Birthing in regional Australia: Women\u27s decision making surrounding birthplace

Objective Although there is some research on women’s choice of birthplace, most of this research has been conducted overseas. This study explored factors influencing the decision to use public or private maternity services within regional Australia. Methods This cross-sectional study consisted of a community-based, anonymous, online questionnaire focused on factors influencing a woman’s choice of birth location and included adult females who had given birth in the past 2 years within two regional areas. Descriptive statistics were used to analyse demographic characteristics and factors influencing decisions regarding birthplace. Pearson’s Chi-squared test was used to compare public and private births for multiple variables. Binary logistic regression was used to determine the odds ratio for each potential factor based on whether participants with private health insurance (PHI) elected to birth in the public or private regional hospitals. Open coding was used to group responses to open ended questions into themes. Results Data from 510 questionnaires were analysed. The three most frequently reported factors influencing a woman’s decision about birthplace were financial reasons, the ability to choose their doctor and not having PHI. Women with PHI who opted for birth in the public system were almost four-fold more likely to select access to intensive care services and 2.6-fold more likely to select a preference for a low-intervention birth as one of their top five most influential factors. The results highlight that women want access to midwifery continuity of care. Conclusion This study provides insights into the factors influencing a woman’s complex decision about where and with whom to birth and how health insurance affects that decision, an area where there is a paucity of peer-reviewed literature. This research highlights the importance of being able to choose one’s doctor and the desire for access to midwife-led models of care, and provides evidence to advocate for improved access to additional models of care in the private sector. What is already known? The viability of regional private maternity hospitals is in question because, once the birth rate goes below a certain threshold, providing private obstetric service becomes unviable. Closure of regional private hospitals means less choice in regional areas. Minimal information is available about the factors influencing a woman with PHI to give birth in the public system, and much of the evidence is anecdotal. What does this paper add? This study provides insight into how PHI status and other factors influence a woman’s decision to birth in the public versus private sector, an area where there is a paucity of peer-reviewed literature. It also highlights a desire from women for access to midwifery continuity of care in the private system. What are the implications for practitioners? This research provides evidence to advocate for improved access to additional models of care, especially for midwifery-led care in the private sector

Starting with the end in mind

Aim: Health workforce planning is often done reactively, assuming continuation of patterns of health care utilisation and adjusting for demographic projections. This HWA-funded research involves partnerships in a geographically bounded area including a regional centre (Cairns) and two small rural communities in north Queensland (Mareeba and Yarrabah) to develop a demonstration model of health workforce planning. The focus is on creating a flexible and sustainable rural health workforce plan that responds to community needs.\ud \ud Methods: An action research methodology, involves key stakeholders in four cyclical stages of health workforce planning, with continuous process evaluation:\ud \ud \ud • Stage 1: Develop an essential health services plan (basket-of services) for each of the planning areas.\ud \ud • Stage 2: Remodel and build appropriate health service models that deliver the agreed upon priority health services.\ud \ud • Stage 3: Assess the skills-sets required and from there configure the desired workforce needed to appropriately deliver these health service models.\ud \ud \ud • Stage 4: Develop a workforce and training plan that details and costs the training of an appropriate health workforce to serve rural population needs.\ud \ud Results: The project is in progress, but by Conference time we will be able to present:\ud \ud • Integrated health service models that deliver the agreed-upon priority health services for the two target areas (including strengthening existing local and outreach models of service provision and balancing this with appropriate regional service location). Likely innovations include increased use of telehealth and innovations in public-private funding.\ud \ud • Analysis of skills-sets required and configuration of the desired workforce to best deliver these health services. The focus for this workforce planning is on ensuring that available health workers have a wide range of general skills, in line with evidence showing that health professionals with more 'generalist' skills provide better outcomes at lower cost in rural areas.\ud \ud • A workforce training and education plan outlining the training of an appropriate health workforce for these communities. This considers adequate support mechanisms (including professional development) for the rural health workforce, local training and providing alternative pathways that allow similar progression and development to urban counterparts.\ud \ud \ud Conclusions: This project demonstrates that participatory health workforce planning is possible, based on strong and respectful partnerships between stakeholders. Although complications often arise due to differences in funding models, employment conditions and inflexible information technology systems between service providers, these can be overcome where there is a shared vision to innovate and a commitment to that process from all stakeholders

Regional health workforce planning through action research: lessons for commissioning health services from a case study in Far North Queensland

Creating a stable and sustainable health workforce in regional, rural and remote Australia has long been a challenge to health workforce planners, policy makers and researchers alike. Traditional health workforce planning is often reactive and assumes continuation of current patterns of healthcare utilisation. This demonstration project in Far North Queensland exemplifies how participatory regional health workforce planning processes can accurately model current and projected local workforce requirements. The recent establishment of Primary Health Networks (PHNs) with the intent to commission health services tailored to individual healthcare needs underlines the relevance of such an approach. This study used action research methodology informed by World Health Organization (WHO) systems thinking. Four cyclical stages of health workforce planning were followed: needs assessment; health service model redesign; skills-set assessment and workforce redesign; and development of a workforce and training plan. This study demonstrated that needs-based loco-regional health workforce planning can be achieved successfully through participatory processes with stakeholders. Stronger health systems and workforce training solutions were delivered by facilitating linkages and planning processes based on community need involving healthcare professionals across all disciplines and sectors. By focusing upon extending competencies and skills sets, local health professionals form a stable and sustainable local workforce. Concrete examples of initiatives generated from this process include developing a chronic disease inter-professional teaching clinic in a rural town and renal dialysis being delivered locally to an Aboriginal community. The growing trend of policy makers decentralising health funding, planning and accountability and rising health system costs increase the future utility of this approach. This type of planning can also assist the new PHNs to commission health services that meet the needs of the population and contribute to service and system improvement and innovation

