Towards equity and sustainability of rural and remote health services access: supporting social capital and integrated organisational and professional development

Christine and John visit the GP once a month, usually when they head into town for shopping trips. The practice has served the region for many years; it is a 2-doctor clinic, but that often there is only one doctor because of staff turnover and difficulties in finding locums. Also, one of the GPs will be retiring early next year, leaving only 1 GP, unless they can attract another from outside the region. John receives twice weekly home visits from the local community nursing outreach; they help Christine to shower John on those days, with Christine doing sponge bathes in-between their visits. Otherwise, Christine provides virtually all of John’s hands-on care needs. They are on a waiting list for further support, as packages are limited. Whilst Christine has become somewhat of an expert in warding off skin problems and infections for John, she has found it increasingly tiring to maintain this role and look after the farm. Although she can call on members of the Lions club (and members respond well), and neighbours from time to time, she does not always want to burden them. Also, John had to be admitted several times to the hospital when his condition deteriorated. This is partially due to his lack of physical activity, diet and borderline diabetes condition.

Todd is a physiotherapist who is based in the larger regional centre about 1.5 h’ drive away. He and Ruth the occupational therapist from the region’s community health centre visited John to perform an initial assessment when John came home from hospital. They undertake a review visit separately every 6 months; though they find this increasingly difficult because their resources have been steadily cut over the past 2 years. There was a private physiotherapist but they moved, leaving Todd to cover the whole region. This means that he is on the road a lot and striving to also provide limited services at the community centre. Whilst the community nurses are able to contact John’s GP with any concerns, communication is limited. The primary care nurse at the general practice is part-time and her scope of practice is limited and does not include involvement in chronic condition care planning. Communication between the various health professionals involved in John’s care is limited more broadly, and was reliant on one-way referral to allied health by the GP initially.

Few health professionals in the region have taken on students in the past 5 years. With no links to tertiary education providers and ever growing pressures to see more people over larger distances, they just haven’t had the time. The GPs runs a small practice with few incentives to take on medical students. Their use of chronic disease care planning item numbers is limited. There is some access to telemedicine, although it seems that fewer health professionals are interested to settle in the community or undertake regular visits since this commenced a few years ago.

John’s GP coordinated his care from the time of the accident, particularly from the subacute stage. This involves a Team Care Arrangement, enabling the GP to coordinate planned care for John’s various healthcare needs [32]. Christine and John visit the GP once a month, usually when they head into town for shopping trips. The practice has served the region for many years; it is a 2-doctor clinic. Although sometimes doctors are replaced over time, the practice has capacity to receive medical students on placement. John receives fortnightly to monthly home visits from the local community nursing outreach, which is co-located with the community health centre, dependent on his needs. They monitor and check for any signs of pressure sores or infections and work closely with John’s general practice. This involves a 2-way electronic communication alert system for emergencies and stepped-up care, and regular planned fortnightly dialogue between the primary care nurse within the practice and the community nurse to flag any pending issues regarding shared patients. John also receives some help with showering 3 times a week, and daily support for dressing and bed/wheelchair transfers from the local council community care service. The care workers (Janet and Margaret) who deliver this service work out of the local community health centre. Janet was born in the area and did her nurse assistant training through the local TAFE (a dual Certificate IV in Aged Care and Disability). She and her husband have a small property on the other side of town. Margaret moved to the area 6 years ago with her husband and children, who attend the local primary and secondary school, to get away from the pace of city life.

Todd is a private physiotherapist who also does some sessional work at the community health centre and the GP clinic. He works together with Ruth, the occupational therapy case manager at the community health centre, and other health professionals to service the acute and non-acute health needs in the community. This flexibility has enabled both services to react and respond effectively to changing resource pressures for their disciplines. He studied in the city but undertook his final placement in the region and gained a job there once he graduated. He enjoys playing in the local football team. His wife teaches at the local high school. Todd was able to enlist input from his occupational therapy colleague Ruth to provide assessment of John’s showering and transfer needs and home modifications when he first came home after his accident. Ruth provided guidance to the local Lions club to build the ramp and to improve access to the aviaries, with John and Christine’s input about their needs.

Despite their workload Todd and Ruth have been able to provide student placements within their roles. They prefer to have more than one student at the time to allow for the peer learning activities between the students [33]; and, by sharing space and other resources, they succeed in doing that reasonably well. The additional benefits are that this model has a positive impact on service capacity, particularly when students are in their final year, and that it allows Todd and Ruth to do other tasks at times. Another benefit is that some of the final year students over the years have been able to work for a few weeks as a locum after they graduate and before taking up a position elsewhere.

John’s care workers, the occupational therapist, physiotherapist and community nurses, recently undertook training developed and delivered by the aged care provider that operates in the region, in collaboration with its metropolitan office. This involved skills in managing complexity and identifying risk of decline and brought interprofessional staff together across the region to strengthen their networking and communication processes for clients like John.

The TAFE and more recent University link to the region has meant that many of the region’s health and welfare services are better supported to provide student placements across a number of disciplines, and the local residents are assured of a range of good quality health services as they age. Since most healthcare providers in region are relatively small, and have fractional staff appointments or use private service providers like Todd, the providers work together in relation to student placement and health service delivery. Also, the services are part of several managed clinical networks, including a diabetes network that is coordinated by a dietician in the region. The region now has the potential to attract more families seeking a better quality of life and older people coming to retire.

The hands-on support with personal care for John helps Christine significantly so that she can continue much of the work needed to manage the orchard, and John is able to assist her with that by some limited pruning and administrative tasks. The support not only keeps him out of hospital, it’s also an important social contact for John and respite for Christine. The care workers, community nurse and occupational therapist are co-located with the local General Practice and are able to liaise directly with each other, the physiotherapist and the practice nurse of the clinic if they have any particular concerns for John’s health.