Co-morbid drug and alcohol and mental health issues in a rural New South Wales Area Health Service

Objective: In 2003 the New South Wales (NSW) Centre for Rural and Remote Mental Health (CRRMH) conducted an analysis of co‐morbid drug and alcohol (D&A) and mental health issues for service providers and consumers in a rural NSW Area Health Service. This paper will discuss concerns raised by rural service providers and consumers regarding the care of people with co‐morbid D&A and mental health disorders. Design: Current literature on co‐morbidity was reviewed, and local area clinical data were examined to estimate the prevalence of D&A disorders within the mental health service. Focus groups were held with service providers and consumer support groups regarding strengths and gaps in service provision. Setting: A rural Area Health Service in NSW. Participants: Rural health and welfare service providers, consumers with co‐morbid D&A and mental health disorders. Results: Data for the rural area showed that 43% of inpatient and 20% of ambulatory mental health admissions had problem drinking or drug‐taking. Information gathered from the focus groups indicated a reasonable level of awareness of co‐morbidity, and change underway to better meet client needs; however, the results indicated a lack of formalised care coordination, unclear treatment pathways, and a lack of specialist care and resources. Discussion: Significant gaps in the provision of appropriate care for people with co‐morbid D&A and mental health disorders were identified. Allocation of service responsibly for these clients was unclear. It is recommended that D&A, mental health and primary care services collaborate to address the needs of clients so that a coordinated and systematic approach to co‐morbid care can be provided.     

Evaluating the impact of sustainable comprehensive primary health care on rural health

Objective: To develop a conceptual framework for monitoring the relationship between health services and health outcomes in rural Australia. Design and setting: Development of an evaluation framework for a rural comprehensive primary health service in Victoria. Results: Evidence regarding essential components for successful primary health care, and objective health service and health status measures were combined to develop a conceptual health service evaluation framework. Application of the framework is illustrated using a case study of a rural primary health service in Victoria. Conclusions: Inadequate health services limit access to health care, delay use at times of need and result in poor health outcomes. Currently, there is a lack of evidence from rigorous health service evaluations to indicate which rural health services work well, where and why that could inform rural health policies and funding. Although the nature of health service models will vary across communities in order to meet their differing geographic circumstances, there is considerable scope for the translation and generalisation of evidence gained from health service models that are shown to be sustainable, responsive and able to deliver local quality health care. This framework can guide future health service evaluation research and thereby provide a better understanding of a health service's impact on the health of the community and its residents.     

Helping and hindering: perceptions of enablers and barriers to collaboration within a rural South Australian mental health network

Objective: To evaluate clinicians’ perceptions of what helps and hinders the delivery of mental health care across a service network in a rural setting. Design: Qualitative, semistructured interviews were conducted with 10 individuals who work in one rural mental health care service network. Setting: A regional centre in rural South Australia involving representatives of the mental health team, general practice, hospital, community health and nongovernment organisations. Results: Clinicians’ perceptions of barriers and enablers to working within their mental health care network were explored. Participants showed a strong shared commitment to effective mental health care delivery and a good understanding of the services that each offers. Interview data suggested that working relationships between local services could be perceived as stronger when a personal or historical element is recognisable. Similarly, the notion of familiarity and community involvement were perceived as facilitators in this network. A perceived barrier for participants was the failure to attract staff with mental health experience, leading to dependence upon the dedication and commitment of existing service providers. Conclusions: Collaboration is especially necessary in rural areas, where access to health care services is known to be difficult. The informality of relationships between service providers was shown to be the main facilitator in the network. This is both a strength as it promotes the communication between services and service providers that is essential for successful collaboration, yet is also a threat to the sustainability of the network based on the difficulties of staff recruitment and retention to rural settings.     

