Needs Assessment 2017-2018 by CSAPHN

Needs Assessment Report 2017-2018 November 2017

Country SA PHN Needs Assessment Report November 2017 Page 1 of 46

Section 1 â&#x20AC;&#x201C; Narrative Needs Assessment process and issues The Country SA PHN (CSAPHN) needs assessment uses an iterative approach where information gained between submissions is used to refresh analysis and triangulation for determining opportunities for action. As expected, over time, large parts of the documentation will remain static between updates. This reflects the incremental shifts in population demographics, health risk behaviour, disease prevalence and improvements in health outcomes in response to implemented initiatives or other factors. CSAPHNâ&#x20AC;&#x2122;s needs assessment process approach, integrates data available publically or obtained confidentially from the Australian Department of Health and key partners such as Country SA LHN with additional evidence collected through stakeholder consultations. An overview of the principal data sources used is given in Appendix 1 of the Needs Assessment Data Report - November 2016 (see attachment). A holistic look at demographic, health, and health service patterns has been undertaken to identify locations and populations with particular health and service needs as well as country SAwide priorities. The data used to inform this report is presented primarily by Statistical Area Level 3 (SA3); a census statistical geography that provides a framework for data analysis at a regional level; and/or by Local Government Area (LGA). During the 2016 - 2017 period, Mental Health, Alcohol and Other Drug community consultations were conducted with both service providers and community members providing context to data already gathered through the literature. To investigate needs and service gaps specifically related to alcohol and other drugs, in addition to utilising the PHN Drug and Alcohol toolkit and secure data, CSAPHN formulated a targeted survey focusing on identified parties and in scope interventions. Moreover, CSAPHN continues to engage in ongoing consultations and joint development of service delivery models and resource distribution with Drug and Alcohol Services South Australia and the SA Network of Drug and Alcohol Services through the Drug and Alcohol Service Planning Model Working Group. The priority level of the key population health and service issues has been summarised in the Needs Assessment Priority Matrix - November 2016 (see attached). In addition, the needs assessment process highlighted the importance of investigating chronic conditions and risk factors beyond the national priority health areas to fully realise opportunities for primary and secondary prevention in future CSAPHN work. Conditions such as Chronic Kidney Disease (CKD) which shares common risk factors and is associated with type 2 diabetes and cardiovascular disease, and Chronic Pain which can relate to a wide range of other chronic diseases including the two afore mentioned, arthritis, cancer and depression or result from another unresolved issues or injury. However, the magnitude of these two disease burdens and service needs are likely to be underestimated owing in part to the difficulty of timely diagnosis along with difficult to obtain, accurate statistics, especially at the small area level. Moreover, the interrelated nature of socioeconomic determinants, risk factors, and health status suggests that acting on any one of the principal needs identified in this report will positively impact on other needs, stated or unstated. Conversely, missing a key need relevant to service access, even where the actual need is located further upstream and not necessarily within the purview of the PHN, risks diminishing the success of programs designed to increase service availability and appropriateness. Remote regions within our catchment are predominantly home to higher concentrations of disadvantaged populations than the rest of South Australia and Australia. CSAPHN sees a need to investigate and advocate for services that are critical to improving health and wellbeing but are possibly of lower priority for PHNs. The issue of transport availability as a determinant of access to service may serve as a case in point; raised consistently across the region as an important issue impacting on health Country SA PHN Needs Assessment Report November 2017 Page 2 of 46

