Concurrent Speakers

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Sandra Walsh
Service learning with a twist: the introduction of regional primary health placements
Biography

Sandra Walsh is currently on secondment in research with the Department of Rural Health, UniSA. Her substantive position is Lecturer. Sandra was the Coordinator of the Regional Strand of Foundation Studies, coordinating the program across the Whyalla Campus and the Mount Gambier Regional Centre. She has been involved in teaching the Foundation Studies program since it began at the Whyalla Campus of the University of South Australia. Prior to returning to Whyalla, Sandra worked in Melbourne at General Practice Divisions - Victoria as the state Mental Health Program Manager; representing General Practitioner stakeholders at a state level. Sandra worked in project and program management at the Wagga Wagga and Districts Division of General Practice, across a number of program areas including mental health, drug and alcohol, aged care, and continuing medical education. Having worked and lived in remote, regional and rural Australia most of her life, Sandra is committed to these areas in pursuing sustainable community engagement and development. She completed degrees at James Cook University Townsville, and began an academic career there.

Abstract

Nursing clinical placements in regional South Australia have typically targeted settings such as hospitals and aged care facilities. However nursing, in practice, encompasses a far broader range of settings than this. To this end, the Department of Rural Health University of South Australia (DRH UniSA) in partnership with the School of Nursing (UniSA) has initiated innovative nursing placements in primary health care (PHC) settings. These placements offer nursing students the opportunity to practice clinical skills while, at the same time, exposing students to a diverse range of settings, from Aboriginal health care to the Royal Flying Doctor Service. Students were also able to engage in work based projects aimed at improving community health and wellbeing, while improving their research skills during the placement period. Breaking new ground in service learning has proved challenging for students and DRH UniSA staff, where traditional notions of placements have been challenged and reconceptualised. This paper will examine some of the staff and student reflections on the PHC placements, the challenges and opportunities. What emerges from this is the revelation that these PHC placements have tapped into something unique for the student experience. Suggestions for how the PHC placements can be improved will be offered along with some cautionary notes.

Slides
Jacki Ward
Working with shared purpose to benefit the community and their health needs
Biography

Jacki Ward is a registered nurse who has worked in rural WA for most of her career. Over the years, Jacki has worked in acute care (specialising in coronary care, intensive care and emergency nursing), and in domiciliary care (specialising in wound care and palliative care) and in various midwest towns, specialising in Aboriginal health, before moving into health service management. After working with the WA Country Health Service as Director of Nursing/Health Services Manager, concurrently managing the two separate health services of Northampton-Kalbarri Health Service and Mullewa-Yalgoo-Murchison Health Service, Jacki was employed by the Combined Universities Centre for Rural Health, a department of the University of Western Australia. During this time, Jacki coordinated the Primary Health Care Research Evaluation and Development program and assisted with projects such as Emergency Care in the Bush, Sustainable Farm Families, Asthma Care in General Practice and the One21seventy project. Jacki is currently employed in the midwest of Western Australia with the WA Primary Health Alliance, Country WA Primary Health Network with the portfolios of Mental Health and Aged Care.

Abstract

The WA Primary Health Alliance (WAPHA), Country Primary Health Network (PHN) has been tasked with ensuring that health services delivered in their regions are required, equitable and affordable. The commissioning of chronic disease and mental health services in three PHN regions (Midwest, Goldfields and South West) afforded the opportunity to challenge long-standing service delivery models, to ensure services were being delivered appropriately and to those in most need.

Each region tailored the look of potential new services to the needs of their communities, with engagement and collaboration being paramount to achieving the common goal of equity and value for money for these services.

To ensure all voices were heard, a community forum was held in each major centre throughout the regions so that the community had an opportunity to discuss their health needs and where perceived gaps were in service provision. Country WA PHN staff also met with general practitioners, representatives from the WA Country Health Service, non-Government organisations, the Police, Shires and community groups, to hear their views on current and potential health services for their district. Cognisant of the fact that funding partners would, potentially, add value to possible new services, staff met with various organisations, such as, the Department for Aboriginal Affairs, the Department of the Prime Minister and Cabinet and the Mental Health Commission. Service providers for a particular region were given the opportunity, in a forum setting, to discuss their services and how better they could interact with each other to negate duplication.

