Reality of introducing a new point-of-care test!

Thursday, May 13th, 2021 | Rory | No Comments

Beazley Catherine, Blattner Katharina, Herd Geoffrey (2021) Point-of-Care Haematology Analyser Quality Assurance Programme: a rural nursing perspective. Journal of Primary Health Care 13, 84-90.

An open access paper that is full of wisdom from the Hokianga. While we can reduce inequalities with near to patient technology, it is important not to neglect safety – QA! – and consider how that looks for your place: what is the resource? 



BACKGROUND AND CONTEXT: Rural health services without an onsite laboratory lack timely access to haematology results. Set in New Zealand’s far north, this paper provides a rural nursing perspective on how a health service remote from a laboratory introduced a haematology analyser suitable for point-of-care use and established the associated quality assurance programme.

ASSESSMENT OF PROBLEM: Five broad areas were identified that could impact on successful implementation of the haematology analyser: quality control, staff training, physical resources, costs, and human resource requirements.

RESULTS: Quality control testing, staff training and operating the haematology analyser was more time intensive than anticipated. Finding adequate physical space for placement and operation of the analyser was challenging and costs per patient tests were higher than predicted due to low volumes of testing.

STRATEGIES FOR IMPROVEMENT: Through a collaborative team approach, a modified quality assurance programme was agreed on with the supplier and regional point-of-care testing co-ordinator, resulting in a reduced cost per test. The supplier provided dedicated hours of staff training. Allocated time was assigned to run point-of-care testing quality assurance.

LESSONS: Having access to laboratory tests can reduce inequalities for rural patients, but natural enthusiasm to introduce new point-of-care technologies and devices needs to be tempered by a thorough consideration of the realities on the ground. Quality assurance programmes need to fit the locality while being overseen and supported by laboratory staff knowledgeable in point-of-care testing requirements. Associated costs need to be sustainable in both human and physical resources.

Does it matter where you have your STEMI?

Tuesday, November 3rd, 2020 | Rory | No Comments

Lee S, Miller R, Lee M, White H, Kerr A. Outcomes after ST-elevation myocardial infarction presentation to hospitals with or without a routine primary percutaneous coronary intervention service (ANZACS-QI 46). The New Zealand Medical Journal. 2020 Oct 30;133(1524):64-81.

Link – NZMJ articles become open access after 6 months.


Commentary from Associate Professor Garry Nixon

Why no difference? There should be a difference!

As expected STEMI patients who present to rural and provincial hospitals are older,  more likely to be Māori and have on average lower socioeconomic status (because our patient populations are). They also get fibrinolytics – a second rate substitute for primary PCI. You’d expect, even with the best will in the world, that there would a measurable difference in outcomes, with patients presenting to urban PCI centres doing better . That this study failed to demonstrate this is, to say the least, surprising.

The authors attribute this to the adoption of the pharmaco-invasive strategy and the implementation of current strategies including the out-of-hospital STEMI pathway (which includes the ‘appropriate bypass of non-intervention hospitals’). But the study period (2011-2016) predates the NZ out-of-hospital STEMI pathway and we were practicing a Rescue PCI strategy targeted at patients who failed to reperfuse back then. This is evidenced by the small percentage of rural patients getting angiography within 24 hours (about 25%; a pharmacoinvasive strategy = PCI within 24hrs of fibrinolysis). And these results are not the result of hospital bypass, the basis of the study groups was hospital of initial contact. The results are however a lot better than studies done in the 1990s that demonstrated much poorer outcomes for provincial AMI patients.  My guess is the key here is good communication between peripheral centres and base hospital cardiology units, and that was becoming well established by 2011 in NZ; and all parties should aim to keep building these networks.

I have to thank the whole ANZACS QI team. Its great to see a major NZ research unit looking seriously at rural outcomes. In large part that’s due to the work of the 2nd author. Well done to him.


