsychologists in the future?

• Is there anything else you would like to add about the usefulness of neuropsychology?

Note: These questions are a guide only, and any interesting and relevant ideas that emerge during interview will be followed up with additional prompts and questions.