service access and utilisation, financial and opportunity cost of travel to obtain services and options to mitigate these. Continuation of activities in a local setting, supplemented with or totally replaced with technological solutions, needs to be investigated as part of future comprehensive needs assessment cycles. Requirements for further developmental work relate predominantly to (1) continuing comprehensive, in depth service mapping; (2) obtaining and analysing quality practice data from a range of GP practices throughout the region, and (3) building and refining stakeholder engagement structures that enable ongoing consultation. All three pieces of work form the foundations to ongoing CSAPHN activities. Additional Data Needs and Gaps Data collection and analysis is an ongoing process that represents an integral part of systematic stakeholder engagement and collaboration in the PHN commissioning cycle. As pointed out above, there are a number of gaps in the data currently available to Country SA PHN, some of which will be addressed through continual service mapping. In particular, this includes data on private providers in the allied health, aged care and disability spaces for which assessment of the actual level of care and operating hours made available by providers including that active in the after-hours period. Such a detailed collection of community-specific data on volume and quality of service provision will enable a finer distinction between service utilisation and service needs. This will also enable provision of further assessment of large remote statistical and governance areas with considerable internal variation of health and demographic data. In addition, an annual comprehensive GP and Allied Health Engagement Surveys covering the entire CSAPHN region will gain further reach as key data is collected through the service mapping process progresses. Stakeholder consultations have been integrated into the agreed mission of both Clinical Councils and the Community Advisory Committee (Primary Health Care Committees or PHCCs) and will continue to contribute significantly to the ongoing needs assessments. These permanent structures will provide a springboard for periodic consultations with the wider community to obtain a broad local perspective, including the views of hard-to-reach consumers. Meaningful engagement and consultation with consumers, carers, local councils, and localised service providers are essential to provide context and add affirmation to data and priorities obtained through more traditional research and needs analysis modalities. In addition, the translation of the results from the needs assessment into service design and commissioning depends on an accurate understanding of existing local context. With PHN responsibilities in the areas of mental health, suicide prevention and alcohol and other drugs programs, there has been focus on sourcing locally relevant health data and a detailed understanding of the spectrum and capacity of services provided to inform commissioning processes. The drug and alcohol sector is an area in which PHNs have only recently started to establish themselves in as key partners and further and continuous consultation and engagement is needed for joint planning with LHNs and state-based drug and alcohol services. The continuation of recent efforts will be crucial to ensuring effective and informed commissioning not only in general and mental health, but also in the new priority area of alcohol and other drugs. Mental disorders and substance use frequently occur together and can interact negatively on one another. While this is commonly known, a specific gap became apparent with regard to drug and alcohol and mental health comorbidity and relevant service provision within our current data streams. Additional comments or feedback Our geographically large and demographically diverse region creates some interesting complexities for a needs analysis. The analysis describes an overall picture of the needs of the region, though perhaps in a somewhat generic way. The larger the area of review the more the generic nature becomes apparent and this may obscure communities of considerable need. Whole communities exist as what could be described as â&#x20AC;&#x2DC;enclaves of needâ&#x20AC;&#x2122; within regions that do not fit the same picture. As such, this Country SA PHN Needs Assessment Report November 2017 Page 3 of 46

work needs to be a ‘living’ or ‘rolling’ activity, perhaps over a longer period. In managing this the CSAPHN has provided a general needs analysis of the regions covered, but works at a more local level with our PHCCs to identify needs targeted to individual or small groups of individual communities. Context for consideration for our region, is that with an area greater than 900,000 square kilometres the population density is fewer than 2 persons per square kilometre. This is a relatively consistent figure. The population density dropping immediately from the outer suburbs to less than 1 person per square kilometre. CSAPHN is with Far West Qld PHN as one of only two PHNs with no communities within the top 50 population centres in Australia. This even takes into account the small suburban areas within the region that fringe Adelaide. The region comprises over 100 communities of significant size, with only 10 communities over 10,000 persons and the greatest remainder, in the range of approximately 500 to 2000 persons. The goal over time is to create a snapshot for each of these perhaps 100 communities. This will expose the ‘enclave’ communities and their particular needs and other idiosyncrasies. Given the geographically large and demographically diverse region it serves, CSAPHN considers the assessment presented here a stepping stone towards continual, in depth assessment of local context, needs and priorities. In particular, the baseline work will assist with the comprehensive needs assessment to be undertaken in the next financial year. At this point in time, CSAPHN will also be in a better position to assess incremental shifts in service needs as a result of targeted commissioning beyond the continuity of service prioritised up to now.

