Improving equity of access in rural and regional health through hybrid and connected care
Authors: India Hardy, Vanya Rufus, Aarthmi Jeyachandran, and Jacqueline Curran
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Accessibility of local healthcare services is essential to health equity and quality of life, yet it remains one of the most significant barriers for residents of rural and remote communities. While hybrid models of care and enabling technology can help bridge the gap in health outcomes, federal and state departments must engage in a holistic approach across public policy, education and private investment to address accessibility shortcomings.
Rural and regional patients and carers are faced with a unique set of challenges which include limited education options, reduced access to appropriate healthcare infrastructure and services, and large distances they must travel to receive any type of care. The public and private sectors across the Australian healthcare landscape are now making concerted efforts in improving the equity of access to health services across rural, regional and remote areas1. This sector-wide effort was evident with the rapid implementation of virtual solutions during the COVID-19 response to support disrupted service delivery. There is an opportunity to apply the successes and lessons learnt, to augment and scale these virtual solutions to support longer standing pressures including workforce shortages and geographical barriers. Successfully implemented models have been seen in Australia, such as the one for Emergency Telehealth Services2 run by WA Country Health Service which uses a hybrid model to deliver specialist emergency care in smaller regional and remote health centres, supported by remotely located clinicians. These hybrid models are starting to gain traction around the country, springboarding other concepts and ideas for virtual support as required by the rural and regional patient. In parallel, national funding of primary care services must expand to align to increasing population growth and shifting population centres, as cities expand and rural and remote townships increase, and the role of General Practitioners becomes increasingly important.
Geography is a major factor in healthcare access
The design of hybrid (blended virtual and in-person) connected models of care needs to include a range of considerations, namely:
the nuances and requirements of patient demographics
the healthcare workforce’s interaction with the target demographic
the pathways, escalation points and options for in-person services.
Studies show only 6% of patients in metropolitan areas report proximity concerns accessing a GP as a reason for not seeing one, but this number is as high as 58% in very remote areas3. Consequently, the number of potentially preventable hospitalisations increases by a factor of 2.5 for those living in very remote areas. A targeted solution design needs to account for geographical barriers but also support appropriate pathways for in-person delivery to ensure a holistic approach to healthcare access and a seamless patient experience.
The geographical barrier is further evident when we look at the workforce that provides services to rural and remote communities. The National Health Workforce Dataset shows that the total clinical full-time equivalent (FTE) for health professionals per 100,000 population generally decreases as remoteness increases4. The result is a highly locum-driven workforce which creates increased financial and operational implications for healthcare services and may not be sustainable as a long-term solution. In primary care settings, this can exacerbate patient instability, lowering satisfaction rates as rapport with clinicians is having to be continually developed.
Introducing innovative, technology-driven models of care can begin to address the geographical constraints experienced by patients and workforce challenges by better connecting rural and metropolitan health services. There is however, a greater challenge in closing the divide of technology infrastructure available, which is necessary for sustained, and longer term health equity. In 2019, the Australian Infrastructure Audit found that coverage gaps are still affecting a large proportion of Australians in regional and remote areas5. When the foundation that virtual health is reliant upon is costly and poor quality, there is less incentive for users in regional and remote areas to opt in to hybrid models of care.
Benefits of digitally-enabled models
While digital healthcare initiatives predate COVID-19, the pandemic was the catalyst that expedited and scaled the use of technology to deliver services across the sector. The results showed us what is possible with the intelligent use of technology in a healthcare setting: not as a substitute, but rather to augment in-person care.
We have seen the use of digital services to connect patients to a range of clinicians across primary, aged care and acute services. The widespread effect of these digitally enabled models of care has shown a reduction in wait times and reduced pressure on the local workforce. These are both important factors in lowering the rate of potentially preventable hospitalisations.
The use of technology enhances opportunities for cross-collaboration between metropolitan and rural health workers. Further down the track this will improve remote access to patient data, benefitting both patients and the workforce.
