Potentially Preventable Hospitalisations

Potentially preventable hospitalisations (PPH) are identified admissions to a public or private hospital for a condition where the hospitalisation could have potentially been prevented through appropriate preventative health care interventions and early disease management (120). Primary and community based care provided by general practitioners, medical specialists, dentists, nurses, and allied health professionals are identified as essential in supporting people with maintaining health and wellbeing for potentially potential hospitalisations (120).

Key Points

• Potentially preventable hospitalisation rates are above the state average across most of Country SA PHN region

• Chronic condition PPH – Port Augusta, Berri, Renmark are all the highest hot spots in SA

• Acute condition PPH - Ceduna, Renmark, Port Pirie, Port Augusta are all the highest hot spots in SA

Identified Needs

1. Reduce potentially preventable hospitalisations.

2. Integrated and coordinated care across the health system

Health Needs

Potentially preventable hospitalisation (PPH) rates are above the state average in all regions except the Adelaide Hills, Barossa, and Fleurieu-Kangaroo Island. Rates in the Outback - North and East are the highest, followed by the Mid North (71)

Acute Conditions

Acute PPH conditions are a defined set of conditions that usually have quick onset and may not be preventable but are identified as potentially not requiring hospitalisation with timely and adequate care delivered in the community (121)

Ceduna had the highest acute PPH for all SA. Renmark, Port Pirie, Port Augusta, Berri, Millicent, Cooper Pedy and the Coorong all have high rates of acute PPH (68).

Conditions of significance:

• Ear Nose and Throat Infections: Highest admission rate in The Coorong, 3.7 times higher than the state average (68)

• Dental conditions: Highest admission rate was Renmark, 2.6 times higher than the SA average (68)

Chronic Conditions

Chronic PPH conditions are a defined set of long-lasting conditions that may be preventable through lifestyle change and be managed in the community to prevent symptoms becoming worse and requiring hospitalisation (68)

Port Augusta has the highest chronic condition PPH for all SA. Berri, Renmark, Port Pirie, Quorn-Lake Gillies, Millicent and the Coorong all have high rates of chronic PPH (68).

Conditions of significance

• Angina: Highest admission rate was Port Augusta, 4.5 times higher than SA average (68)

• Asthma: Highest admission rate was Nairne, 3.8 times higher than SA average

• Diabetes complications: Highest admission rate was in Karoonda – Lameroo, 3.4 times higher than SA average (68)

• Chronic Obstructive Pulmonary Disease: Port Augusta, Port Pirie, Renmark, Berri and Ceduna have been identified areas with high rates of COPD PPH for more than 10 years in the period 2004-2018.

Country SA PHN Needs Assessment Report 2022-2025 (November 2021)

Service Needs

Primary health care interventions are identified as the key mechanisms to support people in health and wellbeing and potentially avoid preventable hospitalisations for some conditions This care is usually delivered by general practitioners, medical specialists, dentists, nurses and allied health professionals and may be accessed through a variety of community settings, including general practice and Aboriginal and Community Controlled Health Services and may include vaccination, early diagnosis and treatment with ongoing management of conditions or risk factors. As such, workforce shortages and ongoing difficulty in attraction and retention of health professionals to rural and remote areas limits delivery of effect care (refer to: Health Workforce section of the report).

Alcohol and Other Drugs

The consumption of alcohol and other drugs (AOD) is a major cause of preventable disease, illness and death for Australians (122). In South Australia, this trend continues with the misuse of alcohol and illicit substances having a significant impact on service provision and the health of a community.

Alcohol, amphetamines and cannabis have been the most prevalent and misused drugs in SA for the past 10 years and they remain the principle drugs of concern within country SA (123). The large geographic region of country SA denotes different region classification, different population cohorts and therefore disproportionately affected areas.

Key Points

• Amphetamines, alcohol and cannabis are the most common drugs of concern in the Country SA PHN region.

• Amphetamines replaced alcohol as the most common principal drug of concern in 2019 and is a growing concern within Country SA PHN.

• There is a high demand for alcohol and other drugs in outer regional, rural and remote areas of SA.

• Males more likely to engage in alcohol and other drug use.

• Areas with the highest level of need for AOD services in rural and remote areas include the APY lands, Port Augusta, Outback and the Riverland specifically Renmark and Berri.

• Lack of access to the right services at the right time is an ongoing issue across the region.

Priorities

1. Delivery of specialist AOD services

2. Community appropriate MHAOD rehabilitation services

3. Integrated and coordinated care across the health system

Health Needs

Overall use of illicit drugs in regional and remote areas is similar to that in metropolitan areas, however the principal drug of concern and frequency of drug use varies considerably across the regions (124).

AOD service use is often collated in terms of closed treatment episodes, these are a key means of measuring drug service use within the region. A closed treatment episode is a period of contact between a client and a treatment provider that is closed when treatment is completed.

Understanding the extent of alcohol and other drug use in South Australia is important as they influence health, social and economic outcomes in the community. Increased use of these substances increases risk of disease, injury, road trauma, mental illness, family and domestic violence and crime overall. The use and misuse of AOD additionally imposes a huge financial burden on the state.