Sustainable primary health care services in rural and remote areas: innovation and evidence

Objective: To highlight how evidence from studies of innovative rural and remote models of service provision can inform global health system reform in order to develop appropriate, accessible and sustainable primary health care (PHC) services to ‘difficult‐to‐service’ communities. Methods: The paper synthesises evidence from remote and rural PHC health service innovations in Australia. Results: There is a strong history of PHC innovation in Australia. Successful health service models are ‘contextualised’ to address diverse conditions. They also require systemic solutions, which address a range of interlinked factors such as governance, leadership and management, adequate funding, infrastructure, service linkages and workforce. An effective systemic approach relies on alignment of changes at the health service level with those in the external policy environment. Ideally, every level of government or health authority needs to agree on policy and funding arrangements for optimal service development. A systematic approach in addressing these health system requirements is also important. Service providers, funders and consumers need to know what type and level of services they can reasonably expect in different community contexts, but there are gaps in agreed indicators and benchmarks for PHC services. In order to be able to comprehensively monitor and evaluate services, as well as benchmarks, we need adequate national information systems. Conclusions: Despite the gaps in our knowledge, we do have a significant amount of information about what works, where and why. At a time of global PHC reform, applying this knowledge will contribute significantly to the development of appropriate, sustainable PHC services and improving access.     

A multidisciplinary primary healthcare clinic for newly arrived humanitarian entrants in regional NSW: model of service delivery and summary of preliminary findings

Objective: To describe a multidisciplinary primary healthcare clinic for newly arrived humanitarian entrants in regional New South Wales and report health problems and issues encountered during the initial period of operation. Methods: A quality assurance study of the Coffs Harbour Refugee Health Clinic (a collaboration between the Area Health Service and general practitioners) was undertaken from February to December 2006. Results: Seventy‐six patients received a comprehensive health assessment: 69 of these within 12 months of arrival. The median time from arrival in Australia to the first clinic visit was five days. Problems detected were categorised according to their management options. GP clinic providers expressed concern about referring patients to GPs in the community for ongoing care. Conclusions: The Coffs Harbour Refugee Health Clinic represents a successful collaboration between relevant stakeholders. It was well utilised by the target community. Implications: The service delivery model used in the clinic could be replicated in other areas in regional Australia, provided financial and human resources are available.     

Evaluation of a community based dental clinic for youth experiencing homelessness in Brisbane

The relationship between homelessness and ill health is complex, and many risk factors for homelessness such as unemployment, low income, and substance abuse are also risk factors for poor oral health. In order to overcome barriers to access dental care, previous studies have recommended integrating dental care, referral pathways, and information within the overall care provided by support services available to people at risk of homelessness. This study aimed to evaluate a dental service developed and implemented to improve access to oral health care of disadvantaged youth in Brisbane. A mobile dental clinic run by volunteer dental professionals was implemented into a community organisation for disadvantaged youth. Participants were clients of Brisbane Youth Services who were disadvantaged youth, ≤25 years and attended the dental clinic in a 1 year period. A questionnaire collected demographic information, a self‐assessment of oral health and an evaluation of their experiences with the dental clinic. Clinical data including DMFT, appointment attendance and items of service provided were collected. One hundred and twelve clients participated in the four dental clinic weeks and its evaluation. Cost was the greatest reported barrier to accessing dental care among participants. More than half (57%) of participants who pre‐booked an appointment failed to attend. A total of 640 services were delivered, with an estimated value of $48,000. The majority (69%, n = 444) of the services provided were preventative services. Almost all of the clients felt the service they received was suitable for them (97%, n = 98) and would use the service again (98%, n = 99). This dental clinic model is feasible and sustainable due to its integration into an existing homeless youth service, low running costs, acceptability to clients and an interest by dental practitioners to volunteer. It provides a useful model which could be scaled up and implemented in other regions.     

Improving access to and outcomes from mental health care in rural Australia

OBJECTIVE: Rural Australians face particular difficulties in accessing mental health care. This paper explores whether 51 rural Access to Allied Psychological Services projects, funded under the Better Outcomes in Mental Health Care program, are improving such access, and, if so, whether this is translating to positive consumer outcomes. DESIGN AND METHOD: The paper draws on three data sources (a survey of models of service delivery, a minimum dataset and three case studies) to examine the operation and achievements of these projects, and makes comparisons with their 57 urban equivalents as relevant. RESULTS: Proportionally, uptake of the projects in rural areas has been higher than in urban areas: more GPs and allied health professionals are involved, and more consumers have received care. There is also evidence that the models of service delivery used in these projects have specifically been designed to resolve issues particular to rural areas, such as difficulties recruiting and retaining providers. The projects are being delivered at no or low cost to consumers, and are achieving positive outcomes as assessed by standardised measures. CONCLUSION: The findings suggest that the rural projects have the potential to improve access to mental health care for rural residents with depression and anxiety, by enabling GPs to refer them to allied health professionals. The findings are discussed with reference to recent reforms to mental health care delivery in Australia.     