Following this extensive consultation, areas of un-met need were identified. Ideas on how to address these were taken to the various government and non-government organisations, ensuring, that where possible, existing partnerships were maintained and strengthened.

In the Midwest, one area of need was the provision of an Aboriginal AoD worker. This worker would complement an existing position by being the opposite gender, for cultural reasons. After negotiation with service providers, a consortium was used to employ the worker to ensure that as many clients as possible have access to this position.

The Midwest is just one of seven regions across Country WA, all with unique characteristics, each requiring different approaches. The presentation will compare the approaches taken in the Midwest, South West and Goldfields and explore the key elements (similarities and differences) in each approach.

Slides | Paper
Meredith Waters
The virtual consumer voice: connecting with country consumers online to improve services
Biography

Meredith Waters arrived in the small regional town of Esperance 18 years ago from Melbourne, and quickly grew to love the lifestyle and the people in the community. Meredith has a variety of working experience, including: the court system, mental health sector, not-for-profit business management, project officer roles in the community sector and volunteer board roles with several community organisations. She has been a community representative on the Tele Mental Health Steering committee with WACHS and in addition to her WACHS board role, is currently the Chairperson of the South-East District Health Advisory Council. With a strong interest in social justice, community advocacy and community connecting, Meredith believes that positive change can be created by providing training and education to people living in remote and regional Western Australia, building understanding and strengthening connections between diverse individuals and groups.

Abstract

In December 2015, the WA Country Health Service (WACHS) began a one year pilot project across three of its regions to implement Patient Opinion, as an accessible, anonymous, and independently moderated online avenue for country consumers to share their health care stories: good and bad. Because of its public and "social" nature, the Patient Opinion platform also provided WACHS with the opportunity to enter into more personalised and open dialogue with consumers and publicly demonstrate how it listens to and acts on the experiences, insights and perspectives shared by consumers in this way.

Using examples of stories shared by WACHS consumers on Patient Opinion, examples of WACHS responses to those stories, and project data, this presentation will explore the success of Patient Opinion as a tool for country consumers to share their health care experiences, and for our health service to listen, learn and improve from the experiences of our vastly dispersed consumer populations.

The presentation will demonstrate the important role of our network of 21 District Health Advisory Councils (DHACS) - volunteer consumer representative/advocacy groups - in establishing and promoting the project. The DHACs have been strong advocates for the use of social media and other online technologies and innovations to engage with country consumers. If a health service is not engaged online, but its consumers are, it loses the ability to remain responsive to its consumers’ experiences in a timely way. It is important to have multiple avenues for consumers to have a voice and be heard within our organisation.

The project has highlighted the role that patient stories can play in the evaluation of health services as well as engaging staff to understand the need for consumer-centred care. The human voice of the story can be a powerful motivator for service and culture change and can draw attention to what matters most to people about the care they receive. While our traditional, formal, and periodic feedback and evaluation methods such as annual patient surveys and complaints forms/systems are useful, they may not address the aspects of care that are most important to the consumer.

Based on the success of the pilot project to date, the remaining five WACHS regions will join the project in early 2017.

Paper
Bruce Waxman
Clinical governance reform and its implementation: developing a subregional hospital in Victoria
Biography

Professor Bruce Waxman is an honours medical graduate from Monash University and trained in general and colorectal surgery, both in Australia and overseas. He was appointed Director of Surgery at Dandenong Hospital, Southern Health in 1995 and simultaneously Director of General Surgery, Director of Colorectal Surgery, Medical Program Director, Surgery Program, Southern Health and Associate Professor, Monash University. He retired from active surgical practice in 2014 and transitioned into medical administration, with successive appointments at The Valley Private and Epworth Richmond and is now Executive Director of Medical Services, Bass Coast Health, Wonthaggi, Victoria. He is also part-time Director of Surgical Education and Research, Monash University, Monash Health.Bruce has held many positions with the Royal Australasian College of Surgeons (RACS) over 33 years as College Councillor and on the Court of Examiners with a focus on education and training, more recently as Clinical Director, Victorian Skills and Education Centre, RACS. He was a Board Member with the Royal Flying Doctor Service of Australia (Victoria) for 22 years and remains involved as an Emeritus Councillor and with the Education Group, having developed a Schools Program to teach children about the RFDS. He was Squadron Leader with the Royal Australian Air Force Specialist Reserves for 15 years having undertaken deployments as a military surgeon to Bougainville, East Timor and Banda Aceh. He was awarded the Order of Australia Medal in the Australia Day honours in 2014 for services to medicine as a clinician, educator and administrator. Bruce is married with five children and six grandchildren and in his spare time manages Kalympa Wildflowers, growing Proteas, Leucadendra, and other South African and Australian natives on his farm on the Mornington Peninsula.

