Needs Assessment. Report 2016

Needs Assessment Report 2016

Section 1 Narrative CSAPHN s needs assessment process took a two-pronged approach, integrating data available publically or obtained confidentially from key partners such as Country SA LHN with additional evidence collected through stakeholder and staff consultations. An overview of the principal data sources used is given in the data annex that is provided as an attachment to this reporting template. The needs assessment took a holistic look at demographic, health, and health service patterns to identify locations and populations with particular health and service needs as well as country SA-wide priorities. The data used to inform this report was presented primarily by Statistical Area Level 3 (SA3); a census statistical geography that provides a framework for data analysis at a regional level; and/or by Local Government Area (LGA). The attached data annex gives a detailed overview of the administrative boundaries within CSAPHN. For a baseline background on drug and alcohol treatment, funding, and state and territory arrangements, the D&A toolkit and Secure Data provided to PHNs were used. To assess general health needs, data and statistics from a wide range of resources were collated and presented to identify burden of disease and levels of service provision throughout the region. Community input was primarily collated from extensive stakeholder consultations using both written surveys and focus groups that were conducted in 2014 by CSAPHN s two main predecessors, Country North SA Medicare Local and Country South SA Medicare Local. Further assessment of perceived needs in local communities and overarching CSAPHN priorities was obtained through a comprehensive survey of all CSAPHN staff along with direct consultation with Country Health SA Local Health Network staff and other provider organisations within the region. To further investigate needs and service gaps specifically related to alcohol and other drugs, CSAPHN formulated a targeted survey focusing on the identified parties and in scope interventions highlighted in the toolkit, receiving over 70 replies. Moreover, CSAPHN continues to engage in ongoing consultations and joint development of service delivery models and resource distribution with Drug and Alcohol Services South Australia and the SA Network of Drug and Alcohol Services through the Drug and Alcohol Service Planning Model Working Group. The priority level of the key population health and service issues has been summarised in the Priority Matrix, which is included as an attachment to this reporting template. Requirements for further developmental work relate predominantly to (1) continuing comprehensive, in depth service mapping; (2) obtaining and analysing quality practice data from a range of GP practices throughout the region and (3) building and refining stakeholder engagement structures that enable ongoing consultation. All pieces of work are cornerstones of ongoing CSAPHN activities. In addition, the needs assessment process highlighted the importance of investigating chronic disease and chronic disease risk factors beyond the national priority health areas to fully realise opportunities for primary and secondary prevention in future CSAPHN work. One such example is Chronic Kidney Disease (CKD) which shares common risk factors and is associated with other chronic diseases such as type 2 diabetes and cardiovascular disease. However, owing in part to the difficulty of timely diagnosis, accurate statistics, especially at the small area level, are difficult to obtain and the magnitude of disease burden and service needs is therefore likely to be underestimated. Moreover, the interrelated nature of socioeconomic determinants, risk factors, and health states suggests that acting on any one of the principal needs identified in this report will positively impact on other needs, stated or unstated. Conversely, missing a key need relevant to service access, even where the actual need is located further upstream and not necessarily within the purview of the PHN, risks diminishing the success of programs designed to increase service availability and appropriateness. More remote and home to higher concentrations of disadvantaged populations than the rest of South Australia and Australia, CSAPHN sees a Page 1

