Development of a transdisciplinary diabetes model of care in a rural service

Ms Petrea Cronwell3, Ms Cristal Newman1, Ms Sonia Small3, Ms Elizabeth Ward2

1Community and Allied Health, Roma Hospital, Roma, Australia, 2Centre for Functioning and Health Research, Metro South HHS; and The University of Queensland, St Lucia, Australia, 3School of Allied Health Sciences, Griffith University, Gold Coast, Australia


Context And Aims
Provision of healthcare for clients with diabetes can be challenging, particularly in rural health services with limited resources. In South West Hospital and Health Service, an Accredited Practising Dietitian (APD) and a nurse Credentialed Diabetes Educator (CDE) traditionally provided care within a multidisciplinary service model. Existing service inefficiencies prompted exploration of a new transdisciplinary service model, aiming to improve service efficiency and patient care.
Diabetes assessment and intervention tasks completed within the scope of practice of a registered nurse, APD and/or CDE were identified and documented. The patient journey was mapped and parameters for inclusion in a shared initial assessment tool were identified. Referral criteria for patients requiring specialised assessment and intervention by either the nurse CDE, APD, Nurse Practitioner or Medical officer were developed. Acceptability of the model was tested with referral sources.

The results of mapping activities were used to develop a transdisciplinary diabetes service model. Opportunities for skill sharing, implementation of extended scope practices (including provision of advice on insulin dose adjustment and pathology requesting) and reducing service duplication were identified. A transdisciplinary diabetes model of care was produced including a comprehensive transdisciplinary initial assessment tool, defined referral criteria and skill share clinical task instructions for new tasks. The model demonstrated high levels of acceptability with key stakeholder groups.
Development of transdisciplinary healthcare models provide an opportunity to identify areas for skill sharing, reduced service duplication and improved patient care.


Coming soon

Mealtime dangers; assessing food allergy practices within a sub-regional hospital.

Miss Elizabeth Walker1, Ms Eleanor  Capel1

1Northeast Health Wangaratta, Wangaratta, Australia


Introduction: In 2011-12, 17% of Australians reported avoiding a food due to food allergy or intolerance¹, with safe management of hospital patients with food allergies essential in reducing risk of adverse outcomes. Current food allergy practices at Northeast Health Wangaratta (NHW) remain unclear and inaccurate, increasing risk of allergen exposure.
Objectives: This study aimed to improve patient safety, minimise harm, and standardise food allergy management at NHW.
Method: Interview-style surveys of admissions and nursing staff (n=8), foodservice staff (n=7), dietitians (n=2) and patients (n=1) was conducted with thematic analysis and process mapping of current management systems completed. A point prevalence study on documentation compliance with key performance indicators occurred on inpatients at NHW (n=85).
Results: Process maps (n=7) identified multiple areas of communication breakdown and system errors, including lack of staff ownership and responsibility. Survey results highlighted the need for improved communication between ward and foodservice staff, and a streamlined process for food allergy management. Foodservice staff training was recommended. Point prevalence results identified 5 patients with food allergies, with 40% documentation compliance with key performance indicators. Alarmingly, 0% of these allergies were entered into the foodservice system.
Conclusions: Establishment of a multidisciplinary food and nutrition committee was recommended to develop food allergy guidelines, initiate staff training, conduct auditing processes, and complete a menu review. Finally, multiple areas of risk within the current foodservice system at NHW were highlighted, indicating the need to investigate the management of other high risk diet codes.

1.Australian health survey. Australian Bureau of Statistics. 2014.


Elizabeth Walker works as a clinical dietitian at Northeast Health Wangaratta. She has worked across multiple regional and metropolitan health services over the past 5 years in acute and sub-acute care. Elizabeth has a passion in improving nutrition outcomes of hospital patients and improving nutritional care within a multi-disciplinary context.

Strong Foundations – child, family, community and environmental toxins

Ms Emma Nunan1, Ms Hannah Herrmann1

1Environmental Health Centre, Port Pirie, Australia


The Port Pirie Smelter has been operating for over 100 years, leaving a lead legacy for the city. The Environmental Health Centre (EHC) works collaboratively with families to help protect children from the harmful effects of lead in their environment.

In conjunction with the Port Pirie Smelter Transformation in reducing lead exposure within the community, EHC’s service delivery model has changed to actively support pregnant women, children and their families during the first thousand days.
In Port Pirie, blood lead levels typically increase in the first two years of a child’s life. The first thousand days is also a period of rapid brain development. Children’s brains are particularly vulnerable to environmental toxins. “Exposures to substances such as lead that have minimal or no discernible impacts in adults can permanently alter brain development and function in a child” (Centre for Community Child Health, The First Thousand Days, 2017 p. 42).