Abstract

Background: Bass Coast Health (BCH) is a 52 bed acute hospital in the Bass Coast Shire of South West Gippsland, Victoria that has recently had a change in executive administration that commissioned an external Clinical Governance Review (CGR), which provided a series of general recommendations and specific recommendations for Maternity services. The hospital is endeavouring to turn around from its current low base of performance to build capacity and capability to become sub-regional overcoming the challenges of data management, finances, infrastructure and reforming the medical model.

The current medical model is that inpatient services, anaesthesia and maternity services are provided by general practitioners (GPs), the Emergency Department staffed by part-time FACEM specialists and GP senior medical officers, with visiting specialist surgeons providing an elective surgical service.

Simultaneously a Clinical Service Plan (CSP) is being developed in collaboration with neighbouring hospitals in South Gippsland Shire at Leongatha, Korumburra and Foster, to develop an integrated medical service with BCH as the Subregional Centre, for the so called catchment, driven by the Department of Health and Human Services, Victoria1

The aim of this study is to evaluate the effectiveness of the implementation plan for incorporating the recommendations of the CGR at BCH and moving towards a sub-regional centre. This is a work in progress

Methods: Implementation of the CRG Recommendations. BCH executive has established a number of discipline specific Clinical Governance Implementation Groups (CGIGs) for Surgery, Medicine, Emergency Department and Maternity Services, with terms of reference and membership covering the range of medical practitioners and senior nursing staff, chaired by the Executive Director of Medical Services (EDMS) and /or the Executive Director of Clinical and Maternity Services (EDCS) reporting to the BCH Executive and Board.

Developing a subregional centre. Significant changes to the medical model will need to occur as BCH moves towards a subregional hospital, which will have a major impact on the current Visiting Medical Staff, particularly the GPs

This will involve developing partnerships with neighbouring metropolitan Health Services to recruit physicians and surgeons, whilst transitioning to an integrated model with the existing GPs and in addition providing services to the other hospitals in the catchment.

Evaluation: The effectiveness of these changes will be determined by a survey monkey of the medical and nursing staff, and the results evaluated independently.

Results and discussion: As this is a work in progress the results of the evaluations will be discussed and relevant conclusions determined.

Reference: Victorian Health Priorities Framework 2012–2022: Rural and Regional Health Plan. https://www2.health.vic.gov.au/about/publications/policiesandguidelines/vic-health-priorities-framework-2012-22-rural-plan (web site accessed 30 September 2016)

Slides | Paper
Jennifer Wehnert
The Right Place: a community initiative that enables streamlined care and services
Biography

Jennifer Wehnert leads the Health and Wellbeing Program for Huon Regional Care, which includes oversight of The Right Place program. This role is pivotal and unique to the Huon and has become embedded in the community, providing flexibility and innovation to address local needs. Jen is passionate about connecting people to services and building positive cross-sectorial relationships in order to deliver coordinated care for people in the community. Jen is responsible for coordinating the Huon Valley Service Providers Network, facilitating The Right Place activities locally and state-wide, and supporting multiple activities and projects in the local community to promote health and wellbeing, and improve social determinants of health. Jen has a bachelor degree in Psychology, and a graduate diploma in Addiction and Mental Health, with a range of other qualifications in community services, management, and information technology. She has a wide array of experience working in the not-for-profit sector in mental health, disability, aged care, employment, and community services. She has experience within various roles developing and implementing community programs, as well as collaborating with multidisciplinary teams across not-for-profit organisations, private business, and government with a strong focus on sustainable community development and improving social determinants of health.

Abstract

Rural health and community support systems can be complex and for many consumers, difficult to navigate without assistance. In many cases, people may only ask for information or assistance once. If they experience a negative encounter, they may not return, and consequently, may miss out on a range of services that are available to them.

Following extensive community consultation in the Huon Valley Tasmania, the community identified that service providers needed improved knowledge of available services in the local area. Also identified was the necessity for consumers to receive a positive reception and easy-to-understand information and assistance at their first point of enquiry.