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Section 2 – Outcomes of the health needs analysis This section summarises the findings of the health needs analysis in the table below

Outcomes of the health needs analysis Identified Need

Key Issue

Description of Evidence

Aboriginal Health *All needs and issues listed in the following sections also apply to Aboriginal and Torres Strait Islander people and communities, and there are often additional challenges to meeting these needs within these populations*

High overall burden of disease compared to non-Aboriginal and Torres Strait Islander population, associated with acknowledged systemic disadvantage and increased rates of chronic disease characterised by : •

High rate of hospitalisation, including potentially preventable hospitalisations • Increased perinatal and child mortality • Decreased life expectancy • Health disparities increase with distance from metropolitan areas. Chronic disease areas included: ∙ Circulatory Diseases • Leading cause of mortality in South Australia at a rate of 218.2 per 100,000 and a ratio of 1.2 to the nonAboriginal population with a rate difference of 41.0. • Age standardized hospitaliations by age indicates a younger profile ∙ Acute Rheumatic Fever and Rheumatic Heart Disease • The prevalence of ARF and RHD in South Australia for Aboriginal and Torres Strait Islander people was 3.1 per 1000

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• Leading issue in priority matrix • Consultation with and feedback from Aboriginal communities and health workers. • CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3 • AIHW national reports on Aboriginal and Torres Strait Islander people health and welfare (AIHW 2015c, 2015d) • ABS Australian Aboriginal and Torres Strait Islander Health Survey • AIHW ‘Closing the Gap Clearinghouse’ Report: Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander People (AIHW 2014b) • Wardliparingga Aboriginal Research Unit South Australian Aboriginal Heart and Stroke Plan (SAHMRI 2016) • ACIR data (compiled by both SA Health and NHPA) immunisation rates for Aboriginal children by SA3 • NHPA Healthy Communities: Immunisation rates for children in 2014–15

Outcomes of the health needs analysis • SA3 Locations included: o Outback - North and East o Eyre Peninsula and South o Mid North ∙ Diabetes • Prevalence rate of 24.4% in country South Australia, increased to 40.2% for remote South Australia for all types of Diabetes • Gestational diabetes was highest in the remote Far West at 10.7% of all births • One of the leading causes of avoidable mortality in South Australia for Aboriginal people, is experienced at 3.2 times the rate of the non-Aboriginal population • Diabetes complications is the third highest rate of potentially preventable hospital admissions at a rate of 6.6 per 1000 and a rate of 1.6 per 1000 for nonAboriginal people this is a rate ratio of 4.2 and rate difference of 5.1. The average number of time spent in hospital is 6.2 days for Aboriginal people and 5.3 for non-Aboriginal people. ∙ Chronic Kidney Disease • The incidence of End Stage Kidney Disease in Aboriginal South Australians is occurring at a rate of 57.8 per 100,000 versus 8.5 per 100,000 in the nonAboriginal population. This is a rate ratio of 6.8 and a rate difference of 49.3.

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• AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW. • Gibson O, Eltridge F, Luz Z, Stewart H, Westhead S, Zimmet P, Brown A. The South Australian • Aboriginal Diabetes Strategy 2017 – 2021. Wardliparingga Aboriginal Research Theme, South Australian Health and Medical Research Institute: Adelaide. 2016. • South Australian Aboriginal Cancer Control Plan 201621, South Australia Department for Health and Ageing.

Outcomes of the health needs analysis ∙ Cancer • Second highest rate of leading causes of mortality at 232.1 per 1000,000 compared to a rate of 171.6 per 100,000 with a rate ratio of 1.4 and a rate difference of 60.6. • Stage of diagnosis occurring later • Survivorship rates lower ∙ Respiratory Disease • COPD is one of the leading avoidable mortality reasons

• Hosptilisations rates at 2.2 times that of the nonAboriginal population. Eye Health

Preventable diseases and conditions of the eyes which lead to blindness and vision loss in the South Australian Aboriginal population is an issue, particularly regarding diabetic patients who have greater risk of cataract and diabetic retinopathy. These are the second and third leading causes of blindness and vision loss. In South Australia 22.2% of Aboriginal South Australians reported eye/sight problems. The rates in nonremote areas included 21.3% and remote areas included an estimate of 26.2%.

Ear Health

In South Australia in 2012-13 hearing problems reported as experienced by Aboriginal people are occurring at a much higher rate found in other states and territories at 15.8. The proportion in remote areas at 16.2% in remote areas. The national reported problems with hearing in 2012-13 was 12.3%. Otitis media is the most common issue within Aboriginal children in South Australia.

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• AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW. • AIHW 2016. Indigenous Eye Health Measures, Canberra: AIHW. • AIHW 2011. Indigenous Eye Health Report, Canberra: AIHW. • The Retinal photography with a non-mydriatic retinal camera in people with diabetes, MSAC application no. 1181 Assessment report submitted to the Medicare Service Advisory Committee. • AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW.