Regional health workforce planning in north Queensland: starting with the end in mind

Presents the findings from a Health Workforce Australia funded project working with health care providers in Mareeba and Yarrabah together with their regional referral hospital of Cairns to develop a process and conduct small area needs based health workforce assessment and planning

Responses of Aboriginal and Torres Strait Islander primary health-care services to continuous quality improvement initiatives

Background: Indigenous primary health-care (PHC) services participating in continuous quality improvement (CQI) cycles show varying patterns of performance over time. Understanding this variation is essential to scaling up and sustaining quality improvement initiatives. The aim of this study is to examine trends in quality of care for services participating in the ABCD National Research Partnership and describe patterns of change over time and examine health service characteristics associated with positive and negative trends in quality of care.\ud \ud Setting and participants: PHC services providing care for Indigenous people in urban, rural, and remote northern Australia that had completed at least three annual audits of service delivery for at least one aspect of care (n = 73).\ud \ud Methods/design: Longitudinal clinical audit data from use of four clinical audit tools (maternal health, child health, preventive health, Type 2 diabetes) between 2005 and 2013 were analyzed. Health center performance was classified into six patterns of change over time: consistent high improvement (positive), sustained high performance (positive), decline (negative), marked variability (negative), consistent low performance (negative), and no specific increase or decrease (neutral). Backwards stepwise multiple logistic regression analyses were used to examine the associations between health service characteristics and positive or negative trends in quality of care.\ud \ud Results: Trends in quality of care varied widely between health services across the four audit tools. Regression analyses of health service characteristics revealed no consistent statistically significant associations of population size, remoteness, governance model, or accreditation status with positive or negative trends in quality of care.\ud \ud Conclusion: The variable trends in quality of care as reflected by CQI audit tools do not appear to be related to easily measurable health service characteristics. This points to the need for a deeper or more nuanced understanding of factors that moderate the effect of CQI on health service performance for the purpose of strengthening enablers and overcoming barriers to improvement

Patients' Psychological and Practical Reasons for Attending the Cairns Hospital Emergency Department: a mixed methods study (P3ED)

This mixed methods research study provides an analysis of patients' psychological and practical reasons for attending the Cairns Hospital Emergency Department (ED) (P3ED study). The research has four main aims: to provide an analysis of current and recent trends in utilisation of the Cairns Hospital ED; to estimate the rate of GP-type patients presenting to the Cairns Hospital ED; to identify the psychological and practical reasons for people attending the Cairns Hospital ED; and to consider alternative models of care to potentially reduce presentations to the ED. The study was undertaken by the Centre of Nursing and Midwifery Research, James Cook University in collaboration with both the Cairns and Hinterland Hospital and Health Service and the Far North Queensland Medicare Local (the research funders). The principle rationale for the study was the increasing number of ED presentations at the Cairns Hospital, above Queensland average per annum increases, and an interest in investigating consumers' motivations in attending the Cairns Hospital ED.\ud \ud The research study has multiple datasets. Firstly, survey data form study participants, defined as consenting patients presenting to the Cairns Hospital Emergency Department from 13 March - 11 April 2014. Consenting patients undertook a 52 item survey instrument administered via iPads, with the assistance of research assistants (3rd/4th year nursing students and 4th/5th/6th year medical students). Secondly, focus groups were held post-ED presentation providing data from 16 focus group participants in total. Willing participants left contact details for follow up to participate in focus groups which were held in April-May 2014 at Smithfield, Cairns North, and Edmonton Community Health Centres. Thirdly, Emergency Department Information System (EDIS) data from 2010-2014, including the period of the survey administration represents the third dataset. This data provided a range of data items for all ED presentations over the period, notably age, gender, postcode, triage category, length of stay, mode of arrival, referral status, ICD code. For the one month survey period the EDIS data was matched to the survey data via Medical Record Number (MRNs). MRNs were collected in a log casebook at the time of the iPad survey and were later matched to the MRNs provided with the EDIS data for the survey month only and for those survey participants that consented to have their medical record accessed (relating to that visit only). This created a fourth dataset - a matched dataset of EDIS and survey data for consenting survey participants only, for the period 13 March - 11 April 2014.\ud \ud Key findings of the study were the following: \ud \ud 1. The most significant increase in ED presentations in the past four years has occurred among adults (16-74yrs);\ud \ud 2. Lack of consumer confidence in primary health care services based on the public perception that many health conditions are "too complicated" for such services is potentiating ED presentations;\ud \ud 3. The increase in ED presentations can be partially linked to acute exacerbations of chronic disease;\ud \ud 4. While parents of young children have good access to GP services, the ED is often considered the 'best place' for medical care.\ud \ud Analysis of the data gathered in the P3ED project has highlighted a number of 'red flag' issues around ED use in the Cairns and Hinterland Hospital and Health Service district. Further work is needed to provide a targeted and more detailed analysis of the existing dataset and an expansion of the dataset to include other sources of information, with a view to supporting projects, people and services that will ease pressure on the ED and strengthen current models of service delivery. Three additional areas are recommended for further investigation: the establishment of a minor injuries clinic, the development of an electronic patient decision making support system, and strategies to prevent exacerbations of chronic disease that lead patients to present to the ED