As a result, early intervention strategies were identified to reduce children’s exposure to lead. A key feature of these strategies is to support families to have access to timely and appropriate prevention services.

A review and service plan proposal was developed utilising the analysis of Port Pirie blood lead levels, Australian Early Development Census and child development knowledge. The Social Work team has refocused on providing intensive early intervention strategies and partnering with pregnant women and children to help promote positive health outcomes within the community of Port Pirie. Early intervention and prevention is the most proactive and efficient way forward.


Emma is the senior social worker at the Environmental Health Centre, she also has a private social work practice. Previously Emma was employed by Families SA and UCWCSA. Emma has been the elected the chair of the Early Childhood Initiatives Group on two occasions; working with an interagency multidisciplinary group to develop plans for development of the Port Pirie community. During Emma’s roles she has engaged intensively with families to alleviate risks and implement client centred case plans; focusing on paediatrics and the dynamics of families.

Families know best – Early childhood intervention in remote Northern Territory communities

Miss Hannah Johnston1

1Office Of Disability – Top End Remote, Darwin, Australia


The transdisciplinary, key worker model is a best practice framework for supporting children and families of children with disabilities or developmental delay. This framework incorporates best practice principles for early childhood intervention, including practice that is family centred, strengths based, culturally responsive and relationships-based. The key worker model of practice has been adopted by the Office of Disability, Top End Remote (TER) team to support children and families living across 33 remote communities and three regional centres in Northern Territory’s Top End region. Given economies of scale, the key worker model is an efficient and effective approach to service delivery across the vast region.

The TER team works in partnership with children and families via a single point of contact, who takes time to develop relationships in community, build trust and gain an understanding of the child’s connection to family, community and country. The TER team have developed structures to support key workers in early intervention, including extensive paediatric and community specific orientation, cultural mentoring, reflective practice and clinical support around complex cases. This presentation will describe practical examples of the key worker model being adapted for the remote context, including approaches to prioritising, kinship mapping, modifying goal setting tools and functional assessment. The key worker model is an evidence based and cost effective model of early intervention, with potential applications in other rural and remote settings. It has particular relevance in addressing the challenges of NDIS service delivery for remote and very remote areas.


Hannah has worked in remote Northern Territory communities since 2011. She works as a Paediatric Physiotherapist and mroe recently, as a Paediatric Clinical Leader with the Office of Diability – Top End Remote team. As part of this role, she provides support to colleagues, as well as clients, families and schools across the Top End Region. Hannah is currently completing a Masters in Public Health through Flinders University. She is passionate about service delivery for children and families in remote areas and enjoys working in partnership with families and commununities.

Enabling change through the key contact service delivery model in the Katherine region.

Miss Rebecca McGrath1, Miss Emma  Brady1

1Office Of Disability Katherine, Katherine, Australia


The Katherine Office of Disability’s key contact service delivery model has facilitated change in the professional skills of the allied health team, and improvement in the quality of service delivery and associated health outcomes for remote communities in the Katherine region. The key contact approach involves transdisciplinary upskilling and ongoing support of allied health professionals to provide a single point of contact for a community. This model encourages each allied health discipline to think outside the traditional boundaries of their profession and consider a more holistic approach to delivering health services in the remote context where resources are limited.
In particular this has been a huge transition for the physiotherapists on the allied health team, who previously worked in specialised areas of physiotherapy and now work in general practice across the lifespan, with the additional role as ACAT assessors. We have acquired increased knowledge, and a broader skill set that includes aspects of occupational therapy and speech pathology roles, that are traditionally outside our scope of practice.
Working in this role has not only altered our professional skills but also our perspective on the provision of culturally appropriate health services to remote communities, and the importance of acknowledging the social determinants of health.
Additionally this service delivery model has enabled the development of stronger relationships between the health service provider and the remote communities leading to increased client engagement, community empowerment to manage health needs, and generally improved health outcomes.


Rebecca has worked with the Office of Disability in Katherine for nearly two years. She has extensive experience as a Physiotherapist working in a variety of clinical areas across diverse health care settings including non-government organisations, private and public health sectors in Australia and Internationally. Over 13 years’ experience working sensitively with diverse client groups, across the whole lifespan.