AIM: Primary percutaneous coronary intervention (PCI) is the optimal reperfusion strategy to manage ST-elevation myocardial infarction (STEMI). Where timely primary PCI cannot be achieved, an initial pharmacological reperfusion strategy is recommended with subsequent transfer to a PCI-capable hospital. The study aim was to assess STEMI outcomes according to the interventional capability of the New Zealand hospital to which patients initially present.

METHODS: Nine thousand four hundred and eighty-eight New Zealand patients, aged 20–79 years, admitted with STEMI to a public hospital were identified. Patients were categorised into three groups— metropolitan hospitals with all-hours access to primary PCI (routine primary PCI cohort), metropolitan hospitals without routine access to PCI, and rural hospitals. The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiac events (MACE) and major bleeding.

RESULTS: Invasive coronary angiography was more frequent in the routine primary PCI cohort compared to metropolitan hospitals without routine access to PCI and rural hospitals (90.6 vs 83.0 vs 85.0% respectively; p<0.001) and occurred more commonly on the day of admission (78.9 vs 28.7 vs 25.7% respectively; p<0.001). There were no differences in multivariable adjusted all-cause mortality, MACE or major bleeding between patients admitted to any of the hospital groupings.

CONCLUSION: Outcomes after STEMI in New Zealand are similar regardless of the interventional capability of the hospital where they first present.

Exploration of rural physician’s lived experience

Friday, September 4th, 2020 | Rory | 1 Comment

Konkin J, Grave L, Cockburn E, et al. Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study. BMJ Open2020;10:e037705. doi:10.1136/bmjopen-2020-037705

Open access

A hermeneutic phenomenological study (look it up or read the methods) undertaken by a group of prominent rural health leaders, most of them well known to a us in Aotearoa. This qualitative study uses interviews with rural doctors to explore a fundamental part of rural medicine, practicing outside your comfort zone aka ‘clinical courage’. The investigators identified a number of features of clinical courage:

the commitment to deliver the care your community needs;

accepting uncertainty;

understanding and making the most of the resources at hand (limited as they are);

consciously testing and understanding your limits;

once you have decided that ‘its needs done’ and ‘you are the best person available to do it’, having the confidence to get on and act;

the importance of supportive rural colleagues in maintaining clinical courage.

The themes will resonate strongly with those working rurally and form a useful insight for those involved in educating the rural workforce.

Comment kindly from Associate Professor Garry Nixon


Objectives: Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services.

Design: A hermeneutic phenomenological study.

Setting: An international rural medicine conference.

Participants: All doctors attending the conference who practised medicine in rural/remote areas in a predominantly English-speaking community were eligible to participate; 27 doctors were recruited.

Interventions: Semi-structured interviews were conducted. The transcripts were initially read and analysed by individual researchers before they were read aloud to the group to explore meanings more fully. Two researchers then reviewed the transcripts to develop the results section which was then rechecked by the broader group.

Primary outcome measure: An understanding of the lived experiences of clinical courage.

Results: Participants provided in-depth descriptions of experiences we have termed clinical courage. This phenomenon included the following features: Standing up to serve anybody and everybody in the community; Accepting uncertainty and persistently seeking to prepare; Deliberately understanding and marshalling resources in the context; Humbly seeking to know one’s own limits; Clearing the cognitive hurdle when something needs to be done for your patient; Collegial support to stand up again.

Conclusion: This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.

Rural post-graduate society:

We are still seeking feedback on developing a voluntary post-graduate rural society that will help fund exisiting CME activities that are free to access and allow development of future activities.

Please click here to let us know what you think!

Technology-facilitated care coordination in rural areas: What is needed?

Monday, July 6th, 2020 | Rory | No Comments

Gill E, Dykes PC, Rudin RS, Storm M, McGrath K, Bates DW. Technology-facilitated care coordination in rural areas: What is needed? International Journal of Medical Informatics. 2020 May;137:104102.


