Management of type 2 diabetes

Objective: This article describes the evaluation of a new model of partnership care using an audit cycle. Results: Statistically significant improvements in foot examination, body mass index, urine albumin creatinine ratio, total cholesterol, triglycerides and visual acuity measurements were observed. Significant increases in the proportion of patients achieving cholesterol and triglycerides therapeutic targets occurred. Most other outcome indicators demonstrated a nonsignificant improvement, which may be due to the short time interval in the audit for potential change. Conclusion: A dedicated chronic disease team and a clinical information system to coordinate culturally appropriate, multidisciplinary chronic disease care enables effective management of chronic diseases such as type 2 diabetes

Community engaged GP training. Does it make a difference?

Much effort and funding is spent on GP training in Australia but there is little data on how GP training in rural and remote areas impacts communities. Since 2001, the Australian General Practice Training (AGPT) program has required at least 50% of general practice training to occur in rural areas despite lack of information about the effectiveness of rural training. A study conducted by a new RTO, Generalist Medical Training (GMT), part of James Cook University's (JCU's) College of Medicine and Dentistry, aimed to identify aspects of GP training which have impacted rural/remote registrars' experience, their supervisors, training posts/practices, and the local community. Perspectives were obtained from 37 semi-structured interviews with 14 GP registrars, 10 supervisors, and 13 practice managers. This presentation focuses on the community impact of training and supervising GP registrars in rural and remote areas of north-west Queensland. The primary themes extracted from the data relate to the perceptions of doctors’ contribution to underserved communities and community expectations of the medical workforce. Rural and remote communities hold three main expectations of the medical workforce: 1) Patient-Centred Care; 2) Preventive Care and Continuity of Practice; and 3) Quality of GP registrars and supervisors. It was also identified that registrars and supervisors who uphold these expectations are involved and invested in the community and in their role of being a trusted 'family doctor'. Effective and well-focused training is also said to impact positively on registrars’ learning by enhancing their scope of practice, their feeling of accomplishment, and resilience. As a whole, community involvement and investment also enhances medical reputation and morale amongst doctors and community members. Further investigations are underway to explore how best to approach community engaged GP training

Factors influencing the use of clinical guidelines by general practitioners working in a setting of complex multimorbidity: a case study by interviews

Background: The Central Australian Remote Practitioners Association Standard Treatment Manual (CARPA) contains protocols for primary health care in remote Central Australia. This context stands in stark contrast to the mainstream settings in Australia and features an Aboriginal population with very poor health status, powerful social determinants of health, geographical isolation and high turnover of health practitioners. The manual consolidates the core elements of national guidelines, particularly as they pertain to Aboriginal health care, into a single document. The aim of this study is to explore factors that promote or impede the use of CARPA by general practitioners (GPs) in Central Australia, with a particular focus on chronic disease management. Methods: In-depth interviews were conducted with GPs and GP registrars employed in the provision of Aboriginal health care in Central Australia. Interview transcripts were thematically analysed from a critical theory perspective. Results: 11 GPs and 3 GP registrars from the two major Aboriginal primary health services in Central Australia were interviewed. The dominant theme in the data was that poor continuity of care impeded the use of CARPA. The second-most dominant theme was that electronic health record systems enhanced the use of CARPA in some ways, and impeded its use in others. Other factors influencing the use of CARPA included the culture of the health service organisation, GPs' first impressions of CARPA, the accessibility and usability of CARPA, and GPs' confidence practicing in such a unique environment. Conclusions: This study identifies factors from multiple domains that influence the use of best practice guidelines in the delivery of chronic disease care. It demonstrates that such factors may not be purely 'enablers' or 'barriers', but may be a mixture of both. It highlights the critical role of continuity of care and the potential benefits and pitfalls of using electronic health records in providing chronic disease care. This study provides empirical insights that can be used to improve chronic disease care

Health profession education in remote or geographically isolated settings: a scoping review

Remote health has been differentiated from rural health in Australia and defined as isolated, with poor service access and a relatively high proportion of Indigenous residents, necessitating different models of care. Educational strategies for remote health practice are often needs driven and the characteristics of remote health may be used to categorise remote health professional education. This scoping review aims to identify the purpose of health professional education for remote settings, the type of educational strategies implemented and the reported outcomes. A broad search of published literature available in online bibliographic databases was conducted. A total of 33 articles met the review inclusion criteria. A further 7 articles were identified for inclusion in the review through citation searches and the authors’ networks giving a total of 40 articles. Six primary themes were established based on the educational purpose: (1) cultural competency; (2) social accountability; (3) rural and remote skill development for the general workforce; (4) remote specialisation; (5) specialist skills required for a remote workforce; and (6) remote teaching. These themes also reflect the philosophical change over time recognising remote health as a separate discipline and its value as a distinctive and efficacious learning environment. The concept of education for remote practice is proposed to describe this unique leaning environment which encompasses critical pedagogy to develop a sense of agency and social accountability, embedding the delivery of primary health care through service learning and developing relationships in a context which is transformative

Community engaged GP training. Does it make a difference?