need to investigate and advocate for services that are critical to access to health services, but possibly lower priority for PHNs in other locations. The issue of transport availability as a determinant of access to service may serve as a case in point: raised consistently as an important issue impacting on health service access and utilisation, the financial and opportunity cost of travel to obtain services and options to mitigate these, including continuation of activities in a local setting or replacement with technological solutions, needs to be investigated as part of future comprehensive needs assessment cycles. Data collection and analysis is an ongoing process that represents an integral part of systematic stakeholder engagement and the PHN commissioning cycle. As pointed out above, there are a number of gaps in the data currently available to Country SA PHN, some of which will be addressed through continual service mapping. In particular, this includes data on private providers in the allied health and aged care spaces and an assessment of the actual level of care and operating hours made available by providers that are reported as active in the after-hours period. Such a detailed collection of community-specific data on volume and quality of service provision will enable a finer distinction between service utilisation and service needs as well as provide further assessment of large remote statistical and governance areas with considerable internal variation of health and demographic data. In addition, comprehensive GP and Allied Health Engagement Surveys covering the entire CSAPHN region are currently under way using key data collected through the service mapping process. Stakeholder consultations are being integrated into the agreed mission of both Clinical Councils and the Community Advisory Committee and will begin to contribute more significantly to ongoing needs assessment in the months to come. Moreover, these permanent structures will provide a springboard for periodic consultations of the wider community to obtain a broad local perspective, including the views of hard-toreach consumers. Meaningful engagement and consultation with consumers, carers, local councils, and localised service providers is essential to provide context and add affirmation to data and priorities obtained through more traditional research and needs analysis modalities. In addition, the translation of the results from the needs assessment into service design and commissioning depends on an accurate understanding of the existing local service landscape. With new PHN responsibilities in the areas of mental health, suicide prevention and alcohol and other drugs, locally relevant health data and a detailed understanding of the spectrum and capacity of services provided and administered is a crucial. The drug and alcohol sector is an area in which PHNs have only recently started to establish themselves as key partners and genuine consultation and engagement is needed for joint planning with LHNs and state-based drug and alcohol services. This is a gradual process that requires a long-term approach which does not easily fit the timelines of this first PHN needs assessment. Hence, the continuation of these recent efforts will be crucial to ensuring effective and informed commissioning not only in general and mental health, but also in the new priority area of alcohol and other drugs. Mental disorders and substance use occur together very frequently and can interact negatively on one another. While this is commonly known a specific gap became apparent with regard to drug and alcohol and mental health comorbidity and relevant service provision within our current data streams. Page 2

This geographically large and demographically diverse region creates some interesting complexities for a needs analysis. This analysis accurately describes an overall picture of the needs of the region, though perhaps in a somewhat generic way. The larger the area of review the more the generic nature becomes apparent and this may obscure communities of considerable need. Whole communities exist as what could be described as enclaves of need within regions that do not fit the same picture. As such, the needs work needs to be a living or rolling activity, perhaps over a longer period of up to two years. In managing this the CSAPHN has provided a general needs analysis of the regions covered, but intends and indeed identified in its original ITA, a rolling activity to identify needs targeted to individual or small groups of individual communities. Context for consideration for our region, is that with an area greater than 900,000 square kilometres the population density is fewer than 2 persons per square kilometre. This is a relatively consistent figure. Adelaide is in geographical terms an exotic city. The population density dropping immediately from the outer suburbs to less than 1 person per square kilometre. CSAPHN is with Far West Qld PHN as one of only two PHNs with no communities within the top 50 population centres in Australia. This even takes into account the small suburban areas within the region that fringe Adelaide. The region comprises over 100 communities of significant size, with only 10 communities over 10,000 persons and the greatest remainder, in the range of approximately 500 to 2000 persons. The goal over time is to create a snapshot for each of these perhaps 100 communities. This will expose the enclave communities and their particular needs and other idiosyncrasies. Given the geographically large and demographically diverse region it serves, CSAPHN considers the assessment presented here a stepping stone towards continual, in depth assessment of local needs and priorities. In particular, the baseline work will assist with the comprehensive needs assessment to be undertaken in the next financial year. At this point in time, CSAPHN will also be in a position to assess shifts in service needs as a result of targeted commissioning beyond the continuity of service prioritised up to now. Page 3

Section 2 Outcomes of the health needs analysis Outcomes of the health needs analysis Identified Need Key Issue Description of Evidence Aboriginal Health **All needs and issues listed in the following sections also apply to ATSI people and communities, and there are often additional challenges to meeting these needs within these populations** High overall burden of disease compared to non-atsi population, linked with embedded disadvantage and marginalisation Increased rates of chronic disease (CVD, diabetes, CKD) High rates of smoking and substance misuse High rate of hospitalisation, including potentially preventable hospitalisations Increased perinatal and child mortality Decreased life expectancy Health disparities increase with distance from metropolitan areas Increased rates of mental illness accounting for 10% of the health gap between Indigenous and non-indigenous Australians in 2003, an additional 4% attributable to suicide - Consultation with and feedback from Aboriginal communities and health workers. - CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3 - AIHW national reports on ATSI health and welfare (AIHW 2015c, 2015d) - ABS Australian Aboriginal and Torres Strait Islander Health Survey - AIHW Closing the Gap Clearinghouse Report: Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander People (AIHW 2014b) - Wardliparingga Aboriginal Research Unit South Australian Aboriginal Heart and Stroke Plan(SAHMRI 2016) - ACIR data (compiled by both SA Health and NHPA) immunisation rates for Aboriginal children by SA3 Lower immunisation rates amongst Aboriginal children at both 1 year and 2 years of age Chronic Disease Potentially Preventable Hospitalisation rates for chronic conditions are higher than the state average in most regions, with the Outback region almost double the South Australian rate. Chronic disease rates in country SA are consistently above the state average High rates of Diabetes and Respiratory Disease in CSAPHN overall, particularly the Mid North, Lower North and Yorke Peninsula. - South Australian Monitoring and Surveillance System (SAMSS) survey of residents aggregated by SA3 - National Diabetes Services Scheme (NDSS) registrations by LGA and SA3 - Australian Atlas of Healthcare Variation prescription rates for respiratory medication by SA3 - Public Health Information Development Unit (PHIDU) cancer screening participation and premature mortality by LGA - NHPA analysis of cancer screening rates Page 4

