Palliative Approach Remains Lacking in Terminal Hospital Admissions for Chronic Disease Across Rural Settings: Multisite Retrospective Medical Record Audit.

INTRODUCTION/AIM: Despite clear benefit from palliative care in end-stage chronic diseases, access is often limited, and rural access largely undescribed. This study sought to determine if a palliative approach is provided to people with chronic disease in their terminal hospital admission. METHODS: Multisite, retrospective medical record audit, of decedents with a primary diagnosis of chronic lung, heart, or renal failure, or multimorbidity of these conditions over 2019. RESULTS: Of 241 decedents, across five clinical sites, 143 (59.3%) were men, with mean age 80.47 years (SD 11.509), and diagnoses of chronic lung (n = 56, 23.2%), heart (n = 56, 23.2%), renal (n = 24, 10.0%) or multimorbidity disease (n = 105, 43.6%), and had 2.88 (3.04SD) admissions within 12 months. Outpatient chronic disease care was evident (n = 171, 73.7%), however, contact with a private physician (n = 91, 37.8%), chronic disease program (n = 61, 25.3%), or specialist nurse (n = 17, 7.1%) were less apparent. "Not-for-resuscitation" orders were common (n = 139, 57.7%), however, advance care planning (n = 71, 29.5%), preferred place of death (n = 18, 7.9%), and spiritual support (n = 18, 7.5%) were rarely documented. Referral to and input from palliative services were low (n = 74, 30.7% and n = 49, 20.3%), as was review of nonessential medications or blood tests (n = 86, 35.7%, and n = 78, 32.4%). Opioids were prescribed in 45.2% (n = 109). Hospital site and diagnosis were significantly associated with outpatient care and palliative approach (P<0.001). CONCLUSIONS: End-of-life planning and specialist palliative care involvement occurred infrequently for people with chronic disease who died in rural hospitals. Targeted strategies are necessary to improve care for these prevalent and high needs rural populations.

Service Level Characteristics of Rural Palliative Care for People with Chronic Disease.

CONTEXT: Despite clear benefit from palliative care in end-stage chronic, non-malignant disease, access for rural patients is often limited due to workforce gaps and geographical barriers. OBJECTIVES: This study aimed to understand existing rural service structures regarding the availability and provision of palliative care for people with chronic conditions. METHODS: A cross-sectional online survey was distributed by email to rural health service leaders. Nominal and categorical data were analyzed descriptively, with free-text questions on barriers and facilitators in chronic disease analyzed using qualitative content analysis. RESULTS: Of 42 (61.7%) health services, most were public (88.1%) and operated in acute (19, 45.2%) or community (16, 38.1%) settings. A total of 17 (41.5%) reported an on-site specialist palliative care team, primarily nurses (19, 59.5%). Nearly all services (41, 95.3%) reported off-site specialist palliative care access, including: established external relationships (38, 92.7%); visiting consultancy (26, 63.4%); and telehealth (18, 43.9%). Perceived barriers in chronic disease included: lack of specific referral pathways (18; 62.1%); negative patient expectations (18; 62.1%); and availability of trained staff (17; 58.6%). Structures identified to support palliative care in chronic disease included: increased staff/funding (20, 75.0%); formalized referral pathways (n = 18, 64.3%); professional development (16, 57.1%); and community health promotion (14, 50%). CONCLUSION: Palliative care service structure and capacity varies across rural areas, and relies on a complex, at times ad hoc, network of onsite and external supports. Services for people with chronic, non-malignant disease are sparse and largely unknown, with a call for the development of specific referral pathways to improve patient care.

Mandatory bulk billing policies may have differential rural effects: an exploration of Australian data.