Comments by the lead author – Dr. Emily Gill from Opōtiki


People who live in rural areas have poorer health than their urban counterparts, and for those with multiple, complex medical needs, this is impacted by health IT systems.  This research suggests US rural settings may contend with more unaffiliated electronic health records (EHRs a.k.a. PMSs), than urban settings.  The equivalent in NZ is that rural areas that border between DHBs are more likely to see patients from outside their own DHB, and this poses challenges of accessing and exchanging electronic information (e.g., electronic referrals) with unaffiliated DHBs.  Policy regulations should require that health information be exchanged between all health services, from pharmacy to private hospital to allied health providers, in a way that is ‘useable’ (e.g., user-friendly; without the need to login to multiple other platforms).  An important way to evaluate whether health IT systems are improving health is to focus on care coordination activities: for patients who see multiple health providers due to their complex, chronic needs, how easily can the patient and all the health providers involved access and know pertinent health information, especially when changes are occurring frequently? 

More details:

To provide coordinated care, health information needs to be frequently transferred across settings such as primary care clinics, acute care hospitals, and community health services. The U.S. government made a major financial investment in health information technology with the aim of improving improve care coordination and provided incentives for healthcare organizations to electronically exchange information in a more efficient and accurate process.  Given the increased health needs of the rural population, this research project sought to understand the experiences of healthcare providers in exchanging information during or in response to a transfer of care.


The interviews and surveys conducted through this research described numerous gaps between the necessary care coordination activities for patients with complex needs and the capacity for technology to facilitate the process. Healthcare professionals described low confidence in the integrity of the information they receive, and the effort required to gather needed information, including challenges with arranging real-time communication with other providers caring for the same patient.  Providers described care plans, a potentially useful tool in care coordination, as being regulated to such an extent that they are not used in routine decision making. In exchanging information between organizations using different Electronic Health Records (EHRs), most systems could not automatically incorporate the new information into the existing patient record. This lack of interoperability explains the large quantities of information the providers described faxing and scanning in.  Finally, rural healthcare professionals described the compounding impact of poverty on coordinating care for their patients. Not having transportation to specialist appointments; being geographically located between multiple larger health systems, which amplifies the number of external EHR systems in use; and the lack of access to specialty services all accentuate the challenges of information exchange during care transitions.

Both the U.S. and New Zealand should continue to focus on policy that drives the development of technology standards for how health information is exchanged.  In addition to promoting EHR systems that can receive and incorporate information automatically, standards should guide the usability of digital health data, and how it is aggregated across settings to create useful longitudinal care plans. Policy in both countries should encourage further research to define meaningful measures of how coordination technology tools impact population health.

Dealing with chest pain – a pathway protocol.

Friday, July 3rd, 2020 | Rory | No Comments

Miller R, Young J, Nixon G, Pickering JW, Stokes T, Turner R, et al. Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations. Journal of Primary Health Care. 2020;12(2):129.
open access link

The study protocol for an observational study examining the safety a novel chest pain pathway that uses point-of-care troponin.

Chest pain pathway’s are used throughout the country but largely rely on laboratory based troponin assays, which are not available for a considerable proportion of the rural population.[1] This will be the first large study that examines a rural and/or primary care population.

Enrolment has been more difficult (and slower) than anticipated, but in more than 300 low risk patients (and preliminary analysis), there have been no missed Major Adverse Cardiac Events in the first 30 days after presentation. This is in line with other chest pain pathways that use the new high-sensitivity assays.

very preliminary analysis of the primary end-point 

If you have access to point-of-care troponin and aren’t involved as a study site then please get in touch with me, and if you are already contributing – thank you!! and think of entering patients with chest pain into the data collection tool!


  1. Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.  ↩

Call to action: American Heart and Stroke association on rural health

Friday, February 21st, 2020 | Rory | No Comments

Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, Hipp J, Konig M, Sanchez E, Joynt Maddox KE. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation.:CIR–0000000000000753.

Open Access

An interesting read from American Heart and Stroke Associations. Key points below – some of which will sound familiar, although in a vastly different health and political (thank goodness) environment!