Alcohol

Risky drinking increases the risk of injury, illness and can correspond with mental illnesses. Most adults consume alcohol and do so responsibly, however a substantial proportion drink in excess of the recommended amount and in turn increase their risk of alcohol related harm and adverse health outcomes (125). Risky alcohol consumption is consistently higher in regional, rural and remote communities (126).

COVID-19 has impacted type and frequency of drug use with Country SA. The use of cannabis, and alcohol increased relative to use before March 2020 while the use of MDMA, cocaine and ketamine mostly decreased over the same period (127)

Issues such as stress, anxiety, domestic violence, social isolation and suicidality additionally increased during the COVID19 active lockdown periods, in correspondence to increased alcohol consumption (127)

Lifetime and short-term risk

Alcohol use is measured in terms of long-term lifetime risk and short-term risk. Lifetime risky drinking is drinking more than 2 standard drinks per day while short term risky drinking is drinking more than 4 standard drinks on any single occasion.

In South Australia in 2019,

• higher percentages of risky drinkers than the national level, 26.6% of males and 10.3% of women compared to 24.4% and 9.4% nationally (128), and

• 28% of people consumed more than 4 standard drinks on a single occasion at least once in the previous month, placing a high percentage of South Australians at short term risk (128)

Alcohol was the principal drug of concern for people receiving AOD treatment during 2018/19 (124), accounting for 60.9% of closed treatment episodes in outer regional areas and 39.5% in inner regional catchments.

Lifetime risk from alcohol in Country SA PHN region increased from previous years(2016-2019) with 20% of people aged 14 years and over consuming more than 2 standard drinks per day on average (128)

In terms of treatment, counselling was the most common main treatment type(41.3%) followed by assessment only (26.8%) for closed episodes in 2019-20 (129).

Prevalence

Despite males drinking at higher rates, women were more likely to seek treatment for an AOD issue within the Country SA PHN region (129), highlighting the need for a targeted approach to help-seeking within the male population.

Males accounted for 63.6% of treatment episodes conducted in 2019-20 for AOD concerns. Fourteen percent of those treated were Aboriginal persons (129)

Country SA PHN region had 20.1% of individuals exceeding the lifetime risk guideline compared to 17.5% in APHN, highlighting an increased need for alcohol education and treatment services (129)

One fifth of high school aged students consumed more than four standard at least once on a single occasion of drinking within the past two weeks, and 26.8% within the last month (128). This is despite the consumption of alcohol in minors being illegal.

Older Australians (70 years and over) were more likely to drink daily than younger cohorts (18-30 years). However individuals aged in their 40s and 50s were more likely to exceed the single occasion guideline at least monthly, thus drinking 4 or more standard drinks increasing their short term risk (128)

Approximately 31% of Aboriginal persons in SA drink at levels placing them at risk of lifetime harm, a further 25% drinking at levels placing them at risk of acute harm at least once a week (130)

People residing in remote and very remote areas were 1.6 times as likely to consume alcohol at levels that increased their risk of injury compared with those in major cities (128). Within Country SA PHN region, the Outback region recorded the highest weekly risky drinking while the Adelaide Hills had the highest proportion of risky month and yearly drinking rates (131).

Positively, the proportion of people classified as ex-drinkers increased from 7.6% to 8.9% from 2016 to 2019, suggesting more Australian’s are giving up alcohol (128)

Illicit drugs

Illicit use of drugs includes use of illegal drugs, misuse of pharmaceutical drugs, and inappropriate use of other substances such as inhalants (132). Illicit drug use varies across rural classification (128).

Harms from illicit drugs affects individuals, families and communities alike, either directly or indirectly. Extended use is associated with increased burden of disease, illness, injuries, trauma and mental illness. Furthermore, heavy use can have significant costs on the health care system and create financial burden for those directly affected (128) In 2018, 1,780 deaths were directly attributed to drug use and contributed to 2.7% of the overall burden of disease and injury (128)

Prevalence

In 2019 in South Australia,

• More than 1 in 7 people in South Australia had used an illicit drug in the past 12 months (128)

• Amphetamines replaced alcohol as the most common principal drug of concern in 2019 (129)

• Individuals aged 30-40 were the most likely to have ever used an illicit drug, whereas in 2001 it was highest among individuals aged 20-30 years (128).

• 15.7% of people in Country SA reported using an illicit drug in the past 12 months compared to 14.8% in the metropolitan area.

• The most common drug of concern for individuals seeking AOD treatment, was amphetamines at 35% of episodes, followed by methamphetamines at 79% of treatment episodes.

The types of illicit drugs used most frequently in Country SA PHN region are cannabis and amphetamines. Unlike cocaine and ecstasy these drugs are more likely to be used regularly. 37% percent of cannabis users and 17% of amphetamine users used weekly compared to 6% and 4% of cocaine and ecstasy users. While these drugs have seen increase of use from 2016-2019 while use of pain-killers and opioids decreased across both lifetime and recent use categories (128). The use of cocaine and ecstasy has however been increasing in recent years (128).