Outcomes of the health needs analysis Immunisations

Vaccination occurs at a higher rate for Aboriginal children at age 5 years, however is lower in other age groups. Vaccinations for people who are high risk of influenza and pneumococcal hospitalisations such as people with a diagnosis of CVD, diabetes or respiratory disease are low. Vaccinations for HPV is also occurring at a lower rate for Aboriginal South Australians.

Early Detection and Treatment

In the 2015-16 financial year in the CSAPHN region 5,538 (26%) country Aboriginal South Australians had a 715 Health Assessment. There are two SA3 regions which exceed this rate. • Eyre Peninsula and South 29% • Outback - North and East 62%

• AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW. • ACIR data (compiled by both SA Health and NHPA) immunisation rates for Aboriginal children by SA3 • NHPA Healthy Communities: Immunisation rates for children in 2014–15 • NHPA analysis of National HPV Vaccination Program Register • MBS Data by PHN and Item for 2012-13 to 2015-16 • MBS Data by SA3 and Item By for 2012-13 to 2015-16. • AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW.

Cancer screening for Aboriginal South Australians is low in comparison to non-Aboriginal South Australians across: • Breast • Cervical • Prostate • Bowel Access to services

There is a general lack of access to services for Aboriginal and Torres Strait Islander people with 24.4 per 100 people accessing doctor consultations in South Australia. Of those accessing services, there is a rate ratio of accessing GPMP and TCAs at 1.5 to non-Aboriginal people, however follow-up services and access to Allied Health and Specialist care remains an issue.

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• AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW.

Outcomes of the health needs analysis Access to prescription medication remains an issue with reduced levels of PBS medications being filled. Cost is cited as an issue. In addition, there is a lack of access to hospital procedures, Aboriginal people tend to stay in hospital in shorter periods and discharge themselves against medical advice. Cultural Competency

In the 2012-13 Australian Aboriginal and Torres Strait Islander Health Survey, 97.3% of Aboriginal or Torres Strait Islander people felt they were treated unfairly in the last 12 months. This is different to the 2014-15 National Aboriginal and Torres Strait Islander Social Survey where 44.8% people felt they were treated unfairly in the last 12 months. 19.5% had indicated by they were treated unfairly by Doctors, nurses or other staff in hospitals or doctors surgeries. In 2012-13, there were 29.5% of Aboriginal South Australians who needed to go to a health provider but didn’t 33.3% provided Cultural appropriateness of the service as the reason.

• AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW.

Potentially Preventable Hospitalisation rates for chronic conditions are higher than the state average in most regions, with the Outback region almost double the South Australian rate.

• Leading issue in priority matrix • South Australian Monitoring and Surveillance System (SAMSS) survey of residents aggregated by SA3 • National Diabetes Services Scheme (NDSS) registrations by LGA and SA3 • Public Health Information Development Unit (PHIDU) cancer screening participation and premature mortality by LGA • NHPA analysis of cancer screening rates • CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3 • AIHW Chronic Disease portal (AIHW 2015a)

Chronic Disease

Chronic disease rates in country SA are consistently above the state average • High rates of Diabetes in CSAPHN overall. The SA 3 level areas which had rates above the state rates included Mid North, Lower North, Yorke Peninsula, Gawler-Two Wells, Murray and Malle, Eyre Peninsula and South West and Outback North and East.

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Outcomes of the health needs analysis • High rates for Respiratory Disease in CSAPHN overall. The SA level areas which had the highest rates above the state level included Mid North, Murray and Mallee, Eyre Peninsula and South, Limestone Coast, Lower North, Gawler- Two Wells, Yorke Peninsula and Outback North and East. • High rates of cardiovascular disease in the Yorke Peninsula and Outback • High rates of arthritis and osteoporosis in the Yorke Peninsula and Mid North.

