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.     

The family and nurse in partnership: providing day-to-day care for rural cancer patients

OBJECTIVE: To explore demands made on family members in managing symptoms and providing for the day-to-day care of relatives with cancer in rural New South Wales and how specialist palliative care nurses support these family members. DESIGN: Cross sectional qualitative study. SETTING: Seven health centres across rural New South Wales that cover a broad geographical area and reflect the diversity in economic conditions, population density and distance from three major urban centres in New South Wales. SUBJECTS: The study involved two groups of participants. The first group consisted of one or more members of families of oncology patients who were accessed through health workers at the seven centres. Nineteen family members from 17 families were interviewed. The second group comprised 10 nursing staff working as specialist palliative care nurses across the same geographical area as the families. MAIN OUTCOME MEASURES: Physical care and symptom management were the two main areas of interest. RESULTS: The rural experience of caring for palliative care patients was challenging, with support nurses needing to take into consideration all aspects of the patients' and families' living environments. CONCLUSION: There is a need for equipment and basic resources to be readily available to practitioners, funding for ongoing education and 24-h care.     

Empowerment through information: supporting rural families of oncology patients in palliative care

A research project examining the support needs of families caring for a relative in palliative care was conducted in New South Wales in 1997. Data were collected from 19 families and 10 specialist palliative care nurses from eight centres throughout New South Wales using audio-taped interviews. The findings show that information was one of the most important support needs for families to enable them to effectively care for their sick relative. The information provided needed to meet the individual and varying needs of families at different stages of their palliative care journey. Often the families described not knowing what their information needs were until a crisis occurred. Lack of information on a range of areas, from practical resources to providing physical care and managing medications, was problematic. Health professionals need to take responsibility in determining if families are aware of the information available, identify the most appropriate medium for this material and provide it at the pace and time wanted by the individual family.     

Far West Area Health Service Mental Health Integration Project: Model for rural Australia?

OBJECTIVE: To see if a new model of service delivery ensures that individuals with a mental illness in rural and remote settings could be assessed, treated and cared for in a more appropriate way. DESIGN: Community mental health teams (CMHTs), general practitioners (GP) and other agencies were provided with clinical and broader support services by consultant psychiatrists from public and private sectors. The occasions of service were logged, audited and relevant provider groups were interviewed. Ethics approval was provided by Human Research Ethics Community of University of New South Wales. SETTING: Far West Area Health Service (FWAHS), remote New South Wales. PARTICIPANTS: An enhanced service was provided for residents, specialist mental health and other healthcare providers. RESULTS: Regular access to psychiatrists for primary and secondary care was achieved in remote communities in FWAHS. 3908 new patients were seen by CMHTs between July 2002 and December 2003 and 380 by visiting psychiatrists between January 2002 and July 2003. Secondary consultation, mentoring and education opportunities were made available by tele-conference and face-to-face for CMHTs and others in FWAHS. GPs and CMHTs in remote settings were satisfied with improved access to psychiatrist care. CONCLUSIONS: This model appears to be sustainable with reasonable levels of funding in FWAHS and may be applicable to other remote contexts.     

New South Wales rural general practice from a Yank's perspective

ABSTRACT: The author, a family practice specialist from Minnesota in the United States, worked as a locum in rural New South Wales for 6months. This provided him with the opportunity to reflect on the differences between the specialty of family practice in his home state of Minnesota and general practice in New South Wales; and to recognise that general practice in New South Wales is at a crossroads. This paper highlights the need for general practitioners (GPs) to work together and support each other, to provide quality care and to lobby both State and Commonwealth governments on the importance of broadly trained GP specialists in rural communities. To influence the future of their profession, GPs in New South Wales need to focus on quality of care and on educating themselves, their colleagues and the communities in which they work.     

Can specially trained community care workers effectively support patients and their families in the home setting at the end of life?

Surveys indicate that many Australians would prefer to die at home, but relatively few do. Recognising that patients and their families may not have the support they need to enable end‐of‐life care at home, a consortium of care providers developed, and received funding to trial, the Palliative Care Home Support Program (PCHSP) across seven health districts in New South Wales, Australia. The programme aimed to supplement end‐of‐life care in the home provided by existing multidisciplinary community palliative care teams, with specialist supportive community care workers (CCWs). An evaluation of the service was undertaken, focussing on the self‐reported impact of the service on family carers (FCs), with triangulation of findings from community palliative care teams and CCWs. Service evaluation data were obtained through postal surveys and/or qualitative interviews with FCs, community palliative care teams and CCWs. FCs also reported the experience of their loved one based on 10 items drawn from the Quality of Death and Dying Questionnaire (QODD). Thematic analysis of surveys and interviews found that the support provided by CCWs was valued by FCs for: enabling choice (i.e. to realise end‐of‐life care in the home); providing practical assistance (“hands‐on”); and for emotional support and reassurance. This was corroborated by community palliative care teams and CCWs. Responses by FCs on the QODD items indicated that in the last week of life, effective control of symptoms was occurring and quality of life was being maintained. This study suggests that satisfactory outcomes for patients and their families who wish to have end‐of‐life care in the home can be enabled with the additional support of specially trained CCWs. A notable benefit of the PCHSP model, which provided specific palliative care vocational training to an existing community care workforce, was a relatively rapid increase in the palliative care workforce across the state.     