Balancing hospital and community treatment: effectiveness of an extended-hours community mental health team in a semi-rural region of australia

Objective: To examine the effectiveness of the introduction of a community mental health team on consumer psychosocial outcomes. Design: Longitudinal panel design. Setting: District general hospital in a semi‐rural region of Australia. Numbers: Two matched groups (n = 37 in each group) Main outcome measure: These included: Brief Psychiatric Rating Scale (BPRS), Global Assessment Scale (GAS), Rosenberg Self‐Esteem, Life Skills Profile as well as self‐report. Results: The study found that the introduction of the new service resulted in few significant differences in consumer outcomes. Conclusions: The paper argues that because the state was the only specialist mental health service provider and it was unable to offer assertive community treatment, hospital care remained central. Evidence that a substantial proportion of consumers and carers preferred hospital to community care is placed against this background. The paper argues that in regions like these, where community‐based services are likely to remain underdeveloped, it may be best to maintain quality hospital services and to target community services more precisely on what is achievable rather than developing community services at the expense of hospital care. What is already known: Studies on the efficacy of assertive community treatment suggest that it can lead to improved consumer outcomes. However, these studies are usually in urban settings and involve experimental teams. In many rural and regional areas community treatment teams offer standard rather than assertive community care. It is therefore important to investigate the effectiveness of community treatment teams in rural and regional Australia. What this study adds: This study suggests that in rural and regional areas characterised by limited resources, it is too much to expect community treatment teams to have a measurable impact on consumer outcomes. In these settings hospital care remains at the heart of the service. This means that regions such as these need to focus their community services on what is achievable given the level of resources and social ecology. For example, they may need to consider offering either crisis intervention or rehabilitation services and to rely on innovations, such as telehealth or strategic alliances with other service providers to fill the gap.     

Improving the mental health of rural New South Wales communities facing drought and other adversities

Objective: NSW has just experienced its worst drought in a century. As years passed with insufficient rain, drought‐related mental health problems became evident on farms. Our objective is to describe how, in response, the Rural Adversity Mental Health Program was introduced in 2007 to raise awareness of drought‐related mental health needs and help address these needs in rural and remote NSW. The program has since expanded to include other forms of rural adversity, including recent floods. Setting: Rural NSW. Design, participants, interventions: Designed around community development principles, health, local service networks and partner agencies collaborated to promote mental health, education and early intervention. Strategies included raising mental health literacy, organising community social events and disseminating drought‐related information. Priority areas were Aboriginal communities, older farmers, young people, women, primary health care and substance use. Results: Over 3000 people received mental health literacy training in the four years of operation from 2007 to 2010. Stakeholders collaborated to conduct hundreds of mental health‐related events attended by thousands of people. A free rural mental health support telephone line provided crisis help and referral to rural mental health‐related services. Conclusion: Drought affected mental health in rural NSW. A community development model was accepted and considered effective in helping communities build capacity and resilience in the face of chronic drought‐related hardship. Given the scale, complexity and significance of drought impacts and rural adjustment, and the threats posed by climate change, a long‐term approach to funding such programs would be appropriate.     

'Shared Care - Shared Dream': Model of shared care in rural Australia between mental health services and general practitioners

OBJECTIVE: To identify a working model between rural and remote mental health services and the local GPs in Australia. DESIGN: Postal questionnaire to assess the GPs' satisfaction level with the involvement of the mental health services in their ongoing management of mentally ill in the community. RESULT: There was a greater sense of satisfaction with the mental health services over the five years this program was implemented. CONCLUSION: This study offers a model on how a rural mental health service could enter into a shared care program with the local GP practice and achieve a greater level of satisfaction in serving the rural communities in Australia.     

Rural physical health care services for people with serious mental illness: A nursing perspective

Objective: To understand nurse perspectives on the physical health needs of their mental health clients and how well rural services are meeting their overall care needs. Design: Focus groups with semistructured format. Setting: Community mental health care in a regional and rural district of Queensland. Participants: Thirty‐eight nurses in public mental health care. Results: The major themes were (i) stigma of mental illness, (ii) barriers to accessing physical health care services, (iii) nurse adaptations under demands, and (iv) community and integration towards better overall health. Nurses integrate overall care and foster its continuity for people with physical and mental co‐morbidity and can be supported much better in sustaining this. Conclusion: Access and continuity of physical health care experienced by all Australians is exacerbated for people in rural areas. Physical health of people with serious mental illness residing in remote Australia needs to be a national health priority.     