Outcomes of the health needs analysis Chronic Disease/Risk Factors Healthy Lifestyles High rates of cardiovascular disease in the Yorke Peninsula and Outback High rates of respiratory prescriptions in the Mid North, Lower North and Yorke Peninsula High rates of arthritis and osteoporosis in the Yorke Peninsula and Mid North Chronic Kidney Disease national trends Under diagnosis of chronic kidney disease (estimated 9 out of 10 cases not diagnosed) Prevalence increases with age and level of disadvantage End stage kidney disease (requiring dialysis) prevalence twice as high in remote areas compared to metropolitan areas Cancer Prevalence of cancer highest in the Yorke Peninsula Screening rates lowest in the Outback and consistently low in the Murray and Mallee HPV vaccination rates very low in the South Australian Outback region Rates of high blood pressure, high cholesterol, insufficient physical activity and unhealthy weight all highest in the Yorke Peninsula, and above SA averages for almost every region. Smoking rates and alcohol risk highest in the Mid North and Eyre Peninsula. - CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3 - AIHW Chronic Disease portal (AIHW 2015a) - Department of Health Chronic Disease portal (Australian Government Department of Health 2015) - AIHW report: Mortality from asthma and COPD in Australia (AIHW 2014c) - AIHW report: Cardiovascular disease, diabetes and chronic kidney disease Australian facts: Prevalence and incidence (AIHW 2015b) - AIHW overview of cancer screening by PHN (AIHW 2016b) - Key theme in stakeholder discussions - SAMSS survey of residents aggregated by SA3 - PHIDU estimates of risk factors - AIHW Risk Factor portal (AIHW 2016c) Immunisation Rates of fruit and, particularly, vegetable consumption are very poor throughout South Australia, including CSAPHN regions. Childhood immunisation rates below national target (95%) in all regions except Yorke Peninsula (5 years only) Rates even lower among Aboriginal children HPV vaccination rates among 15 year old girls very low in the South Australian Outback region one of the lowest rates nationally - NHPA analysis of ACIR data by SA3 - SA Health reporting of ACIR data - NHPA analysis of National HPV Vaccination Program Register by SA4 Page 5

Outcomes of the health needs analysis Remoteness Potentially Preventable Hospitalisations Ageing Population Financial and time costs borne by patients to attend regular/recommended appointments Increasing rates of morbidity and mortality with increasing remoteness Potentially preventable hospitalisation rates are above the state average in all regions except the Lower North and Adelaide Hills. Rates in the Outback are almost double the state and national rates. Increased risk of age-related hospitalisation Increased risk of falls Increasing rates of Dementia Increased rates of chronic disease and multiple comorbidities Social isolation - AIHW report on rural, regional and remote health system performance indicators (AIHW 2008) - Proportion of region classified as outer regional, remote or very remote by ABS classification of remoteness - Issue of concern in priority matrix - CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3 - NHPA analysis of the Admitted Patient Care National Minimum Data Set - Government aged care portals and publications (AIHW 2016a, Australian Government Department of Social Services 2015) - My Aged Care website - CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3 RACF residents at high risk of transfer to an acute facility for low level health events CALD Populations Ageing CALD population in the Riverland. Increasing number of humanitarian visa recent arrivals in the South East and Murray Bridge, primarily from Africa and the Middle East. Stigma around illness especially Mental Health in some CALD populations. Low level of health service utilization - PHIDU analysis of ABS Census 2011: persons born overseas reporting poor proficiency in English, by LGA - CSAPHN analysis of Department of Immigration and Citizenship Settlement Reports by LGA - Health Performance Council Scoping Study (Principe 2015) - FECCA review of Australian Research on Older people from CALD backgrounds (FECCA 2015) High risk of hospital readmission for CALD patients Page 6