There has been a significant increase in the proportion of people aged 60 and over who have used an illicit drug over their lifetime (128)

Recent surveys highlighted the age at which people started drinking and using illicit drugs to be between 17-20 years of age, suggestion a greater effort is required for education and training into drug use and abuse (128)

Illicit drug use in South Australia is associated with increased risk of criminal conviction and imprisonment.

Cannabis

Long term cannabis use has been linked with significant psychological and physical consequences including psychosocial impacts and cognitive problems. Furthermore, the risk of developing psychotic symptoms doubles among heavy users (133). The median age of individuals who used cannabis increased from 26 to 31 between 2016 and 2019 (128)

• Approximately 10.6% of the general population in South Australia used cannabis in 2018-19. In recent years an increase in cannabis potency has been noted due to an increase in hydroponic production (127)

• Males (14.7%) are more likely to have recently used cannabis than females (8.6%). In the 30-50 age cohort men were twice as likely to use compared to females (128).High rates of cannabis use were more commonly seen in inner regional areas with highest use in the Adelaide Hills and Barossa region (131)

• Cannabis use disproportionately affects the Aboriginal population, accounting for a high proportion of closed treatment episodes (127).

Methamphetamines

Regular and heavy use of methamphetamines has numerous links with poor health outcomes, including heart, kidney and lung problems, poor dental hygiene, skin infections, stroke and weight loss(134). Methamphetamine users additionally pose a risk to the community due to increased likelihood of violent and aggressive behaviour, untreated psychosis and potentially brain damage (134).

The median age of individuals using methamphetamines increased from 23 in 2001 to 32 in 2019(128). Amphetamine use in South Australia is 10% higher than the national average (127). Amphetamines accounted for the largest proportion of AOD treatment episodes in 2019 (127)

Crystal methamphetamine is the most common form of methamphetamine used in SA, and is attributed with an increase in harm and violence (127). Use of methamphetamine has been on the increase since 2006 among previous drug users, in contrast use in the general population has decreased in recent years (135).

Methamphetamine lifetime use was higher in rural and remote areas (124, 131). From 2016-2019, the proportion of victims of an incident related to illicit drug use increased

Pharmaceutical drugs

The misuse of pharmaceuticals refers to the consumption of a prescribed or over-the-counter drug for non-therapeutic purposes.

• Use of non-medical pharmaceuticals declined between 2016 and 2019. In 2016, they were the second most commonly used illicit drug, however in 2019 they ranked fourth behind cannabis, cocaine and ecstasy (128)

• In South Australia, illicit use of pharmaceuticals decreased from 5.5% in 2016 to 4.1% in 2019 (127)

• In 2018, 1,740 deaths were directly attributable to drug use, and opioids were present 64.5% of these deaths (132).

• Within Country SA, a social gradient was apparent in regard to dispensed prescribed opiates; with lower Socioeconomic areas having higher rates of prescribing and usage overall (131)

AOD and Mental Health Comorbidity

Comorbidity refers to the presence of two or more illnesses simultaneously in the same individual. For individuals experiencing an alcohol or other drug misuse problem it is not uncommon for them to additionally be diagnosed with a mental illness (136). Just over half of individuals experiencing an AOD use disorder reported a co-occurring mental illness, likewise three quarters of individuals with a mental health disorder experience some kind of AOD dependence (136).

The co-occurrence of a mental illness and drug misuse problem is therefore bi-directional, alcohol misuse can occur as a coping mechanism for an individual with anxiety, likewise depression can occur as a result of alcohol dependence. Illicit drug use is prevalent amongst South Australians being treated for a mental illness or with high or very high levels of psychological distress (123, 131). Many individuals self-medicate with drugs and/or alcohol to ease mental health symptoms or alternatively can develop mental illness as a result of prolonged drug use.

• Estimated 35% of individuals with a substance use disorder have at least one co-occurring affective or anxiety disorder (3).

• Depression and anxiety are common among illicit opioid users. Heavier illicit opioid use is associated with more severe depression (3).

• Stimulants are amongst the most commonly used substances in individuals with psychosis (123). Trends highlight stimulants to be a form of self-medication.

• 50-73% of Australians meet the diagnostic criteria for at least one comorbid mental disorder, with 1 in 3 having multiple comorbidities (3). Furthermore of individuals in residential rehabilitation experience a current anxiety disorder (70%) and depression (55%).

Service Needs

Specialised Drug and Alcohol Services

Excessive alcohol consumption was responsible for increased demand and pressures on the limited country healthcare services. AOD related illness accounted for the highest proportion of emergency department presentations, hospital separations and specialised treatment episodes (137).

• 11% of South Australia’s AOD services are located in remote and very remote regions of South Australia. Overall accounting for 54 agencies, 23 in the Non-government sector and 18 in the Government sector (129)

• Highest level of need for AOD services in rural and remote areas include the APY lands, Port Augusta, Outback and the Riverland specifically Renmark and Berri (123)

• In 2019-20, 41.7% of closed episodes were via the main treatment method of counselling, followed by assessment only and withdrawal management (129) 79.5% of closed episodes were completed within a non-residential treatment facility.