INTRODUCTION: Over the course of the COVID-19 pandemic, Australian general practices have rapidly pivoted to telephone and video call consultations for infection control and prevention. Initially these telehealth consultations were required to be bulk billed (doctors could only charge fees equivalent to the national Medicare Benefits Schedule (MBS)). The potential impact of this policy on general practices − and particularly rural general practices - has been difficult to assess because there is limited published data about which practices are less likely to bulk bill and therefore more impacted by mandatory bulk billing policies. There was concern that bulk billing only policies could have a broader impact on rural practices, which may rely on mixed or private billing for viability in small communities where complex care is often needed. This study aimed to understand the patterns of bulk billing nationally and explore the characteristics of practices more or less likely to bulk bill patients, to identify the potential impact of a rapid shift to bulk billing only policies. METHODS: General practice bulk billing patterns were described using aggregate statistics from Australian Department of Health public MBS datasets. Bulk billing rates were explored over time by rurality, and state or territory. Next, questions about bulk billing were included in a cross-sectional survey of practices conducted in 2019 by General Practice Supervisors Australia (GPSA). Practice bulk billing patterns were explored by rurality, state or territory and practice size at univariate level before a multivariate logistic regression model was done, including the statistically significant variables. RESULTS: Nationally, bulk billing rates for general practice non-referred attendances increased over 2012-2019 from 82% to 86% but declined slightly in Modified Monash Model (MMM)2−7 (rural areas) at the end of this period. Further, bulk billing rates varied by rurality, and were highest in very remote (MMM7) (89-91%) and metropolitan areas (MMM1) (83-87%) and lowest in regional centres (MMM2) (76-82%) over this period. The results from the GPSA survey concurred with national data, showing that the proportion of practices bulk billing all patients was highest in metropolitan locations (28%) and lowest in regional centres and large rural towns (MMM2−3) (16%). Smaller practices (five or fewer general practitioners) were more likely to bulk bill all patients than were larger ones (six or more general practitioners). Multivariate modelling showed that bulk billing all patients was statistically significantly (p<0.05) less likely for larger practices compared with smaller ones, and for rural practices (MMM2−7) compared with those in metropolitan areas. CONCLUSION: Mandatory bulk billing policies should accommodate the fact that bulk billing varies by context, including rurality and the size of a practice, and has been decreasing in rural areas over recent years. Rapidly pivoting to bulk billing only service models may put pressure on rural and large practices unless they have time to adjust their business models and have ways to offset the loss of billings. Policies that allow for a range of billing arrangements may be important for practices to fit billings to their local context of care, including in rural settings, thereby supporting business viability and the availability of sustainable primary care services.

Exploring attributes of high-quality clinical supervision in general practice through interviews with peer-recognised GP supervisors.

BACKGROUND: Clinical supervision in general practice is critical for enabling registrars (GP trainees) to provide safe medical care, develop skills and enjoy primary care careers. However, this largely depends on the quality of supervision provided. There has been limited research describing what encompasses quality within GP clinical supervision, making it difficult to promote best practice. This study aimed to explore the attributes of high-quality clinical supervision for GP registrars. METHODS: In 2019-20, 22 semi-structured interviews were conducted with GP supervisors who were peer-nominated as best practice supervisors, by Regional GP Training Organisations and GP Colleges in Australia. Purposeful sampling sought respondents with diverse characteristics including gender and career stage, practice size, state/territory and rurality. Interviews were conducted by video-consultation and recorded. De-identified transcripts were independently coded using iterative, inductive thematic analyses to derive themes that reflected quality in GP supervision. RESULTS: Seven themes emerged. Participants understood the meaning of quality supervision based on their experience of being supervised when they were a registrar, and from reflecting and learning from other supervisors and their own supervision experiences. Quality was reflected by actively structuring GP placements to optimise all possible learning opportunities, building a secure and caring relationship with registrars as the basis for handling challenging situations such as registrar mistakes. Quality also encompassed sustaining and enhancing registrar learning by drawing on the input of the whole practice team who had different skills and supervision approaches. Strong learner-centred approaches were used, where supervisors adjusted support and intervention in real-time, as registrar competence emerged in different areas. Quality also involved building the registrar's professional identity and capabilities for safe and independent decision-making and encouraging registrars to reflect on situations before giving quality feedback, to drive learning. CONCLUSIONS: This study, although exploratory, provides a foundation for understanding the quality of clinical supervision in general practice, from the perspective of peer-recognised GP supervisors. Understanding and adopting quality within GP supervision may be improved by GPs sharing exemplars of best practice and having opportunities for professional reflection. The findings could be used as a point of reference for devising GP supervisor curriculum, resources and professional development activities.

A Framework to Guide the Implementation of Best Practice Clinical Learning Environments in Community General Practice: Australia.