Outcomes of the health needs analysis Child development Other Population Health Factors Language and cultural barriers to effective use of health services in general and medications in particular Developmentally vulnerable children are at risk of poor health outcomes over the life span Over 2/3 of children in the APY lands are vulnerable on 2 or more domains of the AEDC Communities in the Eyre and Western region more likely to be above the state and national average of children developmentally vulnerable in 2 or more domains Port Augusta and Murray Bridge both have a very high proportion of children developmentally vulnerable on one or more domains Early childhood development is perceived to be an issue across the CSAPHN region Socio-demographic disadvantage High rate of single parent families in the Mid North, Yorke Peninsula and Riverland Homelessness is not well recognised or documented throughout the region Affordability of health care for disadvantaged people Health literacy is perceived to be an issue across the entirety of the CSAPHN catchment. Of particular concern are those areas identified as being of low English proficiency and where there are high rates of disadvantage. Concentration of disadvantage in Peterborough, Coober Pedy, Port Pirie, the APY lands and other remote Aboriginal communities - Australian Early Development Census 2015 results by communities - Stakeholder consultation and feedback - PHIDU analysis of ABS Census 2011 - PHIDU analysis of births and deaths registry data - PHIDU analysis of DSS data - The Kirby Institute, 2015 - Stakeholder consultation and feedback Perinatal health Infant death rates very high in the APY lands, followed by Port Augusta and Murray Bridge Page 7

Outcomes of the health needs analysis Child mortality rates are generally well below the metropolitan rates, but not reported for many areas due to low numbers High proportion of both low birthweight babies and mothers who smoked during pregnancy in Port Augusta, followed by the Outback region. Pregnancy smoking rates also very high in Peterborough and Ceduna Disability and carers Higher proportion of people with a disability living in country SA than Adelaide Sexual Health ATSI people have higher rates of blood borne virus and sexually transmissible infections, including HIV, Hepatitis C, Hepatitis B, gonorrhoea, chlamydia and syphilis Page 8

Outcomes of the health needs analysis Mental Health General Mental Health The statistics and issues reported throughout this section are heavily influenced by socio-economic disadvantage and population structure, especially where there is a high proportion of ATSI residents High rates of people reporting a mental health condition throughout the region, particularly in the Lower North, Mid North and Yorke Peninsula Highest percentage of current mental health conditions is the Lower North followed by the Mid North, Yorke Peninsula, and Limestone Coast, which were also above the state average Psychological distress can have significant impact on people s lives and is linked to anxiety and affective disorders. The highest percentage of current psychological distress was in the Lower North followed by the Eyre Peninsula and Mid North which were all above the overall SA average - SAMSS survey of residents aggregated by SA3 - Characteristics of people using mental health services and prescription medication, 2011 ABS - SA Health Hospital Separations data 2013-14 and 2014-15 - Estimated resident population 2014. - ATAPS MDS data 2014-15 Potentially high rate of undiagnosed mental illness in the Outback region, possibly combined with limited understanding of mental health issues within communities. Supported by evidence of high rates of mental health hospitalisation, yet self-reported (SAMSS) mental health conditions in the Outback region are very low. Lack of mental health support for young people Youth-specific mental health programs and practitioners limited in reach throughout CSAPHN. Long waiting times to access CAMHS services. Mental Health Related Hospital Separations Mental health hospitalisations are used as a proxy for unmet health need because those with met needs are only visible in measurements of current prevalence. This, combined with current service levels, is a proxy indicator of current met need. If client needs escalate beyond service availability or appropriateness, they become visible as acute hospital admissions (and potentially also drug and alcohol, and self-harm hospitalisations). Page 9