The Right Place is a community-based initiative that is underpinned by the philosophy that ‘no door is the wrong door’ to make it easier for residents and visitors in a Tasmanian rural community to find and access the service they need. The Huon Valley working group framed it positively to welcome and reinforce engagement with community members in their services, telling them ‘You’ve come to the right place’. Training and collateral materials were developed to support visual recognition of the concept.

The Right Place is an approach that prioritises people being central to their own care. It promotes communication, collaboration and engagement across all community sectors. A shared approach to transfers of care is linked to fewer hospital admissions, and increased consumer experience satisfaction.

Staff in community centres and local businesses are facilitated in workshops and provided with resources that give ready reference to local service contacts. The essential concept is to facilitate the connection to assist the person to access the service they need.

The concept has been adopted in other Tasmanian communities. Consequently, The Right Place now has a governance structure that facilitates other Tasmanian communities to form local working groups to become The Right Place communities.

A website has been launched to support communication across communities www.therightplace.org.au.

Through analysis and evaluation of The Right Place, several unexpected positive impacts have emerged.

This paper describes the background, initiative, development, implementation and evaluation of The Right Place in the Huon Valley in Tasmania.

Slides | Paper
Mark Wenitong
Barriers and enablers to delivering culturally appropriate aged and palliative care in Cape York: the Apunipima and Catholic Health Australia partnership
Slides
Michael White
Community Healling Project
Biography

Michael White was born in Rockhampton and grew up in Central Queensland. He spent three years in Winton in Far North Queensland, followed by a move to Tully in Far North Queensland, and has been living in Cairns for the past ten years. He is currently the Manager, Strategic Projects - State/National with the Australian Red Cross. Michael has worked in various roles within State and Federal government agencies, non- government and community controlled sectors. Throughout his professional career Michael has had the humbling opportunity to work with people and communities and lead within organisations at a strategic/ppolicy development level. In 1999 Michael was elected as a Member of the Aboriginal and Torres Strait Islander Commission (ATSIC) Regional Council for Central Qld Region and in 2002 was he was elected as Chairperson. Following the abolition of ATSIC 2005, Michael moved into Aboriginal and Torres Strait Islander Primary Health Care profession. In that year he was appointed to the Federal Governments National Indigenous Council Advisory Body. Michael has been appointed to a number of boards, Chairperson of Darumbal Youth Services, Indigenous Representative on the Institute Council (TAFE) Central Queensland, Representative on the Queensland Health Partnership, State Ministerial appointed member of the Ministerial Regional Forum for Fitzroy and Central West, Board Member of the Capras Rugby League Club and a Director of the Frenchville Sports Club. Michael's traditional custodian groups include Iman and Ghungulu clans  situated in Central and South West Queensland.

Abstract

On 19 December 2014, 8 children were found deceased at a Cairns address in Manoora. Following the incident, the mother of 7 of the children, who resided at the same address, was taken into police custody.

This tragic event had significant impacts on immediate and extended family, friends, the Aboriginal and Torres Strait Island community, the Murray Street community and the broader regional community.

On 9 January 2015 the Premier and Prime Minister at that time met with family representatives of the deceased and made a coordinated commitment to implement a community response, over a 12 month period.

Given the large number of people and places affected, and the range of relevant government and non-government services involved in the response a strategic level Planning and Coordination Committee was established to steer and guide the Community Healing Project.

The Community Healing Project had a ‘human and social recovery’ focus (ie: grief and loss, healing, and rebuilding social connections and sense of community).

Key to this response was a community-driven approach and close consultation with family representatives and impacted communities. The Project intent was to address the needs of individuals/families, and communities arising from the tragic event. Through the coordination and delivery of activities, referrals ranging from individual support (eg: individual grief counselling) through to community engagement and community rebuilding efforts (eg: community wide strategies and community events).

The Project covered the Far North Queensland Region, with a particular focus on Cairns, Torres Strait Islands and Northern Peninsula Area. Links were established to other regions as required, (eg: Northern and Central Queensland).

Resources allocated to the project were directed towards healing(therapeutic focus) from grief and loss, rebuilding community connections and sense of community perspectives.