Staying Steady in the Straits: Using the Calderdale Framework to develop a skill sharing service model to address balance and falls in remote communities of the Torres Strait

Ms Jane Doepel1, Ms Catherine  Clarke1, Ms Betty  Mareko1, Ms Corina Billingham

1Tores And Cape Hospital And Health Service, Thursday Island , Australia


The Torres Strait and Northern Peninsula Area stretches from the tip of Cape York to within 4km of PNG. There are 23 island communities spread across 48,000 square kilometres. The  population of 10,886  ( 81% indigenous ) 1 receive  very limited outreach  allied health services from the hub on Thursday Island

The sequelae of diabetes, high incidence of osteoarthritic knees and high set housing are some of the factors influencing balance and falls in this population

If older Torres Strait Islander people are unable to age at home or are hospitalised they are forced to be hundreds of kilometres over the ocean away from home and family

The team used the Calderdale Framework to establish skill sharing between the physiotherapy , occupational therapy and Podiatry services to address the issues of providing timely  assessment and interventions for balance and falls prevention in the older population.



  • Using the Calderdale framework helped focus the project and gave rigour and  clear direction
  • Clinical tasks shared included a balance of assessment and interventions
  • Training each other takes time. Competing priorities and travelling on outreach meant time was difficult to quarantine.
  • Staff turnover was identified early as a high risk and proved to be so. Managing to implement the training phase and sustain the changes required engagement from all levels and ongoing commitment.

Take Home Message

Skill share is a valuable service delivery model in remote contexts


Jane graduated 1985 with a BApp Sc (Physiotherapy) in Sydney and has a Master Public Health and Tropical Medicine form JCU (1997 ). She began her career working as a generalist in rural & remote communities. She has worked in NSW, WA and Qld and also in Timor Leste helping to develop the Community Based Rehabilitation Facilitator program. She has always worked in teams and understands the unique perspectives & skills that each profession contributes
Working for a some years in Early Childhood Intervention and being part of the change of service model to a key worker model helped Jane develop greater understanding of how we can blur boundaries and share skills to improve outcomes for patients . Jane has brought that understanding to helping develop a skill share model in the Torres Strait where she has been working for the past 4 years

Changing the landscape of our rural workforce – Establishing a network of Burns Link Therapists for Country South Australia – the (not so) secret to our success

Mrs Joanne Lawson1, Ms Kathryn Heath, Ms Ruth Adamson, Rochelle  Kurmis2

1Country Health South Australia, Adelaide, Australia, 2The Burns Unit – Royal Adelaide Hospital, Adelaide, Australia


Between 2004 – 2012, the Royal Adelaide Hospital Burns Service and the Women’s & Children’s Hospital Burns Service experienced an increase in referrals of patients with a burn injury from regional areas of South Australia. The RAH experienced a 19% increase whilst the WCH had an increase of around 60%.

Given the specialised nature of burns treatment, there are identified inherent treatment problems in a regional health setting¹. The State-wide Rehabilitation Service Plan 2009-2017 included a principle to “Develop state-wide specialised interdisciplinary rehabilitation service teams that work across all care settings for the management of burns… ” And “Outreach services will be provided to regional and country areas”².  From this, the “Burns Link Therapist” program evolved.

The development of the program aimed to address outreach services for regional burns patients in a novel yet contemporary way. The program was primarily designed to provide evidence based, burns specific training for a locally based therapist (OT or PT). This facilitates early referral for the provision of therapy, locally, and with the aid of technology provides ongoing management.

In the first two years of the program, 210 occasions of service (OOS) were provided and 180,000km of travel were saved by patients of the burns units³.

By the end of 2017, 15 therapists had been trained and 736 occasions of service⁴ had been provided. Local burns link therapists have a high level of confidence & competence in providing the service. Strong links forged with metropolitan counterparts support this confidence.

This is our story of success.


Jo Lawson – A physiotherapist with 20 years experience across regional and metro SA and NSW as well as the UK. Currently supporting the team of Physiotherapists working across Country Health South Australia with a focus on workforce planning, service re-design and supporting regional staff to maintain and build strong, effective and contemporary clinical skills.

Needs based planning and systems thinking in responding to complex service delivery needs in rural and remote communities

Ms Fiona Brooke1

1Sarrah, Deakin West  , Australia


Every rural and remote community is different with different needs, challenges and aspirations. As greater autonomy is directed to Primary Health Networks to address local needs, identifying and prioritising those needs at the community level is a critical step in supporting better health outcomes at the community level.

This presentation presents an approach to working with communities through a needs based planning framework to identify and prioritise local needs, identify culturally appropriate local resources and work with PHNs and other rural and remote service delivery providers and planners to map sustainable options for service delivery and empowering local communities to engage and participate.