New Zealand rural primary health care workforce in 2005: more than just a doctor shortage

OBJECTIVE: To obtain a 2005 snapshot of New Zealand (NZ) rural primary health care workforce, specifically GPs, general practice nurses and community pharmacists. DESIGN: Postal questionnaires, November 2005. SETTING: NZ-wide rural general practices and community pharmacies. PARTICIPANTS: Rural general practice managers, GPs, nurses, community pharmacy managers and pharmacists. MAIN OUTCOME MEASURES: Self-reported data: demographics, country of training, years in practice, business ownership, hours worked including on-call, intention to leave rural practice. RESULTS: General practices: response rate 95% (206/217); 70% GP-owned, practice size ranged from one GP/one nurse to 12 GPs/nine nurses. PHARMACIES: Response rate 90% (147/163). Majority had one (33%) or two (32%) pharmacists; <10% had more than three pharmacists. GPs: response rate 64% (358/559), 71% male, 73% aged >40, 61% full-time, 79% provide on-call, 57% overseas-trained, 78% male and 57% female GPs aged >40; more full-time male GPs (76%) than female (37%) . Nurses: response rate 65% (445/685), 97% female, 72% aged >40, 31% full-time, 28% provide on-call, 84% NZ-trained, 45% consulted independently in 'nurse-clinics' within practice setting. Pharmacists: response rate 96% (248/258), 52% male, 66% aged >40, 71% full-time, 33% provide on-call, 92% NZ-trained, 55% sole/partner pharmacy owners. Many intend to leave NZ rural practice within 5 years: GPs (34%), nurses (25%) and pharmacists (47%). CONCLUSION: This is the first NZ-wide rural workforce survey to include a range of rural primary health care providers (GPs, nurses and pharmacists). Ageing rural primary health care workforce and intentions to leave herald worsening workforce shortages.     

Food for thought: enabling and constraining factors for effective rural eating disorder service delivery

Objective: This study examined the effectiveness of an assessment and referral model of eating disorder service delivery in the Northern Rivers of New South Wales and its potential as a model for rural service delivery. Design: A qualitative evaluative research design used brief and extended semistructured interviews with clients, and surveys and semistructured extended interviews with service providers who either referred clients to the service or to whom clients were referred. Setting: A sole practitioner service based in a small non‐government women's health service in rural New South Wales. Participants: Clients of the service, all but one of whom was woman; service providers including general practitioners, private practice psychologists and social workers, dietitians, mental health service workers. Major outcome measures: Participant identified enabling and constraining factors which contributed to the effectiveness of the service model. Results: Whilst all service providers and most clients found the assessment process to be beneficial, they identified a number of constraining factors in the referral part of the service which undermined the effectiveness of the model of service delivery, especially for those with more complex or severe presentations. Conclusions: For a rural ED service to be effective, a number of enabling factors must be present including the capacity to provide: treatment services as well as assessment; a multidisciplinary team approach to assessment and treatment; and expert consultation and training to generalist practitioners, counsellors, hospital wards and other service providers.     

Health Care Services for HIV-Positive Substance Abusers in a Rural Setting: An Innovative Program

ABSTRACT

Agencies that deliver health care services to HIV-positive substance abusers living in rural areas of the United States face particular treatment challenges and barriers to care. Rural consumers of HIV/AIDS health care–related services identified long travel distances to medical facilities, lack of transportation, lack of availability of HIV-specific medical personnel, a shortage of mental health and substance abuse services, community stigma, and financial problems as leading barriers to access to care. This article discusses barriers to care for rural HIV-positive substance abusers, and challenges for rural health care providers. In addition, it presents a case study of Health Services Center, a model program that has devised innovative practices in the delivery of health care services to HIV-positive substance abusers in rural northeastern Alabama.     