  • There is no single definition of rural in the United States.
  • Rural population: older, lower population growth, more impoverished, less ethnic diverse, but higher percentage of indigenous populations (living close to or on their homelands)
  • Health outcomes significantly worse (and worsening) cf. urban areas
    • 40% higher prevalence heart disease
    • 30% increased stroke
    • higher maternal mortality rates

y axis = deaths; rural = orange line

  • Hospital care is increasing more difficult and further away (10.5miles cf. 4.4 miles)
    • Worsening as hospitals close (>100 rural hospitals closed since 2010; especially if state did not extend Affordable Health Care act (Obama Care))
  • Harder to access ambulance services
  • Some evidence of worse cardiovascular outcomes in rural v urban hospitals (evidence in NZ coming soon)

“In addition, it is hard to measure and track outcomes of rural hospitals for many conditions because volumes are often sufficiently low so as to preclude any conclusions from being drawn about performance for any individual site.”

  • Patient satisfaction higher cf. urban hospitals’
  • 9% of US physicians practice in rural area (despite 20% of population)
    • 77% of rural areas = Primary Care Health Professional Shortage Areas


  • Supply of clinicians need to be addressed
  • Rural specific team based care models
  • Scope of Practice Laws facilitate rural workforce development
  • Telehealth and digitally enabled health care
  • Rural-specific care delivery sites
  • Regionalisation fo care
  • Sustainable funding
  • Flexible payment models
  • Improvement health insurance coverage
  • Broader economic development in rural areas
  • Research!

“The AHA is committed to leveraging our reach and assets and to working with strategic partners to develop solutions to improve rural health in America.”


Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association’s pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association’s commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.


Thanks to Mayanna Lund (Cardiologist @ Middlemore Hospital) for passing on this paper 

RediPred or RediDex? steroid choice in croup

Tuesday, February 4th, 2020 | Rory | 1 Comment

Parker CM and Cooper MN. Prednisolone Versus Dexamethasone for Croup: a Randomized Controlled Trial. Pediatrics. 2019;144(3):e20183772



Comment from Yan:

Parker et al concluded that there is no significant difference between dexamethasone 0.6mg/kg, 0.15 mg/kg and prednisolone at 1 mg/kg in the treatment of croup in this prospective, double-blind, noninferiority randomised controlled trial in an Australian tertiary ED paediatric population. Primary outcomes were an hourly croup score and 7 days re-attendance rate.

My biggest criticism of this otherwise well carried out trial was that only 1 in 7 croup cases were enrolled (deemed ‘convenience sample’). There was also no analysis to look at any potential differences between the enrolled and non enrolled group. The study in the end did not achieve the pre-determined target number of subjects for the non inferiority analysis, but the confidence intervals clearly overlap across the groups.

Also 30% of enrolled patients did not have phone follow up (meaning GP re-attendance not accounted for in this group). Note also that the single dose prednisolone 1mg/kg group is more likely to require further doses of steroids than the dexamethasone groups. I think this study still doesn’t answer the question about which steroid to give these kids conclusively.

In practice, this study seems not to contradict what is probably the most common practice in rural—for the bulk of croup patients, prescribe single dose oral dexamethasone if available or a course of prednisolone if not (Starship recommends 2 days at 1mg/kg.)

Rory – dexamethasone is technically not funded for oral use in the community in NZ, but is available as PSO


OBJECTIVES: The use of either prednisolone or low-dose dexamethasone in the treatment of childhood croup lacks a rigorous evidence base despite widespread use. In this study, we compare dexamethasone at 0.6 mg/kg with both low-dose dexamethasone at 0.15 mg/kg and prednisolone at 1 mg/kg.