People receiving treatment for AOD issues were:

• 63.6% males, 36.3% females

• 73% were aged between 20 and 49 years of age

• 80% of clients were non-Aboriginal and 14.4% Aboriginal

Recruitment and retention of experienced and qualified staff is difficult due to short-term funding cycles and unclear career pathways (138)

There is a lack of capacity in the system, leading to extensive waiting lists for services (127)

Large proportions of the workforce who deliver support for AOD service clients are nearing or reaching retirement. This, coupled with the difficulty to recruit staff members, is leading to a reduced workforce size.

Lack of access to suitable training for clinical and non-clinical workforce, leading to increased clinical risk and inconsistency of service provision.

A training need for AOD service staff around reducing judgement and stigma, which is highlighted as a barrier for clients when presenting to services.

Residential and Non-residential Rehabilitation

Rehabilitation programs are usually based in community treatment centres or residential rehabilitation services (139). Rehabilitation approaches vary from patient to patient, where some require counselling while others benefit most from medications (139). Rehabilitation is not always successful the first time and many need to go through the process more than once.

Currently in the Country SA region there are eight registered residential rehabilitation centres, three of which are Aboriginal and Torres Strait Islander population specific. In terms of non-residential rehabilitation, the region has four: Coober Pedy, Mount Gambier, Berri, and Murray Bridge

Mental Health and Drug and Alcohol Comorbidity

High levels of comorbidity places increased pressures on AOD workers as they are required to manage complex psychiatric symptoms which can interfere with their ability to treat clients AOD use (3). Patients with a comorbidity tend to exhibit a more complex and severe clinical profile including poorer physical and Mental Health , greater drug use severity, and poorer everyday functioning and quality of life (3)

The treatment of comorbidities required skilled professions which are limited at best in remote and regional South Australia.

Community Voice

Consultations in late 2020 facilitated across the sector involved community members, providers and key stakeholders. The following were highlighted as key themes;

• Need for more culturally appropriate services to enable better treatment and navigation through the system.

• Inequality of access for rural and remote clients. Most services are found located in urban centres, such as Adelaide, which require impractically long journeys for clients who live in rural and remote areas. Stakeholder groups described the current resources in rural and remote locations as being limited.

• Impacts of COVID-19 may have caused increases in AOD usage across the overall population as well as increasing the risk of relapse. They felt that this was potentially linked to both an increase in the time available for people to consume substances, as well as a reduction in ‘face to face’ AOD and GP services.

Mental Health

Mental health is ‘a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.’ In the average lifetime, 50% of people will have a lived experience of mental illness and the remaining 50% will know or care for someone experiencing mental illness (140) Fifty percent of people will have experienced some form of mental illness by age 14, increasing to 75% by the age of 24 (140).

Key Points

• Low intensity service delivery to reduce waiting lists and increase access to areas of high disadvantage

• Lack of mental health support for young people

• Address service gaps in the provision of psychological therapies and outreach to rural and remote areas

• Integrated and coordinated holistic mental health services

• Step up and down interface with acute services

• Community education and training opportunities for sector staff

Identified Needs

1. Access to specialist mental health services

2. Access to specialist mental health services for young people.

3. Access to low intensity mental health services

4. Access to mental health services in rural and remote areas

5. Access to suicide prevention and services.

6. Community led suicide prevention approaches

7. Integrated and coordinated care across the health system

8. Whole of person care for people with complex mental illness and psychosocial disability.

Health Needs

Mental Health

Mental illness is widespread in Australia, having substantial impacts at the personal, social and economic levels (141). While rates of mental illness are generally consistent across metropolitan and rural Australia, access to services and exposure to external stressors are a considerable problem in rural and remote communities (142, 143). Harsh climates, higher occupational risks, geographic isolation and long distance travel are a normal part of rural community life, however fewer resources and a general lower social economic status add to these challenges (144). With limited access to mental health services and poorer health outcomes, rates of self-harm and suicide increase with remoteness (142)

South Australia is rich with diversity across outer regional and remote areas. The diversity in these areas include variations in demographic composition. Therefore, understanding the unique diversity of a region is a critical element to providing appropriate services (144)

Many of the risk and protective factors for mental health issues have their origins in early and middle childhood, including the development of adaptive coping and problem-solving skills, and exposure to supportive, caring parenting (145). The onset of Mental Illness is typically around mid to late adolescence. The emergence of disorders during this period can have a lasting impact on the health and wellbeing of the individual and their families (145)

People in Country SA PHN region self-report higher psychological distress in comparison with the state average, with Barossa Hills Fleurieu and Yorke & Northern regions being the highest

Rural communities are subject to unique challenges, particularly economic and environmental changes including fire and droughts, which strain resilience and potentially leads to increased familial conflict, social isolation, and increased rates of mental illness (144).To address the needs of our population Country SA PHN region commissions a range of mental health services to deliver Low intensity services, Psychological therapies and acute coordinated care.

