What do evaluations tell us about implementing new models in rural and remote primary health care? Findings from a narrative analysis of seven service evaluations conducted by an Australian Centre of Research Excellence

Abstract

A B S T R A C TIntroduction: A Centre of Research Excellence (CRE) in Rural and Remote Primary Healthcare was established in 2012 with the goal of providing evidence to inform policy development to increase equity of access to quality health care and the identification of services that should be available to the diverse communities characterising Australia. This article reports on the key findings from seven CRE service evaluations to better understand what made these primary health care (PHC) models work where they worked, and why. Methods: We conducted a narrative synthesis of 15 articles reporting on seven CRE service evaluations of different PHC models published between 2012 and 2015.Results: Three different contexts for PHC reform were evaluated: community, regional and clinic based. Themes identified were factors that enabled changes to PHC delivery, processes that supported services to improve access to PHC and requirements for © D Lyle, E Saurman, S Kirby, D Jones, J Humphreys, J Wakerman 2017. A Licence to publish this material has been given to James Cook University, http://www.jcu.edu.au 2 service adaptation to promote sustainability. In both Indigenous and mainstream community settings, the active engagement with local communities, and their participation in, or leadership of, shared decision-making was reported across the three themes. In addition, local governance processes, informed by service activity and impact data, enabled these service changes to be sustained over time. The considerations were different for the outreach, regional and clinic services that relied on internal processes to drive change because they did not require the cooperation of multiple organisations to succeed. Conclusions:The review highlighted that shared decision-making, negotiation and consultation with communities is important and should be used to promote feasible strategies that improve access to community-based PHC services. There is a growing need for service evaluations to report on the feasibility, acceptability and fit of successful service models within context, in addition to reach and effectiveness in order to provide evidence for local dissemination, adaption and implementation strategies.

Flexible Assertive Community Treatment in Rural and Remote Areas: A Qualitative Study of the Challenges and Adaptations of the Model

“…However, if they fit in well with the model, and are developed into new practices that become established as a new way of working and can be repeated, they can be considered as innovations according to Toivonen ( 61 ). Adaptations in rural areas can be intermunicipal collaboration ( 62 ), part- time employment ( 63 ), fewer internal meetings ( 49 , 51 ), lower caseloads ( 51 ), digital tools ( 13 , 14 , 52 , 56 , 64 , 65 ), good planning ( 13 , 15 ), flexible working methods ( 66 ), and collaboration with other services ( 63 , 67 , 68 ). Limited information is available regarding the modifications made to the FACT model by rural FACT teams and if such modifications work.…”

A qualitative descriptive study of a novel nurse-led skin cancer screening model in rural Australia

“…The model was initiated in response to recognised local need, and oversubscription to early clinics demonstrated community awareness of the issue and demand for the service. The model had elements of co-production insofar as a range of stakeholders were involved in the design of the initiative and shared decision-making, which has been demonstrated to be beneficial in terms of engagement, integration of services, adaptation, and sustainability, particularly in rural areas [ 33 ]. The place-based nature of the initiative addresses issues related to rurality and the unique nature of rural communities [ 34 ].…”

‘Immunisation, I haven't had a problem, but once again the transport, making an appointment, the time that you waste and all of those things are an issue’—Understanding childhood under‐immunisation in Mid North Coast New South Wales, Australia

“…Building partnerships and regularly consulting with the community and AMSs are pillars of good service delivery in Australia, in particular when working with First Nations communities 31,35,37 . In rural and remote Australia, in both First Nations and main‐stream PHC, community engagement and shared decision‐making were found to underpin responsive service models 40 …”

“…31,35,37 In rural and remote Australia, in both First Nations and main-stream PHC, community engagement and shared decision-making were found to underpin responsive service models. 40 In Kempsey, there is an opportunity to better engage with the AMS and the community in planning and guiding immunisation service delivery. There is also an opportunity to develop leadership skills for local immunisation champions who might take on roles in leading community consultations and promoting culturally sound immunisation practices in mainstream services.…”