Much effort and funding is spent on GP training in Australia but there is little data on how GP training in rural and remote areas impacts communities. Since 2001, the Australian General Practice Training (AGPT) program has required at least 50% of general practice training to occur in rural areas despite lack of information about the effectiveness of rural training. A study conducted by a new RTO, Generalist Medical Training (GMT), part of James Cook University's (JCU's) College of Medicine and Dentistry, aimed to identify aspects of GP training which have impacted rural/remote registrars' experience, their supervisors, training posts/practices, and the local community. Perspectives were obtained from 37 semi-structured interviews with 14 GP registrars, 10 supervisors, and 13 practice managers. This presentation focuses on the community impact of training and supervising GP registrars in rural and remote areas of north-west Queensland. The primary themes extracted from the data relate to the perceptions of doctors’ contribution to underserved communities and community expectations of the medical workforce. Rural and remote communities hold three main expectations of the medical workforce: 1) Patient-Centred Care; 2) Preventive Care and Continuity of Practice; and 3) Quality of GP registrars and supervisors. It was also identified that registrars and supervisors who uphold these expectations are involved and invested in the community and in their role of being a trusted "family doctor". Effective and well-focused training is also said to impact positively on registrars’ learning by enhancing their scope of practice, their feeling of accomplishment, and resilience. As a whole, community involvement and investment also enhances medical reputation and morale amongst doctors and community members. Further investigations are underway to explore how best to approach community engaged GP training

How does GP training impact rural and remote underserved communities? Exploring community and professional perceptions

Background: Substantial government funding has been invested to support the training of General Practitioners (GPs) in Australia to serve rural communities. However, there is little data on the impact of this expanded training on smaller communities, particularly for smaller rural and more remote communities. Improved understanding of the impact of training on underserved communities will assist in addressing this gap and inform ongoing investment by governments and communities. Method: A purposive sample of GP supervisors, GP registrars, practice managers and health services staff, and community members (n = 40) from previously identified areas of workforce need in rural and remote North-West Queensland were recruited for this qualitative study. Participants had lived in their communities for periods ranging from a few months to 63 years (Median = 12 years). Semi-structured interviews and a focus group were conducted to explore how establishing GP training placements impacts underserved communities from a health workforce, health outcomes, economic and social perspective. The data were then analysed using thematic analysis. Results: Participants reported they perceived GP training to improve communities' health services and health status (accessibility, continuity of care, GP workforce, health status, quality of health care and sustainable health care), some social factors (community connectedness and relationships), cultural factors (values and identity), financial factors (economy and employment) and education (rural pathway). Further, benefits to the registrars (breadth of training, community-specific knowledge, quality of training, and relationships with the community) were reported that also contributed to community development. Conclusion: GP training and supervision is possible in smaller and more remote underserved communities and is perceived positively. Training GP registrars in smaller, more remote communities, matches their training more closely with the comprehensive primary care services needed by these communities

Insight into rural and remote GP training and supervision in Queensland

Many rural and remote communities are struggling to attract and retain GPs while experiencing poorer population health outcomes and burden of disease. Therefore, the provision of a reliable rural GP workforce is vital. Registered Training Organisations provide high quality training experiences for GP registrars. A collaborative project between JCU and Monash University aimed to identify aspects of GP training which impact registrars’ experience. Perspectives were obtained from GP registrars, supervisors, and practice managers. This presentation focuses on training and supervision aspects in rural and remote north-west Queensland. A mixed methods study was undertaken and both quantitative and qualitative data were collected. A modified survey based on the adapted Critical Access Hospital Community Apgar Questionnaire was used to collect data about perceptions of rural GP training and supervision with the highest rated factor being medical quality and the lowest rated being scope of practice. Semi-structured interviews were then used to gather additional information about training and supervision experiences. Interviews were thematically analysed and primary themes relating to attractors and barriers for workforce training and supervision, and impact of rural remote practice were elicited. Attractors included lifestyle, rural medicine, scope of practice, services and incentives while barriers included workforce factors, lifestyle, location, services and incentives. Rural remote GP training experiences contribute a variety of attractors and barriers which impact on a positive training experience for registrars. Identification of these factors make it possible to tailor training accordingly and foster a positive rural experience that may translate to a future reliable workforce

A curriculum for achieving universal health care: a case study of Ateneo de Zamboanga University School of Medicine