Generally, data for mental health, Alcohol and Other Drugs and Suicide Prevention grows more limited with increasing remoteness. Due to small community sizes, a majority of the data is unable to be deidentified and released publicly. Not knowing and/or including data from the rural and very remote areas of the state, skews the overall data presented. Whereby statistics may show a reduction in mental illness, rather it may simply portray lacking/ or incorrectly coded data, limiting the knowledge and therefore impact a service could have on a region at need

Psychological distress

In the country SA PHN region, an increase in psychological distress is commonly observed with growing remoteness (146) Psychological distress can have a significant impact on an individual’s life and can develop into more serious mental Health disorders. Factors unique to living in rural and remote areas are often heavily associated with increased levels of distress (70)

Within Country SA PHN region:

• 25-34 year old experienced the highest rates of psychological distress across both male and female cohorts (147)

• Psychological distress was the highest in the Barossa Hills Fleurieu region followed by the Yorke Peninsula regions

• A significant increase in the use of low intensity mental health services was identified in the 2017-18 period. Low Intensity services were delivered to 1,303 compared to 133 clients in the previous year (148)

Living with a Mental Health condition

Over the last decade, there has been a statistically significant increase in the proportion of individuals living with a mental health condition in the region.

• 334 people per 1000 (approx.) reported having a mental health condition in 2017. Most commonly diagnosed were anxiety (9.8%) and depression (10.8%) (70).

• An estimated 14.4% of South Australian adults reported experiencing an anxiety disorder in the previous 12 monthsm; this was followed by affective disorders, including depression (6.2%) and substance use disorders (5.1%)(149)

• Based on 2021 Census data, SA3 regions with the highest age-standardised rate of self-reported anxiety or depression are the Mid North, Gawler - Two Wells, Fleurieu - Kangaroo Island, Lower North and the Yorke Peninsula (8, 53).

• Prevalence of multiple diagnosed mental health conditions (including anxiety, depression, stress related, and other) was previously reported to be highest in Barossa, Yorke and Northern and Flinders and Upper North (70)

Table 4: Diagnosed mental health conditions in Country SA PHN and SA regions (2017) (70)

Self-reported mental health service utilisation was highest in the Fleurieu – Kangaroo Island (8.0%) followed by Lower North (7.6%), Limestone Coast (6.5%), and Murray and Mallee (5.6%).

Hospital admissions for a primary diagnosis of a mood and anxiety disorders was highest in outer regional and very remote regions. For many of these people, early identification, support and intervention are provided by general practitioners and other community or primary care providers (147)

In terms of LGA’s, Murray Bridge, Millicent, and several areas in the Riverland had consistently high rates across all mental health diagnoses (147)

The lowest rates of use and access for psychological services are Outback North and East, and the Eyre Peninsula. Despite these regions were amongst the highest rates of schizophrenia disorders for the state, these regions also had the lowest rates accessing clinical psychology, despite higher rates of need (147)

Adelaide Hills Fleurieu has the highest number of GP Mental Health plans prepared (per 1,000 population), while Eyre Far North and Flinders Upper North had the lowest (147). This could indicate lower rates of illness in these areas, poor data collection or a lower rate of individuals seeking help.

Youth Mental Health

Youth mental health within this document reflects children or young adults aged up to 25 years.

• The prevalence of psychological distress among youth has increased over the past seven years, particularly among females (64)

• 27.1% of Youth (aged 15-19) in South Australia in 2018 reported psychological distress, compared to 19% in 2012. (64)

• 36% of youth with psychological distress did not seek help, despite thinking they needed to (64)

• 1 in 7 young people aged 4-17 years were assessed as having had a mental health disorder(s) in the previous 12 months (150)

• 40% of Aboriginal youth indicated concerns about suicide compared to 35.6% of non- Indigenous respondents (64).

The key barriers indicated to help-seeking among youth are stigma and embarrassment, fear, lack of support and accessibility (64).

Mental Health Hospitalisation

In 2016, across Country SA PHN region, the highest rates of mental health related Emergency Department presentations were:

• Ceduna/West Coast (3,158),

• Flinders Ranges/ Port Augusta (2,870)

• Barmera/ Berri (2,680), and,

• Port Pirie (2,295).

Outer regional areas had the highest age-standardised rate per 100,000 persons for schizophrenia, mood and anxiety disorders. Similarly remote regions had increased rates of anxiety and very remote regions showed heightened rates of depression and schizophrenia (147, 151).

• Males had higher mental health admission rates in the outer regional areas while females were highest in very remote areas. Aboriginal and Torres Strait Islander admissions were highest in the very remote areas (152)

• The Murray and Mallee region had the highest proportion of mental health admissions for both males and females in the region, followed by the Outback-North and East and the Mid North regions.