Systems thinking is a logic framework that focuses on the relationships and connections between elements within the larger system. In a small community, understanding the relationships between community members and their existing health service providers is key to empowering that community to look at it’s specific needs and clearly enunciate those needs to PHNs and other service and policy planners.

Relationships are also central to developing culturally appropriate services that address identified priority needs, supporting community aspirations for better health outcomes. Health is not the only part of the system within each community. Unless health is framed within the broader community and identifies its broader socio-economic role, sustainability will continue to bedevil local service providers.

Developing a local workforce through including training and development options within the framework and supporting options for local training is equally important in building sustainable communities, and sustainable services.


Fiona Brooke is Director, Research and Evidence, for SARRAH. She has over 20 years experience working in government and the not for profit sector, including over 10 years working in rural and remote health and workforce policy.

Embracing the NDIS!

Mrs Tanya Whitley1

1Mackillop Family Services, Collarenebri, Australia


Mackillop Family Services have been supporting children and families with a disability in remote communities in western NSW for over 17 years. Access to allied health professionals is a key issue for the delivery of early childhood intervention services for children and families in western NSW and the development of an allied health assistant model has helped Mackillop Family Services to increase access for the people in remote western NSW.  Mackillop Family Services have strong links with the community and a stable local workforce who are responding to the challenges presented by the introduction of the National Disability Insurance Scheme, significantly changing the service delivery environment. Staff have embraced the opportunity to upskill in developing individual plans and to support families to engage with a new and unfamiliar scheme. The service has identified some tensions in transitioning to an individualised funding approach with changes to service eligibility resulting in some existing clients being outside the scheme guidelines. NDIS participants face difficulties due to inadequate provision for travel and associated costs with the delivery of allied health services in remote communities leading to threats to the successful implementation of plans and reduced outcomes.

This presentation will outline the services provided by Mackillop Family Services early childhood/therapy support workers and proposed innovations funded by the NSW Department of Industry through the Disability Sector Scale-Up – Business Acceleration Grants program to develop services in response to the needs of NDIS participants.


Tanya is a Allied Health Assistant ( certificate 4)  working in the small rural town of Walgett delivering Early Childhood Intervention Services. Tanya has been working for Mackillop Family Services for 4 years, during this time Tanya has worked closely with Allied Health Professionals delivering programs, Tanya has been part of the NDIS transition Early Childhood Early Intervention approach. Tanya is committed to providing these supports to families and children in the Walgett community.

Minimising Medication Misadventure in Rural Communities: Bridging the Gap between General Practitioners and Medication Reviews

Ms Eunice Fu1, Mrs Michelle  Rothwell1

1Atherton Hospital Pharmacy Department, Atherton, Australia


Medication misadventure is a significant public health burden and patients are at particular risk when transitioning between care settings. Home Medication Reviews (HMRs) have been shown to reduce medication misadventure for patients transitioning between hospital and the community. Collaboration between General Practitioners (GPs) and pharmacists is imperative in order to utilize the HMR service more effectively.

To identify the enablers and barriers of HMRs in a cluster of rural communities, with the aim of improving HMR utilization for patients when discharging from hospital.

This phenomenological qualitative study explored GP and Community Pharmacist (CP) awareness, experiences and perceptions of enablers and barriers to using HMRs. Semi-structured interviews were conducted with 10 CPs and 9 GPs identified through clinical and community networks. The rationale for inclusion of two participant groups was to derive variant perspectives of HMR utilization. Transcribing and thematic data analysis were undertaken to recognize issues and possible improvement strategies.

Four themes were identified: Benefits and value of HMRs, barriers limiting uptake, strategies for improving HMR process and a hospital-initiated HMR referral pathway model. Perspectives were categorized into GP-related, Pharmacist-related and patient-related. All participants acknowledged the main beneficial roles of HMRs were medication rationalization and patient education. The current HMR system itself was noted as a major barrier. Improvement strategies identified included having a simplified, streamlined referral process and better promotion of accredited pharmacists in the community.

The identified enablers and barriers with the current HMR system gives better understanding into the issues that need addressing to improve HMR uptake.


Eunice Fu is a clinical pharmacist at Atherton Hospital in Queensland, with a background in community pharmacy. Her research interests lie in community engagement, clinical practices and service delivery to close the gap between hospital and community health services, especially from a rural and remote perspective. As a pharmacist, she is a firm believer in advocating patient-centered care through open communication and collaboration with different health professionals to ensure long-term service sustainability. Eunice is a graduate of the University of Queensland and is currently undertaking postgraduate studies at James Cook University under the Allied Health Rural Generalist Training Program.


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