Outcomes of the health needs analysis For all Mental Health related admissions in the CSAPHN, the highest average annual rate was in Outback North and followed by Murray and Mallee and Yorke Peninsula Overall, females were generally admitted to hospital for mental health issues more than males. The highest LGA rate for CSAPHN was for males in Peterborough and females in Coober Pedy The highest average annual rate for ATSI hospital separations was in the Murray and Mallee followed by the Eyre Peninsula and South West. The Yorke Peninsula was also above the state average. Specific conditions Schizophrenia and other psychotic disorders rates were highest in Outback North and East followed by Murray and Mallee and Fleurieu and Kangaroo Island Depressive Disorders rates were highest in Murray and Mallee followed by Yorke Peninsula and Outback North and East Post-Traumatic Stress Disorder and other Stress Disorders highest in Mid North followed by Yorke Peninsula Anxiety Disorders rates were overall highest in females, with Mid North, Yorke Peninsula and Outback North and East the highest Access to mental health services ATAPS The state average service capacity (per annum) for ATAPS is 4.2 sessions per client. Lowest service capacity for ATAPS was Yorke Peninsula with an average of 2.2 sessions for each client, followed by the Mid North with 2.8 sessions per client. Eyre Peninsula and South West (3.7), Lower North (3.6), Murray and Mallee (3.8), and Outback and North East (4.0) were also below the state average. Page 10

Outcomes of the health needs analysis Better Access (MBS) The state average service capacity for MBS Psychiatry is 5.8 sessions per client. For the CSAPHN, only the Adelaide Hills (6.6 sessions per client) was above the state average. All other regions in CSAPHN are below the state average. The lowest service capacity for MBS Psychiatry services was Eyre Peninsula and South West (average 2.9 sessions per client), followed by Outback North and East (3.1 sessions per client), and Murray and Mallee (3.2 sessions per client). The state average service capacity for MBS Clinical Psychology was 4.3 sessions per client. For CSAPHN, access to MBS Clinical Psychology services ranged between an average of 3.5 sessions per client in Outback North and East to an average of 4.4 sessions per client in Adelaide Hills. Regions with the lowest access were Limestone Coast, Yorke Peninsula, Murray and Mallee, and Outback North and East. The state average service capacity for MBS Allied Mental Health was 4.1 sessions per client. For CSAPHN, average capacity ranged between 3.2 sessions per client in the Mid North to an average of 4.5 sessions per client in Fleurieu Kangaroo Island. Regions with service capacity below the state average were Eyre Peninsula, Mid North, Outback North and East, Lower North and Yorke Peninsula. Access to General Practitioner for mental health item numbers was lowest in Outback North and East (1.3 sessions per client), followed by Yorke Peninsula (1.4 sessions per client) and Mid North (1.4 sessions per client). Page 11

Outcomes of the health needs analysis PBS Prescriptions In 2014-15, 12.7% of the CSAPHN population accessed PBS subsidised mental health-related medication. 61.4% were female. 72% of the CSAPHN accessing mental health medication were from the most disadvantaged areas (IRSD Quintiles 1 & 2) The proportion of the CSAPHN population accessing mental health-related medication increases with age. Page 12

Outcomes of the health needs analysis Alcohol and other Drugs Hospital Separations The highest average annual rate of separations for Drug and Alcohol as the primary diagnosis was Outback North and East for both males and females Rates of drug and alcohol separations were also high in Yorke Peninsula and Murray and Mallee. For females, the highest rates were in Murray and Mallee and Eyre Peninsula and South West Some high SA3 rates were driven by specific Local Government Areas. Coober Pedy had the highest rate of female drug and alcohol separations and Peterborough had the highest rate of male drug and alcohol separations - Drug and Alcohol Stakeholder Survey - SA Health Hospital Separations 2013-14 and 2014-15 - Estimated resident population 2014. - Estimated resident population ATSI 2011 Aboriginal and Torres Strait Islander Drug and Alcohol The highest average annual rate of separations for Aboriginal and Torres Strait Islander Drug and Alcohol as the primary diagnosis, was Yorke Peninsula High rates of drug and alcohol separations were also in Murray and Mallee, Lower North and Eyre Peninsula and South West Lack of services on the lands. Lack of continuity of care from acute to community. High comorbidity with mental health. Mental Health Suicide Prevention Intentional Self-Harm Mortality data from Intentional Self-Harm is not reported for regions within the CSAPHN area. Cells counts would also be too small as to be identifiable and inadequate to make meaningful interpretations. ABS statistics (2001-2010) show males in South Australia completed suicide at a rate (1.8 per 10,000) three times - ABS - Suicides, Australia, 2010 - SA Health Hospital Separations 2013-14 and 2014-15 - Stakeholder consultation Page 13

