ABSTRACT
We describe the establishment and operation of a student-led interprofessional chronic disease prevention and management clinic in regional Australia. Our aim was twofold. First, to report on service delivery, student placement, and health outcome data; and second, to discuss key lessons learned during the first 3½ years of clinic operations. Between July 2019 and December 2022, 146 (79.3%) clinic participants completed the 4-month program and participated in an average of 48.4 occasions of service (total 7,060). The clinic supported 1,060 clinical placement weeks across 147 health students. There was a significant improvement across health measures reported at program completion, with the largest changes observed for the 6-min walk test and preference-adjusted quality of life. Nine key challenges and lessons were identified that affected operations and service delivery, which should be of interest to healthcare teams considering establishing an interprofessional student-led clinic.
Introduction
Australians living in regional communities (defined as non-urban, rural, and remote areas) experience poorer health outcomes compared with those living in metropolitan areas, including higher rates of hospitalization, chronic disease, injury, and premature death (Australian Institute of Health and Welfare [AIHW], Citation2020b). Although health needs are greater in regional Australia, there exists a maldistribution of the health workforce with fewer health professionals relative to the population (AIHW, Citation2020a; Colman, Citation2022; Department of Health [DOH], Citation2022). These human resource shortages limit regional Australians’ access to quality health care and contribute to the higher burden of chronic diseases (National Rural Health Alliance [NRHA], Citation2021). Innovative models of care that address chronic disease prevention and offer important educational experiences for health professionals in-training are therefore a priority in regional Australia (Smith et al., Citation2022).
There is growing acknowledgment of the importance of interprofessional collaborative practice to deliver quality health care (Lutfiyya et al., Citation2019; Wei et al., Citation2022), including for chronic disease management (Southerland et al., Citation2016) and in regional settings (Frakes et al., Citation2014; Martin et al., Citation2021; Pullon et al., Citation2016). A key skill for future health professionals is the ability to work effectively as part of an interprofessional team. Interprofessional education, defined as occasions when two or more professions learn from, with, and about each other to improve collaboration and quality of care (World Health Organisation [WHO], Citation2010), is a useful means of preparing health workers for interprofessional collaborative practice (Jones & Jones, Citation2011; Martin et al., Citation2021). Interprofessional education can be delivered to health students via clinical simulation, problem-based learning, group, and classroom activities, and work-integrated learning (Olson & Bialocerkowski, Citation2014). Service-learning models, where students engage in experiential learning activities in a local community, are a useful way to deliver interprofessional education while contributing to community health needs (Forbes et al., Citation2020; Hopkins et al., Citation2022). Although there is emerging evidence for the effectiveness of interprofessional service-learning models to support chronic disease prevention and management (Forbes et al., Citation2020; Kent et al., Citation2016; Lai et al., Citation2015), these models vary in the extent that interprofessional practice and education is core to service delivery (Hopkins et al., Citation2022); there is limited evidence in regional, rural, or remote settings in Australia (Frakes et al., Citation2014; Martin et al., Citation2021).
We describe the establishment and operation of a student-led interprofessional chronic disease prevention and management clinic in a regional community in Southern Queensland, Australia. The aim was, first, to report on service delivery, student placement, and health outcome data, and second, to discuss lessons learned from the first 3½ years of clinic operations. Sharing such insights may enable healthcare teams of existing or prospective student-led interprofessional clinics to proactively manage risks, anticipate potential issues, and optimize service delivery systems.
Background
The Health and Wellness Clinic (HaWC)
Southern Queensland Rural Health (SQRH) is one of the 19 University Departments of Rural Health located across Australia. Established in 2019 as an SQRH initiative, the Toowoomba Health and Wellness Clinic (HaWC) is a student-led interprofessional nursing and allied health service providing a holistic, client-centered, goal-orientated program for people with low to rising risk of chronic disease. The program aims to change individual health trajectories, thereby reducing chronic disease risk and the potential future burden on local health services. On referral by a General Practitioner (GP), eligible participants are required to meet at least two inclusion criteria:
Hypertension ≥140/90 mmHg;
Body Mass Index (BMI) ≥25 kg/m2;
High cholesterol (GP referral and/or currently medicated);
High blood glucose levels (GP referred);
Physical activity less than the Physical Activity Guidelines set out by the Australian DOH (Citation2021) and,
Consuming less than two servings of fruit and five of vegetables per day.