METHODS: Prospective, double-blind, noninferiority randomized controlled trial based in 1 tertiary pediatric emergency department and 1 urban district emergency department in Perth, Western Australia. Inclusions were age >6 months, maximum weight 20 kg, contactable by telephone, and English-speaking caregivers. Exclusion criteria were known prednisolone or dexamethasone allergy, immunosuppressive disease or treatment, steroid therapy or enrollment in the study within the previous 14 days, and a high clinical suspicion of an alternative diagnosis. A total of 1252 participants were enrolled and randomly assigned to receive dexamethasone (0.6 mg/kg; n = 410), low-dose dexamethasone (0.15 mg/kg; n = 410), or prednisolone (1 mg/kg; n = 411). Primary outcome measures included Westley Croup Score 1-hour after treatment and unscheduled medical re-attendance during the 7 days after treatment.

RESULTS: Mean Westley Croup Score at baseline was 1.4 for dexamethasone, 1.5 for low-dose dexamethasone, and 1.5 for prednisolone. Adjusted difference in scores at 1 hour, compared with dexamethasone, was 0.03 (95% confidence interval −0.09 to 0.15) for low-dose dexamethasone and 0.05 (95% confidence interval −0.07 to 0.17) for prednisolone. Re-attendance rates were 17.8% for dexamethasone, 19.5% for low-dose dexamethasone, and 21.7% for prednisolone (not significant [P = .59 and .19]).

CONCLUSIONS: Noninferiority was demonstrated for both low-dose dexamethasone and prednisolone. The type of oral steroid seems to have no clinically significant impact on efficacy, both acutely and during the week after treatment.


Yan Wong is a rural doctor in Balclutha, Otago. He is also a convener for the GENA725 – Communication in Rural Hospital Medicine, which is running in semester 1 of this year. This course covers palliative care, Māori health, mental health, alcohol and drugs/addiction among other things, all with a rural context focus. The residential is based on a marae in the beautiful Hoikianga

Yan relaxing in a boat

Yan relaxing on a boat


1’s and 0’s of wisdom: Don’t be afraid

Monday, November 4th, 2019 | Rory | 2 Comments

Gutenstein M. Daring to be wise: We are black boxes, and artificial intelligence will be the solution. Emergency Medicine Australasia. 2019 Oct;31(5):891–2. EZProxy link

A very well written and thoughtful piece on the future of emergency medicine in a technologically advanced age. There are many similarities between emergency and rural medicine – e.g. just substitute overwhelming patient and time pressure with (professional and geographic) isolation and workforce shortages – and the technology is and will have a very positive effect on the care of our patients – if we let it. I don’t think we will lose our jobs, we will work differently – hopefully more enabled, with more compassion and more satisfaction (and more time at the beach?)


Emergency physicians seek wisdom through personal resilience, deliberate reasoning, clinical consensus and reflective practice. However, there is a limit to how useful psychological training, clinical guidelines and audit initiatives can be in the face of inherent human fallibility, increasing system complexity and escalating demand. Wisdom may be more easily attained through the careful design of new technology and this should be a priority for the emergency medicine community.

Marc is a convener of GENA 723 Trauma and Emergency Medicine in Rural Settings and the Rural Inter-professional Simulation Course. You can find out about both these courses at the Rural Postgraduate Page

Rural and Remote – making it work: Learning from our Euro colleagues

Tuesday, October 29th, 2019 | Rory | No Comments

Making it work
open access
Longer and summary documents available

Taking the long view is essential

Some good stuff in this document. NZ has some of this in place, but tying it together without extra investment hard.


  • Intersectoral investment in training and career promotion
  • Create desirable workplace
  • Create and incentivise a pool of transient workers to make a longer term commitment to your region


Thanks to Fiona Doolan-Noble for the link


The Orange Declaration

Monday, October 21st, 2019 | Rory | No Comments

Perkins D, Farmer J, Salvador‐Carulla L, Dalton H, Luscombe G. The Orange Declaration on rural and remote mental health. Aust. J. Rural Health. 2019;00:1–6. https://doi. org/10.1111/ajr.12560

Open Access:

Contribution by Dr. Fiona Doolan-Noble

The Orange Declaration on rural and remote health evolved out of a meeting in Orange, New South Wales in October 2018 between mental health researchers and service providers from New South Wales, Victoria, the Australian Capital Territory and Western Australia to examine the issue of rural mental health and well‐being. Following the meeting five iterations of the document were developed, with participants agreeing upon a consensus statement that outlined ten problems related to current models of rural mental health and well‐being and ten potential solutions to the problems.