Are rural adolescents necessarily at risk of poorer obstetric and birth outcomes?

OBJECTIVE: The purpose of the present study were to describe the sociodemographic and clinical characteristics of adolescent women giving birth at Wagga Wagga Base Hospital, and compare these with those with all adolescents in New South Wales. DESIGN: An investigative approach. Main outcome measures: Obstetric complications, delivery intervention and adverse infant outcomes. SETTING: Wagga Wagga Base Hospital. Participants: One hundred and sixteen adolescents aged 15-19 years. RESULTS: In relation to obstetric complications and infants with complications, the study sample was found to be representative of New South Wales adolescents. However, for type of delivery there was a higher rate of forceps delivery (12.3% (15) vs 4.7% (415) P = 0.0001), forceps rotation (4.1% (5) vs 0.9% (80) P = 0.004) and fewer normal vaginal deliveries (67.2% (82) vs 80.8% (7108) P = 0.006) at Wagga Wagga Base Hospital. CONCLUSION: These findings suggest that rural adolescents are at risk of delivery complications and are less likely to have a normal vaginal delivery. More research is required into obstetric and birth outcomes for the rural adolescent population.     

A survey on drug-related service by homehelper in the Japanese home care system

The purposes of this study are a) to determine whether homehelpers attend to drug-related service of elder care-recipients at home and b) to determine what cooperating human resources were utilized. A structured questionnaire survey was conducted in 1997 with 403 homehelpers who provided in home care to dependent elderly person. Of the total, 19% subjects did deal with care recipients' medication. Regarding the type of service, the highest proportion of subjects had assisted by picking up medicine from pharmacy and talking it to the care recipients' home. Results showed that physicians and home visiting nurses were the most depended upon human resources in the home health care system among health, medical and welfare facilities. Results also suggested that many homehelpers are not aware that pharmacists are readily available resources for providing home health care. Hence we conclude that the respondents tend to rely on physicians or home visiting nurses to respond to care recipients care, and pharmacists should be made aware of the necessity of providing the appropriate drug-related information to physicians or home visiting nurses.     

Tailoring immunisation service delivery in a disadvantaged community in Australia; views of health providers and parents

In 2014 the Australian immunisation target was raised from 90% to 95% of children to be fully immunised. A national priority is to identify geographic areas of low coverage and implement strategies to improve immunisation rates. Using The World Health Organization’s Tailoring Immunization Programmes (TIP) Guidelines, the aim of this study was to identify areas of low immunisation coverage for children in the Hunter New England Local Health District, New South Wales, and to gain a deeper understanding of the factors influencing immunisation in those areas in order to develop tailored strategies for increasing immunisation coverage. Data from the Australian Immunisation Register was used to identify geographic areas of low coverage. Data from interviews and focus groups with parents and service providers were used to gain a deeper understanding of the factors influencing immunisation in those areas. The regional city of Maitland in New South Wales was identified as having a persistently high number and relatively high proportion of children not fully immunised (n = 427, 15.4% in 2016). Themes from 59 stakeholder interviews and focus groups included; (i) limited engagement with health services unless the need is urgent, (ii) multi-dimensional access barriers to immunisation services in Maitland, (iii) a flexible, supportive family centred, primary health care approach, utilising strong partnerships, is most likely to be effective in increasing childhood immunisation rates in Maitland, (iv) data can be used more effectively to inform service providers about trends and individual children not fully immunised. TIP guidelines proved useful for identifying areas of low coverage and providing an understanding of determining factors and the strategies most likely to be effective. Understanding the complex problems many parents face and the access barriers that contribute to low immunisation coverage is essential in developing appropriate solutions. Finding ways to support parents and remove those barriers can contribute to higher coverage. In Maitland, targeted outreach and home visiting has been implemented in consultation with community and health service representatives to ensure that the children from socially disadvantaged populations identified do not miss out on vaccination.     