Community Awareness

Individuals with mental illness are often stigmatised and excluded in the community and workplace (154)

Community mental health training and suicide prevention activities have shown to increase levels of knowledge and attitudes toward mental health and in turn create safer, supportive communities and workplaces (153, 154)

• 1 in 6 working age people will be struggling with mental illness, 1 in 5 workers will take time off work each year and on average 3-4 sick days are taken each month due to untreated moderate depression across our population (154)

Despite the growing prevalence of mental illness in Australia; literacy on knowledge, education and training about it remain limited in comparison to general health. Good mental health literacy is to have the knowledge, understanding and skills necessary to promote mental health and enhance the ability to recognise, manage and prevent poor health Learning the early warning signs of poor mental health, and taking action can help reduce the severity of the illness, and possibly prevent or delay the development of a major mental illness

(155-157)

Psychosocial Support

Encompassing a holistic approach to health including the mental, emotional, social, and spiritual dimensions of what it means to be healthy, psychosocial health is the result of complex interaction between a person’s history and his or her thoughts about and interpretations of the events and circumstances in their life.

Psychosocial support includes a range of non-clinical, community-based supports that can be either group based or individual, depending on one’s needs. Programs may assist people with severe mental illness to participate in their community, manage daily tasks, undertake work or study, find housing, get involved in activities, and build on one’s social connections and support networks. While psychosocial supports are nonclinical in nature, services should ideally be embedded within or linked to clinical services to support a team approach, form part of a multiagency care plan and provide holistic healthcare.

In the Country SA region (2021):

• 20,629 (6.9%) of individuals aged 16 to 64 were on a disability support pension and a further 7,448 were receiving a carer payment.

• 6.7% of persons needed assistance with core daily activities and approximately 11,133 were unemployed.

• 578 individuals were accessing capacity building supports under NDIS. Capacity Building Supports enable NDIS participants to build their independence and skill and must be used to achieve the goals set out in their NDIS plan.

• 13% experienced high or very high levels of psychological distress, exceeding the state average of 11.9% (2)

Service Needs

Low Intensity Service Delivery

Low Intensity services appropriately support individuals with or at-risk of mild mental illness at a local level, providing an initial service ‘step’ within the primary health stepped care framework. Through adopting a stepped care approach, services match individuals to a service adequate for their need and reduce waiting lists for more intense therapies

As of July 2022, Low Intensity Services are operating in the following regions:

• Riverland Mallee Coorong

• Limestone Coast

• Barossa Hills Fleurieu

• Flinders Upper North

• Eyre Far North

• Yorke and Northern (148)

For regions without a physical service in place, Regional Access (24/7 phone and online services) and the Royal Flying Doctors Service are available.

Psychological Therapies

Psychological therapies are delivered to mild to moderate groups within the stepped care approach. Clinical outcomes for people receiving Psychological Therapies showed 71% of clients had a decrease in levels of distress after receiving a service (148)

Currently psychological therapies are delivered in most regions of Country SA PHN region. However, service provision rates are lower than the state average across all regions in country SA, indicating an imbalance with service provision in the metropolitan area despite equal or greater need in many rural areas.

Generally, there is a workforce shortage across the region. Psychologists are in high demand and yet are limited particularly in rural and remote areas(158). Workforce availability in rural regions impacts consistency of delivery for psychological therapies and clinical care coordination services despite most Country SA PHN regions having some level of need

Where Psychologists are available, extended waiting periods exist and/or high cost gap payments prevent consumers from attending their services.

The need for psychological therapies is growing consistently, whereby client access for moderate mental illness increased significantly from approximately 3800 to 6800 between 2016-2018.

Youth Mental Health

Youth mental health services are directed at children or young adults aged up to 25 years. Services range from Low Intensity, across Psychological Therapies and are primarily delivered via Headspace centres.

Workforce shortages and retention of appropriately qualified staff impact delivery of Youth specific mental health services in the country region. These limitations affect all aspects of health in the region and are not specific to youth mental health (146, 159). Commissioned service providers and tertiary partners across country region have identified heightened and escalating demand for service resulting in extended wait times (160)

For youth aged 12-25 years, Headspace is the predominant mental health service provider across the region with eight operational centres in the Country SA PHN region.

The 8 Headspace centres in Country SA PHN are located in:

• Port Augusta

• Berri

• Murray Bridge

• Mount Gambier

• Victor Harbour

• Port Lincoln

• Whyalla

• Mount Barker (148)

In the 2021-22 period, Headspace delivered 12,203 occasions of service to 2,935 young persons, including 1,631 new clients. This represents an increase of 863 clients since 2017-18 (161). Occasions of service was highest for centres located in:

• Mount Gambier (1,874)

• Mount Barker (1,809)

• Port Augusta (1,792) (161)

Integrated and coordinated holistic care

Integrated care is the organisation and delivery of health services to provide seamless, coordinated, efficient care that responds to a person’s health needs. An individual engaged within an integrated care model will receive a continuum of care inclusive of health promotion, disease prevention, diagnosis, treatment, disease management and rehabilitation coordinated across different levels and sites of care, accounting for comorbidities and external factors that influence ones health (144, 162).

Community consultation consistently identifies the lack of cohesive and integrated services and health provider communication across the care continuum.

Step up and Down Interface

For many rural communities, Emergency Departments are the only option for people experiencing an acute mental health crises(163). The national average wait for 90% of patients with mental health conditions was 11.5 hours compared to just 7 hours for physical conditions (163).

In SA, the average waiting time in an Emergency Department for a mental health crisis is 16.5 hours (163)

Currently help seeking at the emergency department (ED) for acute mental and behavioural care currently sits at 185 per 100,000 in remote areas compared to 101 in major cities, highlighted an issue in rural and remote regions (163).