Digitally-enabled models of care that incorporate both virtual and in-person elements also have the potential to enhance the provision of clinical services to a wider geographical region, improve the integration of healthcare services and improve workforce cultures through greater cross-collaboration. Solutions that are designed with both a workforce and patient-centric focus will ultimately deliver higher adoption rates and provide better outcomes for patients in our rural and remote communities.
The uniqueness of challenges of regional and remote areas
There is no one-size-fits-all solution when it comes to digitally enabled models of health care in rural and remote communities. Virtual care without adequate training, cultural and community consultation and infrastructure investment has the potential to amplify and deepen the digital divide, where over-reliance on ineffectual technology further isolates patients in rural and remote areas.
Greater importance needs to be placed on rural and remote voices to ensure we adequately capture the challenges and cultural context of these communities in a way which acknowledges the geographical barriers and additional challenges preventing equity of access to services.
Taking into consideration how digital solutions meet specific patient demographics, particularly First Nations Australians, is critical for adoption. The total population who are Indigenous increases from 1.8% in major cities to 32% in remote and very remote areas and consequently, a disproportionately higher percentage of those that face healthcare and accessibility barriers within remote and very remote areas are First Nations Australians.6
While hybrid connected care is not a panacea for optimising access to healthcare in rural and regional areas, it is an essential component in addressing the current inequalities we see in health outcomes across Australia.
Investing in rural and remote healthcare is investing in equity of access
Investing in rural and remote communities must be central to Australia’s healthcare strategies and policies, and further investment will be required to improve digital infrastructure and to integrate solutions across local government agencies and communities. To enable an effective rollout of equal access, organisations can look to invest in rural areas by addressing the following opportunities.
- Building on capability that exists within regional health settings reduces the cost of implementation. Usually, this means taking stock of existing clinical workflows, infrastructure, cyber, data and technology stacks and approaching startups or vendors that can customise their clinician and patient-facing solutions for a particular rural health service. Integration of these services, workflows, infrastructure and the technology behind it will empower clinical decision makers to provide a best-in-class service, improving the overall patient experience in rural and remote sites.
- Making use of improved network coverage: For example, the NSW Government is taking conscious steps towards closing the infrastructure divide in regional NSW. The Regional Digital Connectivity program has committed over $400 million in bringing a faster and more reliable digital network coverage to regional NSW. The program focuses on enabling better mobile coverage, high speed internet and new technology and data solutions to regional NSW. Undoubtedly, this will mean more options for rural and remote patients, carers and providers to opt into hybrid models of care.
- Facilitating community and workforce consultation and co-design is critical in creating models for effective solutions. Of late, there has been concern in regional and rural communities from patients that feel like all their care is delivered remotely. Hybrid solutions, in consultation with communities, allow clinicians to engage with their patients holistically. With recommendations on the parts of service delivery that could and should be virtual, there are others that must be maintained in-person. In 2021, PwC's Indigenous Consulting assisted the Australian Digital Health Agency in developing future state Concept of Operations, Journey Maps and workflows to support Indigenous healthcare consumers living remotely to upload their Advance Care Plan to MyHealthRecord. Through the process of consulting Aboriginal Health practitioners and mapping out their journeys, a more targeted and improved service delivery model reflected the true needs of the community.
It is also important to understand that hybrid solutions are just one consideration to address workforce challenges faced in rural and remote settings, the other being an increased investment in primary care providers. A dedicated focus and investment in General Practitioners needs to be part of a considered plan to address future gaps in care delivery, and to address already forecast GP shortages in all settings, let alone those that rely on them most. - Enabling cross-collaboration between health providers is key in seamlessly integrating digital solutions with in-person care. Existing partnerships between rural and metropolitan sites have proven to be effective at creating virtual networks of clinicians that are able to lean on each other for support when required. A great example of repurposing solutions for collaboration includes the use of over-the-bed cameras in the peak of the pandemic when rural sites required additional assistance to deal with the influx of patients into Emergency Departments. Today, in rural sites like those at Murrumbidgee LHD, clinical decision-makers have explored the use of these digital solutions for clinical assistance (for example between graduate and experienced nurses) and knowledge-sharing between clinician groups for complex disease management and urgent care support. Virtual clinician-assisted models of care allow the junior rural health workforce to continue developing their skills while receiving the required peer-support for fluctuating patient loads. These solutions also allow cross-collaboration between provider groups across State lines.