Promotion of service integration among home visiting programs and community coalitions working with low-income, pregnant, and parenting women

This study assessed service integration promoted by home visitors and community coalitions in Baltimore's Comprehensive Family Support Strategy. The study first assessed home visitors' coordination of services for their clients. Two yearly home visitors surveys (n = 32) assessed changes in their perceptions of 11 community resources' availability, service quality, and referrals made to those resources. There were statistically significant increases in the percentage of home visitors who (a) reported availability of seven resources, (b) gave high service quality ratings for six resources, and (c) referred clients to all 11 resources. The study also assessed six community coalitions' actions to promote service integration during 1 year through observation of coalition meetings. Coalitions discussing more service integration exhibited greater increases in home visitors' perceptions of high service quality and referrals. Home visiting practitioners should consider including coalitions as part of their program models in order to better link clients to appropriate community resources.     

The pattern of diabetes care in New South Wales: a five-year analysis using Medicare occasions of service data

OBJECTIVE: To use Medicare occasions of service data to establish the pattern and standard of care received by people with diabetes. METHOD: Information about visits to medical practitioners as well as utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997 was retrieved using a Health Insurance Commission data file. Individuals were deemed to have diabetes if an HbA1c which can only be ordered for a person with known diabetes, had been performed over the five-year period. RESULTS: On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. A large proportion of patients also received care at the specialist and consultant physician level, 51.2% and 38.6% respectively, a three to four fold increase when compared with their non-diabetic counterparts. There was also a 1.3 to 1.8 fold increase in the mean number of attendances to the various medical practitioners. Surveillance of diabetes parameters was inadequate but small improvements were seen over the 5 year study period (proportion of persons with diabetes with a HbA1c performed: 48.8% to 56.8%; Lipids: 49.4% to 52.0%; HDL cholesterol: 18.3% to 18.8%; microalbuminuria: 4.7% to 11.6%). CONCLUSION: This study has highlighted the heavy burden imposed by diabetes on our health care system. IMPLICATIONS: The use of Medicare occasions of service data represents a cost efficient way of monitoring health service utilisation.     

Home assessments in geriatrics revisited: an audit of a routine home visiting service.

Routine home visiting is a luxury not afforded to other medical specialties. The practice of routine home assessment visiting in geriatric medicine was evaluated in a prospective study of 110 consecutive referrals to determine whether; the response to general practitioners referrals could be predicted from the information given at the time of referral and; to identify where home visiting identified additional information of value in directing services more appropriately. Requests for admission were accurately predicted in 86-96% of cases by the visiting and a control doctor respectively. Additional information of value in directing services and patient management was gained from the home visit in 30% of admissions, 58% of day hospital cases and 80% of outpatients. It is possible to predict the outcome of home visits although implementation of such predictions without direct communication with general practitioners would result in a small number of unnecessary admissions and referrals to day hospital services.     

General practitioner's recognition of service cooperation with community pharmacists related to home care in a suburban area

OBJECTIVES: To clarify the factors affecting a general practitioner's demands and the recognition of service cooperation with community pharmacists related to home care in a suburban area. METHODS: A questionnaire on pharmacy services and functions was administered to 215 general practitioners in a suburban area. Gender, age, specialty, length of practice, status of home visiting, requests for community pharmacists, awareness of a home visiting service by community pharmacists, status of issues about home visiting orders to community pharmacists and the criteria for deciding to issue an order, recognition of the necessity of a home visiting service by pharmacists, expectation value to the community of the pharmacists' participation in the home care service and requests, recognition of cooperation with other home care related professions, ease of cooperation with community pharmacists, disincentives for cooperation with community pharmacists, factors necessary to promote cooperation between practitioners and community pharmacists, and factors necessary to promote the home care system were surveyed. Using the results, chi 2 test and principal component analysis were performed. RESULTS: It was found that the general practitioners' main demands were support and management of pharmaceutical therapy. Meanwhile, the practitioners' low cognition of pharmacists' home visiting seemed to be one disincentive to cooperation with pharmacists. Every practitioner who had issued visiting orders to pharmacists practiced home visiting and issued the visiting orders based on patients' condition at home. Practitioners who practiced home visiting were more active in promoting the home care system and had a better cognition and more extensive demands for pharmacists' home visiting compared to practitioners with no home visiting. Practitioners with good recognition of cooperation with community pharmacists had better cognition, realized the necessity of, and expected pharmacist's home visiting compared to practitioners with low awareness. However, practitioners' overall recognition of cooperation with pharmacists was relatively low. As disincentives, practitioners pointed out lack of acquaintance, the unclear function of pharmacists, and no opportunity for cooperation. So, enhancing practitioners' awareness of home care, clarifying the pharmacist's role, establishing a relationship of mutual trust through information feedback and/or exchange based on practice would be effective in promoting service cooperation with community pharmacists.     