Outcomes of the health needs analysis than that of females (0.5 per 10,000). With slightly higher rates for males in Rest of SA (1.9 per 10,000) and slightly lower rates for females in Rest of SA (0.4 per 10,000) Hospital Separations for Intentional Self-Harm Females are more likely to be hospitalized than males. This difference is likely due to males being more than three times more likely to complete suicide than females. This is not a difference in need for suicide prevention, but a reflection of lethality of mechanism. Areas above the CSAPHN annual average rate were, Eyre Peninsula and South West, Yorke Peninsula, Limestone Coast, Lower North and Outback North and East Most common mechanism was self-poisoning, than sharp/blunt objects. Aboriginal and Torres Strait Islander Suicide Prevention Aboriginal and Torres Strait Islander South Australians completed suicide at a rate more than twice that of non- Indigenous South Australians, at 2.7 deaths per 10,000 population compared to 1.1 per 10,000 for non-indigenous South Australians. There are no suicide statistics (attempted or completed) available at the small area level for ATSI populations due to low numbers Stakeholders report very high levels of suicide in Aboriginal communities Page 14

Section 3 Outcomes of the service needs analysis Outcomes of the service needs analysis Identified Need Key Issue Description of Evidence Aboriginal Health **All needs and issues listed in the following sections also apply to ATSI people and communities, and there are often additional challenges to meeting these needs within these populations** Concentration of population in remote locations and the need for cross-border care provision and coordination in the Anangu Pitjantjatjara Yankunytjatjara lands and the Western Australian Central Desert Transient flows of Aboriginal people to and from different communities often without health records - add to the challenges of care coordination Disadvantage and marginalisation exacerbates challenges in coordinating and managing chronic diseases conditions, especially in remote locations. Individuals whose conditions are poorly managed then become frequent users of the acute care health system. - PHIDU analysis of ABS Census 2011 and ERP 2013 - AIHW Closing the Gap Clearinghouse Report: Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander People reports significant rates of poor social and emotional wellbeing outcomes.(aihw 2014b) - Consultation with and feedback from Aboriginal communities and health workers - CSAPHN service mapping geographic distribution of ACCHOs - RDWA Indigenous Medical Outreach programs (RDWA undated c, undated d) - Communities struggle to respond appropriately to individuals with mental health episodes, especially in the after-hours period. Lack of culturally appropriate service provision No operational ACCHO in the Riverland, Mallee, Mid North, Lower North or Yorke Peninsula ACCHOs and AMS need support to operate effectively and become more sustainable Existing GPs, pharmacists and other mainstream services may require ongoing cultural competency training and facilitation to engage with ATSI-specific providers Page 15

Outcomes of the service needs analysis Health Workforce Difficulty of getting GPs and allied health professionals to work in rural and remote areas All of region except Port Augusta, Port Pirie and areas of the Barossa, Hills and Fleurieu is considered a GP district of workforce shortage GPs often responsible for ED and acute hospital services as well as primary health care via General Practice Many localities with limited or no services Rates of Podiatrists, Psychologists, Registered Nurses, Optometrists, Physiotherapists below state averages in all CSAPHN regions, despite higher rates of chronic disease and mental illness Rates of GPs, Pharmacists and Dentists below state averages in nearly all CSAPHN regions. Long wait times to see a practitioner Ageing of the rural and remote health workforce - HWA rates of health practitioners - DoH District of Workforce Shortage mapped via DoctorConnect - Key theme in all stakeholder engagement and feedback - NHSD and CSAPHN internal service mapping - SA Health inpatient data - HWA report: National Rural and Remote Health Workforce Innovation and Reform Strategy (HWA 2013) - RDWA Medical Outreach programs by specialty and location (RDWA undated a, undated b, undated c) All of region apart from a few metropolitan periphery locations is considered a district of workforce shortage for Medical Specialists Challenges in accessing business improvement and professional development opportunities for rural and remote practitioners Prescribing practices and medication management especially for patients with chronic and complex conditions Lack of connection and communication between various health providers both within and between rural communities Chronic Disease Prevention and Mitigation Difficulty of acquiring accurate, comprehensive service data around allied health particularly level and quality of outreach services High rates of chronic disease, high rates of potentially preventable hospitalisations due to chronic conditions, low rates of allied health professionals practicing in rural and remote areas. - Key theme in all stakeholder engagement and feedback - HWA rates of health practitioners Page 16