Reading the paper the identified problems and associated solutions could easily be applied to any health and social care service. As the authors highlight this is driven by the association and relationship between the challenges associated with provision of services in rural areas- geographical, demographic, social, economic and environmental. All of which are not addressed satisfactorily by the current mix of services, the distribution of the health and social care workforce, nor the associated skill mix within those workforces.

Sadly what is missing from the Declaration is any mention of the need to prioritise addressing the crisis in Aboriginal and Torres Strait Islander mental health and well-being.

The publication of the Declaration is a useful way to start a conversation about rural mental health and well-being and as a strategy for bringing the varied organisations and academic institutions working in the space together. However, it is to be hoped that any funding secured will be used in the first instance to co-develop programmes and interventions that are culturally appropriate for rural Aboriginal and Torres Strait Islander people.



Ten problems related to current models of rural mental health and well‐being were identified. They are as follows:

  1. Rural communities are different from cities and are not homogenous: they are distinctive, each with different local assets and challenges. Community contexts can change rapidly due to economic instability, dependence on particular leaders or natural disasters. One‐size‐fits‐all service models that cannot adapt to time, place and context are therefore inappropriate.
  2. The rural mental health system is not working: Indicators of rural health and illness suggest that current service models are failing, not fit for service or overly stretched; this situation has been recognised in the public imagination, the media and in political debate.
  3. Top‐down service models are based on urban assumptions: Rural service models in Australia are based on large region‐wide analyses of service activity data, with relatively little evidence of community co‐design or co‐production. People in rural communities can draw on available local evidence and participate effectively in service design. This requires providing them with appropriate data so that they can partner with local providers and commissioners. An example of these productive partnerships is the rural and remote Aboriginal Community Controlled Health Services that provide integrated and locally managed services which have achieved notable health gains.
  4. Services are not based on needs: Emerging evidence suggests that service provision does not always map to population need, nor does spending necessarily achieve better mental health outcomes. This suggests that the available services are failing to provide what is needed and could be due to demand exceeding supply, service fragmentation, challenges in service navigation or services not reaching vulnerable rural clients.
  5. The current forms of public financing are misaligned disproportionately rewarding outreach, telehealth and city‐centric models at the expense of the local public, private and NGO services from medical, allied health, nursing, peer and care partners. Short‐term funding constraints such as 12‐month contracts offered by Primary Health Networks discourage providers from making investments in rural and remote communities.
  6. Fragmentation and competition hinder sustainable, robust service provision: With a large number of service providers in small communities competing for short‐term contracts, addressing different performance targets and often based elsewhere; the role, past performance and track record of services can be highly confusing and their work uncoordinated. Navigating fragmented services increases transaction costs is a challenge for both clients and for health practitioners.
  7. Structural inequity in mental health service provision is amplified in rural areas: While there are rural residents with acute mental health needs, many of the current gaps in rural mental health might lie in areas of awareness, acceptability, prevention, mental health literacy and social connectedness. An over‐emphasis on specialist and hospital services neglects the first‐line “self‐care” that community members could provide for themselves.
  8. The rural mental health workforce cannot be a miniature version of that found in large cities. Its location, skills, scope of practice, supervision, support and development are all problematic. Mental health jobs are very demanding, responses are needed around the clock, personal and professional boundaries are hard to maintain in small communities and burnout is common.
  9. While telehealth and online services should augment mental health services for all clients whether rural or urban, people with mental health challenges often need to speak in person with a health professional, and on some occasions, very quickly. Rural residents need a range of appropriate options to cater for the different situations in their lives.
  10. Data sets are incomplete, disjointed and limited: many different and incompatible data sets are gathered and there is little data‐sharing or linkage. It is therefore complex to analyse service data and find out which services are associated with improvements in access or health outcomes in which communities.