Pediatric palliative care: an assessment of physicians' confidence in skills, desire for training, and willingness to refer for end-of-life care

This study determines the confidence levels of physicians in providing components of pediatric palliative care and identifies their willingness to obtain training and to make palliative care referrals. Surveys were mailed to all physicians at Primary Children's Medical Center. The survey instrument includes 3 demographic items, 9 items designed to assess physician confidence in core palliative care skills, and 4 items designed to assess what steps physicians would be likely to take to assure that patients receive palliative care. Physicians were asked to rate their confidence levels to provide palliative care components on a 4-point scale for each of the items. Five hundred ninety-seven surveys were mailed, with 323 usable surveys returned. The proportion of physicians who rate their ability to provide palliative care as "confident" or "very confident" ranges from 74% for giving difficult news to families to 23% for managing end-of-life symptoms. Thirty-six percent of the physicians say they would be "likely" or "very likely" to attend training to improve their ability to provide palliative care to children. Eighty-six percent would be "likely" or "very likely" to refer for a palliative care consult and 91% to a home health agency or hospice. There is wide variation in the confidence levels of physicians to provide the core components of palliative care. Few are interested in obtaining additional training, but most are willing to obtain consultation or to refer to a palliative care service. These results argue in favor of hospital-based palliative care teams and for specialty training and certification in pediatric palliative care.     

Predictors of social service staff involvement in selected palliative care tasks in nursing homes: an exploratory model

Little research has been conducted on nursing home social service staff and end-of-life care in nursing homes. To address this gap, a cross-sectional study on end-of-life issues for people with dementia in nursing homes was conducted in New York State, in which 138 nursing home social service staff participated. This exploratory study examined issues such as perceived confidence, perceived influence, and demographic variables in relation to self-reported frequency of tasks related to palliative care of nursing home residents with dementia. Results showed that participants in this survey who discussed specific treatment issues during advance directive discussions perceived themselves to have higher degrees of influence in their respective facilities, were directors or managers of their departments, and were more likely to engage in tasks related to palliative care.     

Mental health service use by the elderly in nursing homes.

OBJECTIVES. Because current Omnibus Budget Reconciliation Act regulations influence the disposition of US nursing home residents who have mental illness, National Nursing Home Survey (1985) data are analyzed for predictors of mental health service use. METHODS. Elderly residents' rates of mental health service use are presented. Logistic regression yielded odds ratios for treatment by both mental health specialists and general practitioners for client and service system variables. RESULTS. Among the two thirds of elderly residents with a mental disorder (including dementia), only 4.5% receive any mental health treatment in a 1-month period. The ratio of specialist to general practitioner care is approximately 1:1. Patients seen by a specialist are likely to be younger (aged 65 to 74); live in the Northeast; and have a diagnosis of schizophrenia (13:1), dementia (3:1), or other mental disorders (5:1). Prior residence in a psychiatric hospital predicts care by both health professional types. Rural location, nonproprietary ownership of the nursing home, and aggressive behavior point to general physician care. CONCLUSIONS. Our findings indicate significant neglect of the mental health needs of older nursing home residents and underscore the importance of monitoring the regulations for screening and treatment of mental disorders under the Omnibus Budget Reconciliation Act.     

Utilisation of home‐based physician,nurse and personal support worker services within a palliative care programme in Ontario,Canada: trends over 2005–2015

With health system restructuring in Canada and a general preference by care recipients and their families to receive palliative care at home, attention to home‐based palliative care continues to increase. A multidisciplinary team of health professionals is the most common delivery model for home‐based palliative care in Canada. However, little is known about the changing temporal trends in the propensity and intensity of home‐based palliative care. The purpose of this study was to assess the propensity to use home‐based palliative care services, and once used, the intensity of that use for three main service categories: physician visits, nurse visits and care by personal support workers (PSWs) over the last decade. Three prospective cohort data sets were used to track changes in service use over the period 2005 to 2015. Service use for each category was assessed using a two‐part model, and a Heckit regression was performed to assess the presence of selectivity bias. Service propensity was modelled using multivariate logistic regression analysis and service intensity was modelled using log‐transformed ordinary least squares regression analysis. Both the propensity and intensity to use home‐based physician visits and PSWs increased over the last decade, while service propensity and the intensity of nurse visits decreased. Meanwhile, there was a general tendency for service propensity and intensity to increase as the end of life approached. These findings demonstrate temporal changes towards increased use of home‐based palliative care, and a shift to substitute care away from nursing to less expensive forms of care, specifically PSWs. These findings may provide a general idea of the types of services that are used more intensely and require more resources from multidisciplinary teams, as increased use of home‐based palliative care has placed dramatic pressures on the budgets of local home and community care organisations.