Outcomes of the service needs analysis Need for more sub-acute care options (e.g. nurse led clinics, support groups), especially outside of the major population centres Education and awareness of risk factors and preventative measures for chronic disease must be maintained and improved in all communities, but especially those that are identified as being at higher risk Support for rural and remote residents after an acute event to prevent relapse and/or rehospitalisation Health Service Coordination and Integration Communities may not support healthy lifestyles built environment, community programs, information and resources Referral pathways can be unclear. Practitioners may not be aware of all referral options - Key theme in ML and PHN stakeholder consultations - Issue highlighted by CHSA LHN Having to travel long distances to access multiple consultations/treatment, patients are often unable to coordinate appointments and/or face hardship in affording transport, accommodation, absence from home, etc. Gaps identified in discharge planning Patients with complex conditions require care input from multiple practitioners, which is currently difficult to coordinate effectively in many regions After Hours Services Palliative care - Palliative care options are perceived to be limited in smaller communities - Limited information available about current services and care pathways throughout the region No/limited after hours sites in the Tintinara and upper South East regions. - CSAPHN internal service mapping database and listing of PIP practices. - After hours clinics and hospital ED locations mapped Page 17

Outcomes of the service needs analysis Reliance on country hospital EDs for after-hours treatment in many country locations. - Key theme in stakeholder consultations Many country hospital EDs do not have a doctor readily available for consultation PIP scheme inadequate to fully resource some practices for necessary after hours operations Ageing Population Difficulty in distinguishing need from service availability through MBS after hours billing rates Concentration of population in outer regional locations where agespecific services are more limited, especially the Fleurieu Peninsula, Yorke Peninsula and Mid North Projected increases in aged population throughout the region, but particularly in the Riverland, Mallee and South East Projected increasing demand for both home based and residential aged care services throughout the region Projected increase in dementia diagnoses - ABS Census 2011 and ERP 2013 (via PHIDU) - CSAPHN service mapping - Stakeholder consultation and feedback - Department of Health Aged Care Data Warehouse - Feedback from LHN Community Home Support staff RACF places No RACF places in Robe or Mallala Very low rate of RACF dementia specific places in the Outback, Adelaide Hills and Gawler Requests for domestic assistance often related to social isolation Gap in timely primary care services to RACFs leading to increased ED presentations of residents Inadequate nursing workforce to support both in-home and residential aged care needs Page 18

Outcomes of the service needs analysis As people age, the often have reduced access to private transportation Lack of access to geriatricians throughout country SA Community health allied health providers only able to support the most complex clients Community Home Support Program No HCSP places in many LGAs in the Mid North, Eyre Peninsula, Mallee and Fleurieu-Kangaroo Island Referrals are affected by operation of MyAgedCare portal Increase in complex clients requiring higher level of care than their current package can support Increased numbers on waiting lists CALD Populations High rates of non-english speaking migrants in the Riverland, Mallee (specifically Murray Bridge) and South East regions. More recent arrivals clustered in the regional cities plus Naracoorte & Tintinara. Humanitarian visa holders most likely to settle in the South East - PHIDU analysis of ABS Census 2011 - Department of Immigration and Citizenship Settlement Reporting - Health Performance Council scoping study (Principe 2015) Presence of discrete communities with different cultural backgrounds in dispersed locations throughout the region Lower level of health service utilisation Populations ageing with lack of cultural specific services Language barriers Varying levels of health literacy Difficult to access interpreters outside of the metro area New arrivals particularly humanitarian visa holders need support to settle and integrate. Refugee experiences and cultural Page 19

Outcomes of the service needs analysis norms may result in poorer physical and mental health and form barriers to accessing and engaging with mainstream health services Transport CALD needs often not considered in service planning No public transport throughout most of the region. Some local bus services operate with varying regularity. Residents of areas with no or limited public transport options face significant barriers to accessing timely primary health care and can have difficulty coordinating appointments - Extensive community engagement done via MLs and within PHNs - Report on transport options within the former Country South SA ML region Services provided from centralized locations create a burden of cost, time and lost income on clients and client support or carers. The great majority of specialist services are accessed from Adelaide and, to a lesser extent, regional centres which are remote from populations in need. Immunisation Significant travel cost (time and financial) is often required to facilitate simple follow up appointments of short duration. The issue is felt across the region, but accentuated the further the travel demand from Adelaide Lack of coordination between different providers - Concerns raised by immunisation nurses throughout the region Uncertainty around the validity of ACIR data Health Information and Technology Very low uptake of My Health Record by providers throughout the region despite a high level of GP registration and a moderate level of consumer registration - DoH ehealth statistics Oral/Dental Health Low rate of dental practitioners in country SA - HWA rates of health practitioners Mental Health General Mental Health Limited availability of practitioners in most areas, especially those working within programs designed to minimise costs for eligible patients. Large gap payments charged by many private providers - Recurring themes in ATAPS provider needs assessments - DoH District of Workforce Shortage - Drug and Alcohol Stakeholder Survey Page 20

