The Virtual Rural Generalist Service: a hybrid virtual model of care designed to improve health access and outcomes in rural and remote communities

Abstract

It is well known that rural and remote communities globally experience inequities in both health outcomes and access to health provision.¹ In Australia, despite a range of initiatives to address the shortfall for doctors in rural and remote areas, there remain substantial gaps in access to doctors in many rural communities.^{2, 3} Telehealth is a means to manage this gap; however, few models have been developed to deal with workforce challenges for small rural hospitals and fewer have been evaluated through the lens of the Quadruple Aim: improved health outcomes that matter to patients, improved experiences of receiving and providing care, and improving health care costs.⁴ This article introduces the MJA supplement on the Virtual Rural Generalist Service (VRGS), which is a model of care designed to provide medical support to rural hospitals where there is limited onsite medical staff or where there are no local doctors available. This perspective provides the background for four articles evaluating the VRGS.

Western NSW Local Health District (WNSWLHD) is a vast health district in the state of New South Wales, Australia. It covers some of the state's most vulnerable communities across 246 676 km² and is home to a population of about 279 000 people, of whom 14% identify as First Nations peoples.⁵ Of the 38 health facilities within the WNSWLHD footprint, six are classified as “inner regional”, 14 are classified as “outer regional”, and the remainder are either “remote” or “very remote”, and no local government area is classified as a metropolitan area, according to the Australian Statistical Geography Standard – Remoteness Areas.⁶ WNSWLHD is primarily responsible for the acute and emergency services across this region, operating 38 inpatient facilities, including three rural referral hospitals, four procedural hospitals, six community hospitals, and 25 multipurpose hospitals.⁵

Like many rural and remote regions across Australia, and internationally, workforce access in western NSW remains a challenge.^{3, 7} This is particularly true for rural general practitioners, who provide primary care and are also the main medical workforce for 35 of the region's 38 acute care services. Medical workforce has faced increasing strain over the past five to ten years, with the Western NSW Primary Health Network predicting that 41 of the region's 49 communities will be without a general practitioner by the end of the decade.³ Consequently, WNSWLHD became increasingly reliant on contracted short term medical officers, with many towns reliant on a locum medical model sometimes having no consistency in visiting medical officers. Even where general practitioner visiting medical officers were available, doctors in small communities were under severe strain, given the demands of providing care 24 hours, seven days a week, increasing administrative demands, credentialing barriers, and balancing challenges of professional, sociocultural and geographic isolation.³

In 2008, a group of general practitioner visiting medical officers worked with the then Local Area Health Service (now WNSWLHD) to create a Remote Medical Consultation Service (RMCS). The RMCS primarily provided telephone-based ad hoc consultations between general practitioners and local nursing staff across community hospitals and multipurpose services when there was no local medical coverage. RMCS functioned with one doctor rostered over 24 hours in a limited digital health environment, using a paper-based workflow for note taking, prescribing and other clinical requirements. These workflows and rostering, including telephone communication, continued over 11 years, despite substantial increasing demand on the service, implementation of electronic medical records (EMRs), and significant investment by WNSWLHD in telehealth mobile carts in all its rural and remote health facilities.

In 2019, noting the shortfalls of the RMCS model, WNSWLHD undertook a process to evolve the service. This process designed and implemented a novel hybrid virtual model of care that met the Institute for Healthcare Improvement's Quadruple Aim⁴ and modern clinical governance standards. An agile project methodology ensured that the project met changing demands, integrated continuous quality improvement, and was able to quickly adapt to arising challenges.^8-11 The service was co-designed with new and existing clinicians, and a lean working group was established to consult on and implement the new service model. The model was built on the dimensions described below.

The VRGS launched two months before the COVID-19 pandemic was announced in Australia. During the pandemic, the VRGS was used to provide consistent and flexible medical support to numerous communities across WNSWLHD. Given the reliance of the WNSWLHD on a locum workforce, many of whom reside interstate and were unable to travel due to border restrictions, the VRGS was instrumental in stabilising the medical workforce. The VRGS provided consistency of medical care in rural and remote communities where there would have been significant service gaps due to rapid and often unpredictable border closures between Australian states and territories. Due to the inbuilt resilience of the model and its virtual delivery components, the VRGS rapidly adapted to need, sometimes within hours. The VRGS proactively increased shifts early in the COVID-19 pandemic, anticipating increased pressure on the service due to staff furlough, fatigue, or concern regarding treating patients with COVID-19.

The first case of COVID-19 in Western NSW was identified on 10 August 2021. By 12 August, the VRGS had expanded to roster the WNSWLHD COVID Care in the Community (CCIC) — a virtual service specifically servicing patients with COVID-19 in their homes. The VRGS continued to staff and assist the CCIC until it could recruit enough staff to maintain its own roster.

This MJA supplement provides an additional four articles reporting a mixed methods evaluation of the VRGS against the Quadruple Aim⁴ of values-based health care, specifically, (i) health outcomes that matter to patients;³¹ (ii) experiences of providing care;³² (iii) experiences of receiving care;³³ and (iv) effectiveness and efficiency of care.³⁴ The evaluation drew upon the experiences of patients, carers, clinicians, and health managers and administrators, in conjunction with linked service usage (administrative data) and health outcomes data. As a contrast, an additional two articles in this supplement discuss other virtual models of care supporting health care delivery in rural and remote contexts.^{35, 36}

In the context of rural workforce shortages, the VRGS has an important role in providing continuous medical coverage to complement the local visiting medical officer workforce in rural and remote hospitals. The service fills medical roster gaps, making rural medical and nursing positions more attractive and sustainable, while also being acceptable to patients and carers as providing good quality medical care that can meet many of their needs. The service is recognised locally to increase access to a doctor and provide equivalent medical care to that of traditional medical models (ie, general practitioner visiting medical officer). It is also a cost-effective solution that is acceptable to manage patients in rural community hospitals and multipurpose services. Further investment is needed to train and resource local nurses who play an integral role in providing virtual medical care, in addition to investment in data capture to ensure administrative datasets can capture VRGS encounters to transparently demonstrate cost and time savings with comparable benefits to in-person services over time.

Collectively, the evaluation articles reported in this supplement show that the VRGS promises to be an economically viable solution to attract, retain and sustain existing medical care, and may be applicable in other rural and remote areas in Australia and internationally.

No relevant disclosures.

Not commissioned; externally peer reviewed.