The community re-building effort was not a ‘bricks and mortar’ re-build and did seek to address pre-existing social and economic issues that may have already been impacting on local families and communities (eg: public safety, employment, housing, health services). However, if some of these pre-existing issues are were addressed through the project, this was a welcome flow on effect.

Slides
Robyn White
Our community driving our health
Biography

Robyn White is a Clinical Nurse Consultant at Yorke Island Primary Health Care Centre, Torres Strait Islands. Robyn grew up on a sheep station in New Zealand, where she qualified as a registered nurse. Her travels around the world also gained further experiences with her nursing career in England, Africa and New Zealand. The variety of skills achieved during her time in the peak of the terrorist war in Zimbabwe in the late 1970s was the desire to return to Africa after her return to New Zealand. Instead, in 1983, a unique opportunity came up for her to work in Australia, where she found her niche in nursing, as a remote area nurse. After three years in WA at Cundeelee Aboriginal Community and assisting with the move and adjustments to their new community, Coonana, Robyn left to study for three years in Perth at Curtin University in 1987. She then went to Derby Regional Hospital to further her practical experience as a midwife. Derby Hospital is the only hospital she has ever worked in in Australia. During her time there she was often called away do relief nursing in remote Aboriginal communities around the Kimberley region. In 1992 another opportunity took her away from the love of the desert lifestyle, to Queensland, the tropics of the Torres Strait Islands where she has remained since, based at Yorke (Masig) Island. The locals often remind her that she is a 'Masig gal' now.

Abstract

Aim: Our project “Lessons from the Best to Better the Rest” looked at high continuously improving services to find factors that might be associated with high continuous improvement. We found that ‘communities driving health’ was one of them. The aim of this paper is to understand the way in which one Torres Strait Islander community drove healthcare resulting in high levels of continuous improvement.

Methods: A case study design, in partnership with the services, was used. The services were selected through standard continuously quality improving (CQI) audits. We visited services and interviewed service providers, clients, community members, and managers at the local and regional levels (n=134). We then looked at themes within each service and compared themes across the services at the macro (external system), meso (local system) and the micro health system (client – health provider interaction). Feedback visits and collaborative meetings with all services were conducted.

Relevance: Community participation in health care is continually promoted. How this plays out in different services varies. The benefits of community participation are seen to be a level of community ownership and more relevant and accessible health services.

Results: In this health service, located in the Torres Strait, we have an important example of a community driving health care, using a holistic model of health, and working in partnership with trusted health professionals. Community history and culture influenced all aspects of health so that a unique local way of doing things prevailed. ‘Our culture is our way of life’. This resulted in a highly continuously improving accessible service with trusting and valued relationships between community members and dedicated health providers. The usual clear distinction between ‘patient’ and ‘provider’ was absent. “Whole of community” means health promotion and treatment is for all. One crucial element is the Gudhmud Aboriginal and Torres Strait Islander Health Corporation Health Committee bringing together community and health leaders, and other agency staff about issues to do with the overall health of the whole community. 

Conclusions: This is a clear example of what is often talked about as the ‘gold standard’ in community participation.  “Our culture is our way of life’ and ‘serving our people’ underlie all aspects of service and result in a high continuously improving health service. The community is in control of operationalising their health care and working in highly valued partnerships with their dedicated health professionals.

Slides
Megan Williams
#JustJustice online campaign: enhancing access to Aboriginal-led health-based solutions to incarceration
Biography

Megan Williams, a Wiradjuri descendent, has qualifications in human services, social science and public health, with 20 years' experience combining service delivery with research. Megan Is currently a Senior Research Fellow at Western Sydney University. She has mixed-methods research experience among Aboriginal service providers, and people with multiple health and wellbeing issues. Megan focuses on the strengths of Aboriginal people, drawing out insights for educators, health planners and policy makers. Megan is a research partner of First Peoples' Disability Network and Mibbinbah health promotion charity, and an Associate Investigator with the Centre for Research Excellence in Offender Health at the Kirby institute, UNSW. Megan is active in the #JustJustice social media campaign, and with #JustJustice and Project 10%, an Aboriginal-led justice campaign, has published several narratives celebrating Aboriginal leadership.

Abstract

Social media has grown in popularity right across the health sector. It can greatly enhance access to clinical, practical and policy information – well beyond simply ‘friending’ other people and socialising. This presentation will explore how a small group of Aboriginal health practitioner-scholars, independent journalists and creative production consultants developed and carried out the wide-spread #JustJustice social media campaign.

