Rural challenges to in-home treatment

 

In-home rehabilitation can sometimes be a challenge for clinicians in rural parts of the country.

As a busy rural clinician in private practice, I have some thoughts about the Rehab at Home option run by Medibank. There is no doubt that getting out of hospital faster for those who are able should be an advantage from many perspectives. Theoretically, patients will be more active in their own environment and be more connected with social supports. It is easier to prescribe exercises at home knowing what the home environment is like— exercises can be better tailored to suit the person and their environment.

However, success with this program will hinge on the required services being available— and I suspect this is easier to procure in metropolitan and inner regional areas than in rural ones.

I work in a small town of less than 1500 people, and I service a relatively large geographical area. My area would not be classified as remote—it has a Modified Monash Model (2015) classification of 5 (1 being metropolitan, and 7 very remote locations). However, it has traditionally been very difficult to recruit new therapists into my region, and we do not have a large pool of therapists locally. Everyone is very busy and working to capacity, or beyond, much of the time. This seems to fit with the statistics presented in the November 2018 InMotion article on rural physiotherapy [‘Five reasons to go rural’, p.40].

I have now provided this in-home rehabilitation service to several patients over a couple of years, and it has become more difficult on each occasion as I have become more and more busy in my location of practice. With waiting lists in place most of the time, home visits are something I am now extremely reluctant to provide, as the travel time will mean less appointments available for me to see other patients. These in-home patients came from places ranging from 60 kilometres from my place of work, to less than two kilometres. The provider I agreed to work through for these clients expected one hour appointments each time I visited the client. In one circumstance, with one hour travel in each direction, that was a significant amount of time out of my day.

The last time I agreed to do some home- based service, it was for an existing client, who had gone for surgery and was discharged home early. The provider was very insistent that I provide service, and demanded a frequency I did not have the capacity to provide. As there was no other therapist in the region able or willing to provide this service, they agreed for me to see the patient at a reduced frequency after quite some discussion. There were also a series of administrative demands—none major in terms of time required but additional tasks nonetheless. Additionally, there was a requirement for me to provide a verbal handover within a certain timeframe after each appointment. Mobile phone blackspots, regular internet outages, and insufficient people on the provider’s end to take these calls meant this could be a frustrating exercise.

So the dilemma is: see these patients at home and have others wait longer on the waiting list, or decline the home-based service? From what I could gather regarding how each of these home-based rehab clients was discharged, they were simply asked whether there was a physiotherapist near them that they would like to see. If they said ‘yes’, then they went onto a home-based pathway. No consideration was given as to whether the physiotherapist concerned had the capacity to provide the service needed—direct liaison with the physiotherapy provider may have led to a different pathway being followed.

A one-sized procedure to fit all patients whether rural or metropolitan does not seem to make good sense either from the point of view of the patient (who gets a less frequent than would be ideal service) or for the provider who may be stretched to their limit. I think the whole plan needs further tweaking before it can be rolled out equitably.

 

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