The step up and down interface provides an intermediate level of care between the inpatient and community setting, used as a bridging support between pre and post-acute services (164). The step up and down services provide an alternative to hospital admission in addition to a support mechanism following hospital discharge, ensuring consumers remain supported through out.

The Mental Health Shared Care program aims to assist individuals with complex mental health needs to increase their capacity to manage their physical and mental health, avoid relapse through early intervention or the onset of acute symptoms(164). A key element of the service is the communication and integration between the services involved in a person’s care including their GP. In Country SA, the shared care locations are Port Augusta, Whyalla, Kadina, Murray Mallee, Berri, Mount Gambier, Adelaide Hills, Fleurieu and Kangaroo Island

The Clinical Care & Coordination (CCC) program is aimed at providing clinical care and coordination of services for an individual experiencing severe and persistent mental illness. Consultation and liaison may occur with primary healthcare providers, acute health, emergency services, rehabilitation and support services, family, friends, other support people and carers and/or other agencies that have some level of responsibility for the client’s treatment and/or well-being. In the 2021-22 period, Clinical Care Coordination (CCC) was delivered to 6,893 service contacts across the Country SA PHN region. CCC is delivered by 4 regional providers in: Port Lincoln, Barossa Hills Fleurieu, Yorke and Northern, Murray Mallee Coorong, Limestone Coast and the Riverland (161)

Community Voice – Mental Health

Face to Face consultations, paper based and online surveys in conjunction with community forums have been both participated in and facilitated by Country SA PHN to hear directly from the community, key stakeholders and service providers alike to ensure their thoughts and views are heard. The below summarises key community or stakeholder consultations conducted in the region over the past 6 years

1. Services that work together collaboratively

• Integrated service delivery, with holistic view on health to encompass all aspects of an individuals life

• Service providers talk to one another for a seamless referral pathway from low intensity to acute care

• A coordinated approach to the promotion of mental health and wellbeing and early-in-life intervention

2. Accessibility and meeting the needs of the population

• More mental health services based in rural and remote regions to reduce travel, distance, and time away from work

• Youth mental health specific services and trained health professionals within this field

• After Hours services – available outside 9-5 and on weekends and after work hours

• Confidentiality around seeking help in small communities, where everyone knows each other

• Utilising technology and digital media to reach those in more remote and rural communities

• Services and interventions which recognise that some population groups are at higher risk of having or developing mental health issues or have diverse needs

3. Improve community awareness and reduce stigma

• Forums and workshops for community members and health workforce, from basic to advanced knowledge bases (Mental Health First Aid, ASSIST, Question Persuade Refer)

• Improve knowledge and skills of health staff in rural and remote areas – particularly around the increased stressors experienced with drought, bushfires, and floods.;

• Having strategies in place and training for managers from all walks of life so people feel confident to disclose knowing they will be cared for by their employer

4. Simple and clear pathways of care

• Knowing where to go and that you will be referred to the right level of care

• Communication between providers, to ensure information is passed on rather than having to start from scratch at each level of care.

5. Importance of strong leadership, governance, planning and funding

• South Australians and organisations are seeking greater sustainability in funding models which support innovation, opportunities for collaborative or shared approaches to developing best practice in care delivery, and excellence in service provision

• Improved governance of services to ensure person-centred, recovery-focused and outcomes-oriented approaches

Health Needs – Suicide Prevention

While suicide is an infrequent occurrence in Australia, the effects and aftermath can be both traumatic and long-lasting for families and communities alike. Across Australia, people residing in rural and remote communities have a higher risk of suicide than those living in metropolitan areas. Particular rural communities across the state experience significantly higher rates of attempts and deaths, compared to the national and state averages (153).

Rural and remote South Australian communities are diverse with each varying in size, population dispersion, culture, ethnicity, proximity to other towns and regional centres, and other demographic factors (165). Rural communities face a higher threat of periods of adversity due to natural events including fire, drought and flood (165). When these occur, the wellbeing and economic security of rural communities are negatively impacted often for prolonged periods causing significant effects for the residents within these communities (165). Planning for the prevention of rural suicide at the local and regional level needs to take this diversity and variation into account.

In response to the growing rates of suicide in rural and remote communities, part of the Country SA PHN region was selected as one of the 12 National Suicide Prevention Trial sites in 2017. The trial brought significant resources, activity, and funding to areas of need throughout the Country North region of South Australia, including Whyalla, Port Augusta, Port Pirie, Port Lincoln and the Yorke Peninsula. The trial was placed at a regional level to respond to local needs and identify new learnings in relation to suicide prevention strategies. The trial has adopted elements of the Black Dog Institute’s LifeSpan model – a system-based approach to the delivery of suicide prevention services, targeting populations identified at a local level as ‘at-risk’.

The pathway to suicide is varied and complex, particularly so when comparing Indigenous and non-Indigenous Australians. Generally, Indigenous Australians are more likely to experience racism, disempowerment, cultural dislocation, increased rates of trauma and grief, involvement in the justice system and a myriad of physical illness and chronic disease (166). These factors in addition to high proportions living in rural and remote communities, further increases an individual’s risk of suicide and self-harm.