The #JustJustice campaign focuses on public-health informed, holistic and rights-based responses to the 15-fold over-incarceration of Aboriginal and Torres Strait Islander peoples in the Australian criminal justice system, compared to others in Australia. The campaign was developed as a crowd-funded and multi-disciplinary social media campaign hosted by the health-focussed social journalism project Croakey.org.

Informed by a decolonising methodology, #JustJustice has published 75+ articles written by a wide range of authors, and from a range of perspectives including public health leaders, peak service delivery organisations, health service providers and community members. It has had over 3000 participants from across Australia, and hundreds of millions of Twitter impressions.

This presentation overviews key themes from the articles and online engagement, highlighting the diverse experiences of Aboriginal and Torres Strait Islander peoples as leaders in health care, and it puts forward solutions that Elders, leaders and others recommend to reduce incarceration rates and promote the health and wellbeing of people in rural areas.

#JustJustice is an exemplar of the use of new and emerging technologies in community engagement, public health education and advocacy. In reflecting on #JustJustice, this presentation offers unique insights into the development of online communities relevant for rural health services and individuals, and the many emerging opportunities for knowledge exchange and research transfer - as well as contributing to a better understanding of the profound public health risks of rising prison rates.

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Dianne Wills
Theatre to engage audiences on social issues that create vehicles for conversation
Abstract

Theatre can play a vital role in influencing discussions in the community. One dark aspect that costs our communities both lives and millions of dollars is domestic violence, and yet the issue continues to grow as a silent and shameful destroyer of lives.

Driven by community demand, Creative Regions has developed two resources to address this issue—a verbatim theatre production titled ‘It All Begins With Love', and a children’s picture book called ‘My Big Bear Story'. Join our session to hear more about these projects and discover how the arts has the capacity to help tackle your local beasts.

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Geoff Witmitz
Hub and spoke cardiac rehab telehealth model: improving access for rural people
Abstract

Background: People living in rural Australia do not always have the same opportunities for good health as those living in major cities and health outcomes tend to be poorer outside major cities. One of the main contributors to higher death rates in regional and remote areas is coronary heart disease. These higher death rates may relate to differences in access to services, risk factors and the regional/remote environment.

Over the past two years, the Wimmera Southern Mallee Health Alliance has collaborated with the Wimmera Primary Care Partnership (WPCP) to provide innovative community focused cardiac rehabilitation education via telehealth. Prior to this work, cardiac rehabilitation as an eight week multi-disciplinary program was only available at Wimmera Healthcare Group (WHCG) in Horsham. Many patients in the region previously have not accessed, or completed, such programs due to the burden of travel. Economy of scale has dictated that multi-disciplinary approaches to cardiac rehabilitation have not been available in the rest of the 29,000 sq/km of the Wimmera.

Method: During the pilot, a multidisciplinary team based at WHCG Horsham, Western Victoria (the `Hub’), provided the education component via telehealth, with outlying health services, Rural Northwest Health and West Wimmera Health Services ( the `Spokes’) providing the physical activity component. Staff were trained to use videoconferencing effectively with groups so that all patients could be ‘virtually’ brought together to learn and interact as if they were all in the same room. This allows remote community members to access a high quality, best practice program, close to home, with improved peer support.

Results: This regional alliance has developed a Hub and Spoke Cardiac Rehabilitation Model of Care. Delivered via videoconferencing, practitioners at rural centres can now provide best practice, multi-disciplinary cardiac rehabilitation programs for remote patients.

This model has:

  • provided access to rural community members who may have limited or no access to rehabilitation
  • saved thousands of dollars in travel costs and time spent travelling
  • provided opportunities for peer support and increased social connectivity
  • supported staff and enhanced telehealth skills
  • enabled rural practitioners to broaden their scope of practice
  • provided cost effective delivery of a multidisciplinary secondary prevention cardiac rehabilitation program
  • been embraced with enthusiasm by practitioners and consumers
  • been analysed against both heuristic and human factors
  • provided a replicable model for delivery of specialised interventions to remote populations.

Conclusions: Evaluation of this model shows a significant increase in uptake of cardiac rehabilitation in the Wimmera, a more skilled rural workforce and better coordinated services for rural patients.

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