Clinical education/training is increasingly being expanded to community general practice settings (primary care clinics led by doctors). This plays an important role in developing a skilled "primary-care ready" workforce. However, there is limited information to guide the implementation of high-quality learning environments suitable for the range of general practices and clinical learners they oversee. We aimed to develop a consensus-based framework to address this. A co-design participatory action research method involved working with stakeholders to agree a project plan, collect and interpret data and endorse a final framework. As a starting point, an initial draft framework was adapted from an existing framework, the Best Practice Clinical Learning Environment (BPCLE) Framework. We gathered feedback about this from a national GP Supervisor Liaison Officer Network (SLON) (experienced GP clinical supervisors) during a 90-minute face-to-face focus group. They rated their agreement with the relevance of objectives and elements, advising on clear terminology and rationale for including/excluding various components. The resulting framework was refined and re-tested with the SLON and wider GP educational stakeholders until a final graphically designed version was endorsed. The resulting "GP Clinical Learning Environment" (GPCLE) Framework is applicable for planning and benchmarking best practice learning environments in general practice.

A national survey of COVID-19 challenges, responses and effects in Australian general practice.

METHOD: A national cross-sectional online survey of Australian general practitioners was conducted in April and May 2020, with 572 respondents. RESULTS: The COVID-19 pandemic in Australia has resulted in major changes to general practice business models. Most practices have experienced increased workload and reduced income. DISCUSSION: Australian general practices have undertaken major innovation and realignment to respond to staff safety and patient care challenges during the COVID-19 pandemic. Increased administration, reduced billable time, managing staffing and pivoting to telehealth service provision have negatively affected practice viability. Major sources of information for general practice are primary care-specific, but many practices turn to colleagues for support and resources.

Paramedicine students' perception of preparedness for clinical placement in Australia and New Zealand.

BACKGROUND: Clinical placement is an essential element of paramedicine education and training as the profession completes the transition from vocational training to a pre-employment, university based model. The objective of this study was to survey pre-employment paramedicine students at Universities in Victoria, Australia and Auckland, New Zealand to measure their self-assessed preparedness for clinical placement. METHODS: This was a cross-sectional study involving paper-based questionnaires employing a convenience sample of 682 undergraduate paramedicine students (years 1-4) who had completed at least one clinical placement. Student perceptions of preparedness for clinical placement were measured using an adaptation of the 'Preparedness for Hospital Practice' questionnaire. RESULTS: There are significant differences in students' perception of preparedness for clinical placement, which reflects the differences between universities in relation to structure of their paramedicine programs, the timing of clinical education and the number of hours of clinical placement. DISCUSSION: There needs to be clinical placement agreements between the ambulance services and universities that clearly describe the standards and expected elements of a quality clinical placement. CONCLUSIONS: In order to improve the preparedness for placement for paramedicine students, a united approach is required by all stakeholders, including ambulance services, students and universities.

Paramedic instructor perspectives on the quality of clinical and field placements for university educated paramedicine students.

OBJECTIVE: To determine the elements of quality clinical and field placements through the eyes of paramedic instructors. DESIGN: Qualitative study. SETTINGS: Two large paramedic services in two countries where the entry to practice qualification for paramedics has been set at the Bachelors degree level. PARTICIPANTS: Fifteen purposively selected paramedic instructors were invited to voluntarily participate. The criterion for inclusion was that they had supervised at least one university paramedicine student on a field placement. Recruitment ceased when saturation was reached. METHODS: Face to face semi-structured interviews were conducted with participants who were asked their views and expectations of paramedicine student clinical and field placements. Inductive thematic analysis of the transcripts was completed using Nvivo software. RESULTS: The elements of quality clinical and field placements from the perspective of paramedic instructors were identified. With no agreed clinical and field placement paramedicine standards in the countries studied there is variation in the focus of placements, preferred settings, and expectations. Vocationally trained paramedics favoured paramedic service placements, whilst university educated paramedics see benefits in placements in more diverse settings. CONCLUSIONS: Paramedic services and universities need to collaboratively address the variation in paramedicine university student clinical and field placements. Standards need to be developed that address the purpose of placements, expectations of students and instructors, and be scaffolded across the education spectrum from undergraduate student to graduate paramedic to instructor.