“Morir En Camino”: Community Narratives about Childbirth Care in Rural Chiapas

ABSTRACT

This anthropological study explores why more women in the rural Sierra Madre region of Chiapas, Mexico birth at home rather than at the hospital. Between January and May of 2014, the primary investigator conducted in-depth, semi-structured interviews with twenty-six interlocutors: six parteras (home birth attendants), nine pregnant women, four mothers, four healthcare providers, and three local government leaders. Participant observation occurred in the health clinic, participants’ homes, and other spaces in a community with a population of 1,188 people. Drawing from narrative analysis, the findings suggest that women face structural obstacles to accessing high-quality childbirth care, which lead them to give birth at home instead of the hospital. These obstacles include financial barriers in obtaining facility-based care and poor quality of care, such as mistreatment in the facility. The study highlights the importance of centreing community narratives in healthcare programming in order to bridge the implementation gap between women in rural communities, healthcare workers, and policymakers.     

Role of multi-purpose service programs providing residential aged care in rural Australia: a discussion paper

Objective: To determine if multi‐purpose service (MPS) Programs deliver improved residential aged care as opposed to traditional rural hospitals. Design: A variation on comparative–experimentalist: type 4. In this design 2 groups providing different service models of rural health services are compared. Setting: Six MPS Programs and three traditional hospitals in rural New South Wales. Subjects: Key stakeholders – area representatives, health service managers, MPS managers, doctors, staff, MPS or hospital committee members and consumer groups including residents. Main outcome measure: To analyse the ability of MPS Programs to deliver quality residential aged care as opposed to using traditional hospitals for such services. Results: Multi‐purpose service programs provided better residential environments and greater flexibility of service provision. There were few apparent differences between the two service models in regard to organisational culture and training. Conclusions: The findings of this evaluation suggest that in the provision of residential aged care in rural communities, MPS Programs demonstrated better standards of care than traditional hospital based services. What is already known on the subject: The development of multi‐purpose service programs to replace the older traditional rural hospitals is a relatively new practice in Australia. With the introduction of MPS programs there has been little evaluative research to demonstrate their effectiveness in health service delivery and the provision of residential aged care. Multi‐purpose service programs aim to integrate and coordinate acute, aged and community rural health services under one structure and so it is imperative that evaluative studies such as this one takes place. What does this study add?: The findings of this study demonstrate that the MPS model provides a better solution than hospitals to the problem of providing residential aged care in rural communities. With Australia looking to further develop MPS Programs in rural areas, it is hoped quality aged care services will be enhanced allowing older adults to remain in the communities of their choice.     

Barriers to managing mental health in Western Australia

Objective: To explore the views of community‐care and mental health workers on barriers to the management of mental health problems in rural Western Australia, and how these could be addressed. Design: Qualitative content analysis of semi‐structured interviews. Setting: Community and mental health services in Esperance. Subjects: One hundred per cent of relevant mental health workers, 86% of community health professionals and representatives from a wide range of community organisations were interviewed (n =38). Main outcome measures: The views of community‐care and mental health workers on barriers to the management of mental health, and how these could be addressed. Results: Barriers included confusion about the role of mental health services, limited after‐hours access and help for those in situational crisis, communication problems between services, differences in working practices and difficulties in dealing with the stigma of mental illness in rural communities. Suggested solutions were an expansion of counselling services and multi‐agency shared care with clinical streams for adults, those aged > 65 and children. Conclusion: This study revealed a number of barriers that are being addressed through a memorandum of understanding between services.     

Older people's mental health in rural areas: Converting policy into service development,service access and a sustainable workforce

This paper describes the older people's mental health workforce development, policy development and implementation process and quantifies the rural service delivery and access impacts over a 15‐year period in New South Wales. It highlights the factors that are considered to be critical to successful rural service development such as commitment to funding parity, investment in strong local service leadership, and development of innovative, locally adapted rural service models. Building on these foundations, the Older People's Mental Health Program in New South Wales was able to address key challenges relating to service access in rural health and develop new, sustainable specialist older people's mental health service networks. A sustained focus on policy and implementation which explicitly supports rural older people's mental health service enhancement, and development of evidence‐based models of care, has significantly improved access to specialist mental health care for older people in rural areas. It has delivered 23 new rural older people's mental health community teams and a 440% increase in the number of people accessing these teams. It has also doubled the number of acute inpatient units and established new specialist mental health‐residential aged care partnership services in rural New South Wales. It has resulted in increased access to services for the “older old,” while not diminishing older people's rates of access to general adult mental health services. It has also supported innovative, sustainable rural service models such as “hub and spoke” models and step‐up step‐down inpatient services that build on existing health and hospital infrastructure and link geographically dispersed specialist clinicians and services together in rural service delivery.