Clinic services are tailored to participant needs around the main pillars of Movement, Nutrition, Behaviour Change, and Social Connection. The multifaceted program includes comprehensive health assessments, land, and aqua-based exercise programs, health education sessions, individual and group consultations, and food preparation demonstrations. Services are delivered by physiotherapy, exercise physiology, dietetics, psychology, social work, and nursing students under the supervision of clinical educators. The program includes an interprofessional intake assessment, interprofessional case conferences, progress review sessions, and activities to ensure that participants are equipped to independently manage health goals outside of the clinic. The structured component of the program – and focus of this study – lasted 4 months. Follow-up contact occurs at 6 and 12 months following program completion.
Methods
Ethical approval was granted by the University of Queensland Human Research Ethics Committee for patient data collected prior to (2022/HE000928), and after January 2022 (Citation2022/HE000076).
Service delivery and student placements
Individual-level data were collected for all participants from July 2019 to December 2022 Demographic data were summarized. Information on student discipline and placement duration was extracted for all students. Health disciplines were summarized.
Health outcomes
Health measures were collected at program commencement and completion. Participant anthropometrics (weight, BMI, and waist circumference) were measured in the clinic by staff and students but were at times self-reported by participants during COVID-19 pandemic-related restrictions, which necessitated telehealth appointments. Functional exercise capacity was measured using the standardized 6-min Walk Test (6MWT; Enright, Citation2003). Quality of life was measured using the Assessment of Quality of Life (AQoL)-8D instrument, a validated multi-attribute utility tool (Richardson et al., Citation2014). All data were normally distributed (Shapiro-Wilk). Repeated measures t tests were used to compare mean scores at intake and program completion (IBM SPSS Statistics v.26).
Challenges and lessons learned
The authors of this study comprise members of the SQRH senior leadership and HaWC clinic governance teams. Identified challenges and lessons learned during the first 3½ years since the clinic was established were based on our collective experiences as well as wider feedback provided by participants, staff, and students. Feedback from participants and students was synthesized from anonymous internal evaluation surveys, and staff feedback was documented in regular reflection workshops. The authors reviewed these internal feedback mechanisms, and jointly developed the list of challenges and lessons learned.
Results
Participant demographics
A total of 146 (79.3%) participants completed the 4-month program out of the 184 who commenced ().
Service delivery
Clinic participants received on average 48.4 occasions of service, with a majority attending in-person (in-person: 95.2%; telehealth: 4.8%; ). There was a relatively even split of group and individual occasions of service (group: 50.5%; individual: 49.5%).
Student placements
Nursing and allied health students completed 147 placements and 1,060 weeks of clinical placement (). The average placement duration was 7.2 weeks, although this varied considerably between disciplines. Over the 3½ years of clinic operations, the staffing profile varied, however generally included a clinic coordinator and administration support staff as well as nursing, dietetics, physiotherapy, exercise physiology, social work, and psychology clinical educators.
Health outcomes
Participants who completed the program recorded improvements in anthropometric, aerobic, and quality-of-life outcomes (). Medium-to-large effect sizes were found for reduction in waist circumference (d = 0.67), increases in meters walked in 6 min (d = 0.71), and preference-adjusted quality of life (d = 0.84; Lakens, Citation2013).
Lessons learned
Nine key themes and challenges associated with HaWC service delivery were identified. Where relevant, refinements or fundamental changes to healthcare practices have been made. In other cases, challenges remain, and workarounds are in effect until the solutions are implemented ().