Introduction: Universal Health Care requires equal distribution of a health workforce equipped with competencies appropriate for local population needs. While health inequities persist in the Philippines, the Ateneo de Zamboanga University School of Medicine (ADZU-SOM) in Zamboanga Peninsula – an impoverished and underserved region – has demonstrated significant success retaining graduates and improving local health statistics. This study describes the qualitative evidence of ADZU-SOM students and graduates having positive impacts on local health services and communities, and the contextual factors associated with the school's socially-accountable mission and curriculum that contribute to these impacts. Methods: This qualitative study involved 41 one-on-one or group interviews conducted across seven participant groups (faculty, graduates, final-year students, health professionals, health workers, community members, community leaders). Gale et al's method for analyzing qualitative data inmulti-disciplinary health research, WHO's "6 Building Blocks for quality health systems" framework and THEnet's social-accountability framework were used to organize and interpret data. Results: Local community members, community leaders, and health staff consistently reported examples of ADZU-SOM students and graduate doctors developing health infrastructure and providing health education, health promotion, and disease prevention activities accessible to all population groups. Students and graduates suggested these impacts were due to a number of factors, including how ADZU-SOM’s sandwich model of longitudinal community-engagement culminating in 10-months continuous community placement in the final year helped them develop a strong motivation for community service, the teachings and curriculum activities that focused on public health and the social determinants of health, and faculty's commitment and ability to operationalize ADZU-SOM's mission and values. Staff also reported impacts were driven by integration of regional and national health priorities as core curriculum, and involving local stakeholders in curriculum development. Conclusions: This study provides qualitative evidence that ADZU-SOM's curriculum content and immersive community placements are training a medical workforce that is strengthening local health systems and health infrastructure across all 6 WHO "Building Blocks for quality health systems." These findings suggest ADZU-SOM has managed to evolve a consciousness toward community service among final year students and graduates, adding evidence to the assertion it is a fully socially-accountable health professions institution

The Alice Springs Hospital Readmission Prevention Project (ASHRAPP): a randomised control trial

Background: Hospitals are frequently faced with high levels of emergency department presentations and demand for inpatient care. An important contributing factor is the subset of patients with complex chronic diseases who have frequent and preventable exacerbations of their chronic diseases. Evidence suggests that some of these hospital readmissions can be prevented with appropriate transitional care. Whilst there is a growing body of evidence for transitional care processes in urban, non-indigenous settings, there is a paucity of information regarding rural and remote settings and, specifically, the indigenous context. Methods: This randomised control trial compares a tailored, multidimensional transitional care package to usual care. The objective is to evaluate the efficacy of the transitional care package for Indigenous and non-Indigenous Australian patients with chronic diseases at risk of recurrent readmission with the aim of reducing readmission rates and improving transition to primary care in a remote setting. Patients will be recruited from medical and surgical admissions to Alice Springs Hospital and will be followed for 12 months. The primary outcome measure will be number of admissions to hospital with secondary outcomes including number of emergency department presentations, number of ICU admissions, days alive and out of hospital, time to primary care review post discharge and cost-effectiveness. Discussion: Successful transition from hospital to home is important for patients with complex chronic diseases. Evidence suggests that a coordinated transitional care plan can result in a reduction in length of hospital stay and readmission rates for adults with complex medical needs. This will be the first study to evaluate a tailored multidimensional transitional care intervention to prevent readmission in Indigenous and non-Indigenous Australian residents of remote Australia who are frequently admitted to hospital. If demonstrated to be effective it will have implications for the care and management of Indigenous Australians throughout regional and remote Australia and in other remote, culturally and linguistically diverse populations and settings

Demonstrating a new approach to planning and monitoring rural medical training distribution to meet population need in North West Queensland

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.Background Improving the health of rural populations requires developing a medical workforce with the right skills and a willingness to work in rural areas. A novel strategy for achieving this aim is to align medical training distribution with community need. This research describes an approach for planning and monitoring the distribution of general practice (GP) training posts to meet health needs across a dispersed geographic catchment. Methods An assessment of the location of GP registrars in a large catchment of rural North West Queensland (across 11 sub-regions) in 2017 was made using national workforce supply, rurality and other indicators. These included (1): Index of Access –spatial accessibility (2); 10-year District of Workforce Shortage (DWS) (3); MMM (Modified Monash Model) rurality (4); SEIFA (Socio-Economic Indicator For Areas) (5); Indigenous population and (6) Population size. Distribution was determined relative to GP workforce supply measures and population health needs in each health sub-region of the catchment. An expert panel verified the approach and reliability of findings and discussed the results to inform planning. Results 378 registrars and 582 supervisors were well-distributed in two sub-regions; in contrast the distribution was below expected levels in three others. Almost a quarter of registrars (24%) were located in the poorest access areas (Index of Access) compared with 15% of the population located in these areas. Relative to the population size, registrars were proportionally over-represented in the most rural towns, those consistently rated as DWS or those with the poorest SEIFA value and highest Indigenous proportion. Conclusions Current regional distribution was good, but individual town-level data further enabled the training provider to discuss the nuance of where and why more registrars (or supervisors) may be needed. The approach described enables distributed workforce planning and monitoring applicable in a range of contexts, with increased sensitivity for registrar distribution planning where most needed, supporting useful discussions about the potential causes and solutions. This evidence-based approach also enables training organisations to engage with local communities, health services and government to address the sustainable development of the long-term GP workforce in these towns