Ten solutions are proposed for rural mental health and well‐being that together would benefit from robust testing and evaluation. They are as follows:

  1. Whole‐of‐community, place‐based approaches are promising: These approaches are established in many countries and place‐based planning is increasingly popular in Australia. Resources and toolkits have been developed by organisations such as the World Health Organisation (WHO). The WHO model has been shown to be successful in an international systematic review but has not yet been trialled in Australia.
  2. New service models tailored to context must be considered: There are numerous innovative models, methods and ideas being tested at a community level that could be scalable. These models need to be tested at a larger scale using appropriate investigative methodologies. Ideally, much of this research would be conceived and conducted by rurally based researchers and partnerships, helping to build rural research capacity. Moreover, these new ways of working (different models) are likely to require new skills in health care providers and new organisational arrangements, which will also require development.
  3. Co‐designed bottom‐up processes should be pursued in collaboration with state and federal partners: Involving place‐based communities in collaborative co‐design can help to build local partnerships, awareness and generate appropriate solutions. These are beginning to be tested using rigorous methodologies. Such approaches can build empowerment, capacity, resilience, social connection and empathy in diverse cultures. Local partnerships are best placed to plan models about how to care for people in crisis locally who could be at serious risk if they cannot access timely assistance.
  4. Holistic and integrated care models need testing: Many rural communities and primary health services have already given‐up on one‐size‐fits‐all centrally imposed models. Many new non‐clinical, community‐based roles are emerging, including service navigators, connectors, peer supporters and outreach workers who can visit isolated‐community members, provide navigation and support. Such workers can provide a cost‐effective source of local prevention, connection and support. However, models engaging lay personnel to complement health and community services would benefit from large‐scale testing.
  5. New better‐aligned funding models are needed: New funding models that reward collaboration provide rural residents and service providers with choices and referral options, enable clinical supervision and professional mentorship need to be developed, modelled and tested.
  6. Whole of community approaches are needed, not pilot studies: These should be co‐designed with rural communities and tested over longer time periods (at least 3‐5 years). Incremental design and improvement is a much better model with a clear recognition that one size will not fit all and that those without personal experience of living in rural communities might not be the best source of wisdom.
  7. Prevention and early intervention must be considered: Local providers and community leaders suggest that prevention is a largely neglected strategy. Building local strategies to address social connection, transport accessibility, mental health literacy and stigma reduction is a fundamental step. Further research summarising and exploring effective and ineffective approaches at the community level would help identify locally relevant strategies.
  8. New rural workforce models are needed: To address specific rural mental health workforce challenges “grow‐your‐own” and “skills escalation” strategies appear promising. These approaches seek to identify existing local practitioners and residents with the potential to become future health and community service workers, peer supporters or volunteer navigators. These strategies require local incentives to encourage staff to work at the top of their scope of practice; “task‐shifting” to non‐clinical or community roles; effective supervision and governance structures. Workers involved could include personnel from the health sector in general, alcohol and other drugs workers, social care, police, social workers and finance/banking workers.
  9. Digital technology contributes now and can do more as part of new systems: Digital and telehealth services continue to play an important role in extending services to rural communities, but they are not a panacea and people might also need immediate face‐to‐face help or specialist advice and care. Understanding the place and value of online, digital and telehealth offerings is a significant research gap. Social media such as Facebook pages that are created and maintained by local practitioner‐community member collaboratives might be useful for people isolated by distance, culture, poverty, negative relationships or lack of connection. The use of online sources of care and support is partly dependent on increased access and expanded bandwidth.
  10. Enhance data collection, monitoring, linkage, analysis and planning: To address the issues of service fragmentation, gaps, duplication and lack of information sharing, there needs to be a substantial investment in better data collection, monitoring and evaluation to enable services to assess outcomes in a timely manner, thereby facilitating responsive service improvement activities.”