- Articulating a clear digital strategy that includes realistic hybrid care to ensure services and technology such as ‘hospital in the home’ (HITH) services and remote patient monitoring are supported by adequate infrastructure and are future-proofed to enable further enhancements. Across rural and remote settings, digital strategies need to take into account specific dependencies (like critical infrastructure and reliable network coverage) to underpin supporting virtual solutions. Often, these solutions are heavily reliant on and assume a level of broadband coverage that must exist should a digital implementation be pursued. Further, in order to embed sustainable virtual care practices into clinical workflows, it is critical for models of care to maintain flexibility throughout, to cater to unique preferences and capabilities of the rural and remote patient.
- Introducing technology to support a population with a growing digital literacy. Digital assets (such as online resources and libraries), while available, are rarely prioritised by a health service; however, there are opportunities to provide rural health consumers with the tools they need to manage their own healthcare. Digital literacy is essential for solutions like remote monitoring devices that remove the large geographical travel distances for patients, while allowing them to check-in and track their healthcare outcomes autonomously, and with their providers. Patients would benefit from in-app guides, quick tips and customised virtual coaching, alongside their remote monitoring for health vitals tracking. This creates better patient experience through educating consumers on technology as they manage their own health. Vendors have started incorporating these guides into their solutions; for example health tracking solution Perx8 has created effective and quick walkthroughs of their solution upon first use so that patients have an understanding of the primary digital in-app tools from the very beginning. Federal and State bodies could also invest in digital literacy upskilling through programs created for patient education, enabling self-management of symptoms, and in turn improving the workload and time commitment for clinicians.
Healthcare for tomorrow’s rural and remote Australia
As the spotlight on rural and regional requirements continues to grow, so must our evolution to its need for tangible outcomes. Responsible and intentional investment must be made to ensure Australian healthcare is driven in the parts of the country that are most vulnerable to disease; where distances and a lack of access are often overlooked, however they are the most fundamental issues that are being grappled with. While much is being done at a local level, a longer-term and more focused strategy will allow the voices of those in the workforce and those receiving healthcare to be heard and accounted for. By expanding our reach to cover some of these underlying challenges, we will arrive at the heart of the problem for regional and remote areas, and can look to provide hybridised services that deliver impact, in healthcare and beyond.
References
1. NSW Parliament, Health outcomes and access to health and hospital services in rural, regional and remote New South Wales (report), Portfolio Committee No. 2 - Health, NSW Parliament, 2022, accessed 20 December 2022.
2. Government of Western Australia, Emergency Telehealth Service, WA Country Health Service, WA Health, 2021, accessed 11 January 2023
3. AIHW (Australian Institute of Health and Welfare), Survey of health care: Selected findings for rural and remote Australians (web report), AIHW, 2018, accessed 13 December 2022.
4. AMA (Australian Medical Association), Rural workforce initiatives, AMA, 2017, accessed 13 December 2022.
5. Infrastructure Australia, Australian infrastructure audit 2019: An assessment of Australia’s future infrastructure needs. Commonwealth of Australia, 2019, accessed 20 December 2022. [cited 2021 Sep]. Available from: www.infrastructureaustralia.gov.au/publications/australian-infrastructure-audit-2019
6. AIHW (Australian Institute of Health and Welfare), Rural & remote health (web report), AIHW, 2017, accessed 13 December 2022.
7. NSW Government, Regional Digital Connectivity Program, NSW Government website, 2022, accessed 20 December 2022.
8. https://perxhealth.com/