Discussion
This study has described initial findings of a student-led interprofessional chronic disease prevention and management clinic in a regional community in Southern Queensland, Australia. Findings suggest that HaWC is contributing to improvements in individual health outcomes and overall quality of life. The largest improvements were associated with the submaximal exercise tolerance test, a measure of cardiovascular capacity, and preference-adjusted quality of life. Given that the program targets members of the community who require intervention to reduce chronic disease risk or progression, these results are encouraging, not only from our perspective as a relatively new student-led interprofessional health clinic but also for other health teams who may aim to establish a similar model of care.
This study adds more generally to the interprofessional education and collaborative practice literature (Forbes et al., Citation2020; Lutfiyya et al., Citation2019; Olson & Bialocerkowski, Citation2014; Pullon et al., Citation2016; Southerland et al., Citation2016; Wei et al., Citation2022; WHO, Citation2010), and more specifically to the paucity of research evaluating outcomes associated with student-led interprofessional health clinics in regional settings (Frakes et al., Citation2014; Martin et al., Citation2021). Indeed, over the 3 ½ years, several challenges and lessons covering various aspects of the HaWC program were identified, from referral, triage, and intake, through to student allocation and the timing and delivery of interprofessional education. Whilst two of the identified challenges continue to warrant further investigation, several challenges have been addressed, either as a result of the natural passage of time, as is the case with increasing clinic referrals due to growing community awareness, or via changes to program structure and service delivery systems. Changing the method of program intake from a rolling to a block intake model, for example, was one of the most important decisions made as a clinic team. According to staff and student feedback, continuity in contact among the same participant cohort has contributed to goal attainment, social cohesion, and ultimately improved health outcomes. Similar flow-on effects from each of the other changes implemented have been observed. Whilst service delivery has been enhanced as a result of these amendments, we continue to closely monitor activities and remain open to the idea of refinement in the face of new and existing challenges.
Conclusion
This study provides evidence that a student-led interprofessional nursing and allied health clinic in a regional Australian community has contributed positively to individual health outcomes in its first 3½ years of operation. Interprofessional healthcare teams may hereby reflect on the challenges and lessons learned to enhance service delivery. Future studies will report on physiological, behaviour change, and health student evaluation outcomes over a longer follow-up period.
Acknowledgments
The authors would like to acknowledge all staff at Southern Queensland Rural Health (SQRH) and the passionate interprofessional team of clinical educators and students at the Health and Wellness Clinic (HaWC) who have worked tirelessly since 2019 to deliver high-quality healthcare services.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
Notes on contributors
Clara Walker
Clara Walker, is a Principal Project Officer at Southern Queensland Rural Health (SQRH). She is an Adjunct Research Fellow at the Centre for Health Research, University of Southern Queensland.
Bahram Sangelaji
Bahram Sangelaji, is a Senior Research Assistant at Southern Queensland Rural Health (SQRH). He is Adjunct Research Fellow at the Centre for Health Research, the University of Southern Queensland.
Dayle Osborn
Dayle Osborn, is the Health and Wellness Clinic Coordinator and Clinical Educator Nursing and Mental Health Nursing at Southern Queensland Rural Health (SQRH).
Nicola Cotter
Nicola Cotter, is Deputy Director (Darling Downs) at Southern Queensland Rural Health (SQRH). She has 15 years’ experience working as a Physiotherapist and Manager of multidisciplinary and interprofessional healthcare teams.
Geoff Argus
Geoff Argus, is the Director of Southern Queensland Rural Health (SQRH). He is an Associate Professor with The University of Queensland and Adjunct Associate Professor with the University of Southern Queensland. He is a Board Director with Australian Rural Health Education Network (ARHEN) and the National Rural Health Alliance (NRHA).
Adam Hulme
Adam Hulme, BSc Hons (ExSc), MA (Health Promot), PhD (Systems Epidemiol), is a Research Fellow and Senior Research Officer at Southern Queensland Rural Health (SQRH). He is a School Research Chair (University of Queensland), Deputy Chair of the Australian Rural Health Education Network (ARHEN) Research Staff Network and serves as an Associate Editor for the Australian Journal of Rural Health (official Journal of the National Rural Health Alliance.
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