Outcomes of the service needs analysis Area of workforce shortage (psychologists) ATAPS service provision rates all lower than the state average, indicating an imbalance with service provision in the metropolitan area despite equal or greater need in many areas. Service is not provided at all in some areas. Neither ATAPS nor MHNIP services are consistently provided within all regions, despite most having some level of need. - ATAPS referral rates - CSAPHN ATAPS Provider evaluation report, 2016 High ATAPS waiting lists Areas with high rates of hospitalisation for mental health and low service capacity need resources to minimise the risk of both well populations and at risk populations, from requiring higher level services through unmet lower level need. Client needs go unmet while waiting for services. Areas with high rates of hospitalisation for mental health and low service capacity need further analysis to determine if the service capacity needs to increase, or is inappropriate. Range and coordination of services needed to better address different stages and severities of mental illness along the continuum. Treatment needs outstrip the services available for both metro and rural providers and patients Service appropriateness Areas with high female mental health admissions, and/or high Indigenous female mental health issues require more specific services for females and Indigenous females. Page 21

Outcomes of the service needs analysis Alcohol and Other Drugs General For rural patients, there is lack of coordination for drug and alcohol comorbid conditions such as mental health and suicide prevention. There is also lack of coordination and continuity of care for rural patients from acute to community care to facilitate a Stepped Care Model. - Drug and Alcohol Stakeholder Survey, CSAPHN - 2016 - SA Health Hospital Separations 2013-14 and 2014-15 - Estimated resident population 2014. - MBS mental health providers - ATAPS DoH Little access, lengthy waiting times, and travel means Stepped care models for more rural and remote patients are near impossible. For residential treatment, rural patients are left with no option but to relocate to metro areas for treatment. Service gaps and comorbidity of Mental Health conditions with drug and alcohol is evident in the hospital separations for each region, correlating as high for both. Client needs go unmet while waiting for services. Stakeholder consultation indicated extensive waiting times clients are unlikely to be re-motivated after waiting. Clients left with little option but to continue using in the meantime. Extensive waiting lists indicate service capacity unable to meet need. If provided additional funding for drug and alcohol services 100% of respondents identified the money would be put towards counselling and rehabilitation as first preference followed by brief intervention and withdrawal management. Stakeholder consultation indicated a need for an immediate action plan for clients who are motivated to engage in treatment. Page 22

Outcomes of the service needs analysis Areas with low service capacity and/or no outreach service, require additional hours or more providers to bring waiting times down, especially in areas where there are higher rates of drug and alcohol admissions, as well as mental health admissions. ATSI Specific Aboriginal and Torres Strait Islander clients in more remote, dry zones have to travel to regional areas which aren t dry to withdraw/sober up. Stakeholders indicate this can cause issues. Clients are then lacking in follow-up and outreach back in the community. Eleven percent of services contributing to the Drug and Alcohol Stakeholder Survey identified as Indigenous organisations and Indigenous specific drug and alcohol treatment services. Brief intervention, withdrawal management and counselling were offered by 75% of organisations, while 25% provided rehabilitation and/or pharmacotherapy services. The treatment ranged from moderate to high, with the main treatment gaps/needs being centred around alcohol (100%) and amphetamines (75%). Further ongoing consultation Currently, five locations have been consulted in the South East region including Mt Gambier, Naracoorte, Kingscote, Victor Harbor and Nuriootpa equating to 10 sessions in total. Consultations are currently being held in Mount Barker and Murray Bridge before moving to the Riverland and Northern regions to consult Port Lincoln, Ceduna, Whyalla, Berri, Clare, Roxby Downs, Port Augusta, Jamestown and Port Pirie. Thus far, an average of 15 service providers have attended each session (estimated 75 in total) while community participants have varied. Of the sessions conducted thus far, two priorities have been repeatedly raised identifying the need for skilled DOA professionals Page 23

Outcomes of the service needs analysis and psychosocial support services. The overall suggestions regarding psychosocial support were the need for services accompanying consumers through detox to rehabilitation to reduce the likelihood of relapse. Page 24