In 2020:

• Country South Australia had a higher rate of suicide compared with the greater Adelaide region

• Country SA saw a decrease in the age-standardised rate of suicide from 16.1 per 100,000 in 2019 to 15 4 per 100,000 in 2020

• Females accounted for 62.9% of intentional self-harm hospitalisations in Country SA PHN

• The highest age-standardised rate of death by suicide was in the Eyre Peninsula and South West (16.9), Yorke Peninsula (16.8) and Limestone Coast (17.6)

• Suicide accounted for 5.5% of all deaths of Aboriginal persons compared to 1.9% for their non-indigenous counterparts

• Twenty five percent of all deaths by suicide in Indigenous people were female, this was greater than that seen in the non-Indigenous population (23% females) (167).

Within Country SA PHN region, the highest rate of suicide was in Eyre Far West, Flinders Upper North and Yorke Peninsula, while the highest attempt rates were in the Limestone Coast, and Riverland Murray Coorong (168, 169)

Hospitalisation for Intentional Self Harm

In 2018-19, South Australia recorded 2,506 hospitalisations for intentional self-harm. The highest rates were in the Mid North, Outback and Murray Mallee regions (167).

Females are more likely to be hospitalized than males for intentional self-harm (152) based on intentional self-harm and hospital separations data. This difference is likely due to males being more than three times as likely to complete suicide than females.

Emergency Department presentations for intentional self-harm are difficult to capture because the recorded data is only for principal diagnosis and does not include an external cause code for intent. This makes it likely that many occasions of intentional self-harm are underestimated due to clinical coding limitations.

At-risk groups

The causes of suicide are complex. A range of factors can contribute to suicide and self-harm, however particular groups/communities are identified as being at a higher risk than others. Within Country SA PHN region rurality, gender, cultural background and age contribute to the most at-risk populations.

Rurality

Data on suicide and self-inflicted injuries in Australia shows that with growing remoteness there is an increased death rate from such causes (165). Country SA PHN is predominantly regional, rural and remote communities. The table below depicts the change in prevalence and rate of suicide from major cities to very remote communities within Australia (144)

The increased risk within rural communities relates to unique challenges, particularly economic and environmental circumstances including fire, floods and droughts within these regions (165). Such events can create, anxiety, loss of income, social isolation, increased familial conflict, mental illness and lowered resilience which in turn can increase suicide risk (144). Additionally, access to mental health service is limited in some rural communities, in turn reducing help-seeking and appropriate counselling or treatment options.

Gender

Males die by suicide at a greater rate than females, however females attempt suicide more often than males (151). In Country SA PHN region males accounted for 79% of all deaths by suicide, a ratio of more than 3:1 (168). Comparatively females accounted for the highest rates of suicide attempts and self-harm(170). This difference is likely due to males being more than three times more likely to complete suicide than females. This is not a difference in need for suicide prevention, but a reflection of lethality of mechanism (165)

Culture

In 2020, the suicide rate among Aboriginal and Torres Strait Islander people was approximately twice that of nonIndigenous Australians (167, 171). Factors specific to culture, racism and general health all contribute to these rates. Suicide was the second leading cause of death among male Aboriginal and Torres Strait Islander people in 2019 and 7th for females (171) The majority of suicide deaths Aboriginal people occur before the age of 35 and rates of self-harm within these communities are significantly higher than those observed within other communities (166). In accordance with national trends, males represent the majority of Indigenous suicides (151)

Suicide is a considerable issue for Aboriginal youth. Persons aged 15-24 years of age were over five times as likely to suicide as non-indigenous counterparts (165). Aboriginal youth currently account for 30% of suicide deaths in those under 18 years of age in Australia (165).

Community Voice – Suicide Prevention

Face to Face consultations, paper based and online surveys in conjunction with community forums have been both participated in and facilitated by Country SA PHN to hear directly from the community, key stakeholders and service providers alike to ensure their thoughts and views are heard.

Accessible Services

• Main barriers to accessing Suicide Prevention services: - Availability of services

- Limited access to integrated suicide prevention services within the region

- Waiting times - Distance of travel required to attend service

• Lack of targeted services for social minority groups such as lesbian, gay, bisexual, transgender, and intersex community (LGBTIQ+) people and people from CALD backgrounds

Follow up Care

• The risk of suicide attempts and death is highest within the first 30 days after a person is discharge from an ED or inpatient Psychiatric unit, yet in Country and regional areas, follow up care is limited

• Aftercare services are needed across the region – particularly Aboriginal aftercare services

Need for community training in suicide prevention

• More community suicide prevention training for the general public (e.g. ASIST)

• Training in risk assessment and safety planning is required for all of community and employers alike as identifying the at-risk person is inconsistent and often missed

• Communities and front-line worker need awareness raising and training

Workforce Collaboration

• Prevention services exist in some areas but are not well integrated or known

• Appropriate service mapping is required and needs to be transparent and show how services interconnect