• Department of Health Chronic Disease portal (Australian Government Department of Health 2015) • AIHW report: ‘Mortality from asthma and COPD in Australia’ (AIHW 2014c) • AIHW report: ‘Cardiovascular disease, diabetes and chronic kidney disease – Australian facts: Prevalence and incidence’ (AIHW 2015b) • AIHW overview of cancer screening by PHN (AIHW 2016b)

Chronic Kidney Disease – national trends • Under diagnosis of chronic kidney disease (estimated 9 out of 10 cases not diagnosed) • Prevalence increases with age and level of disadvantage. • End stage kidney disease (requiring dialysis) prevalence twice as high in remote areas compared to metropolitan areas. Cancer • Prevalence of cancer highest in the Yorke Peninsula • Cancer mortality highest in remote areas • Cancer screening rates lowest in the Outback (SA4) and consistently low in the Murray and Mallee • HPV vaccination rates very low in the South Australian Outback (SA4) region.

Chronic Disease / Risk Factors / Health Lifestyles Rates of high blood pressure, high cholesterol, insufficient physical activity, and unhealthy weight all highest in the

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• Leading issue in priority matrix • Key theme in stakeholder discussions

Outcomes of the health needs analysis • • • •

SAMSS survey of residents aggregated by SA3 PHIDU estimates of risk factors AIHW Risk Factor portal (AIHW 2016c) AIHW 2017. Aboriginal and Torres Strait Islander health performance framework 2017: supplementary online tables. Cat. no. WEB 170. Canberra: AIHW.

Childhood immunisation rates below national target (95%) in all regions except Yorke Peninsula (5 years age). Rates are lower again among Aboriginal children. HPV vaccination rates for 15 year old girls is very low in the South Australian Outback region, one of the lowest rates nationally.

• • • •

Issue of concern in priority matrix NHPA analysis of ACIR data by SA3 SA Health reporting of ACIR data NHPA analysis of National HPV Vaccination Program Register by SA4

Financial and time costs borne by patients to attend regular/recommended appointments.

• AIHW report on rural, regional and remote health system performance indicators (AIHW 2008) • Proportion of region classified as outer regional, remote or very remote by ABS classification of remoteness • Issue of concern in priority matrix • CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3

Yorke Peninsula, and above SA averages for almost every region. Smoking rates and alcohol risk highest in the Mid North and Eyre Peninsula. Rates of fruit and, particularly, vegetable consumption are very poor throughout South Australia, including CSAPHN regions. Higher rates found in the Aboriginal population when compared to non-Aborigina in all areas Immunisation

Remoteness

Increasing rates of morbidity and mortality with increasing remoteness.

Potentially Preventable Hospitalisations

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Outcomes of the health needs analysis Potentially preventable hospitalisation rates are above the state average in all regions except the Lower North and Adelaide Hills. Rates in the Outback, North and East are almost double the state and national rates, while the Adelaide Hills are around three quarters of the state average.

• NHPA analysis of the Admitted Patient Care National Minimum Data Set

Increased risk of age-related hospitalisation • Increased risk of falls • Increasing rates of Dementia • Increased rates of chronic disease and multiple comorbidities • Social isolation.

• Leading issue in priority matrix • Government aged care portals and publications (AIHW 2016a, Australian Government Department of Social Services 2015) • My Aged Care website • CSAPHN analysis of SA Health inpatient admissions database by LGA and SA3

Ageing Population

RACF residents at higher risk of transfer to an acute facility for ‘low level’ health events. Culturally and Linguistically Diverse Populations Ageing Culturally and Linguistically Diverse populations in the Riverland. Increasing number of humanitarian visa recent arrivals in the South East and Murray Bridge, primarily from Africa and the Middle East. Stigma around illness – especially Mental Health – in some CALD populations. Low level of health service utilisation. High risk of hospital readmission for CALD patients.

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• Issue of concern in priority matrix • PHIDU analysis of ABS Census 2011: persons born overseas reporting poor proficiency in English, by LGA • CSAPHN analysis of Department of Immigration and Citizenship Settlement Reports by LGA • Health Performance Council Scoping Study (Principe 2015) • FECCA review of Australian Research on Older people from CALD backgrounds (FECCA 2015)

Outcomes of the health needs analysis Language and cultural barriers to effective use of health services in general and medications in particular.

Child Development Developmentally vulnerable children are at risk of poor health outcomes over life span • Over 2/3 of children in the APY lands are vulnerable on 2 or more domains of the Australian Early Development Census • Communities in the Eyre and Western region more likely to be above the state and national average of children developmentally vulnerable in 2 or more domains • Port Augusta and Murray Bridge both have a higher proportion of children developmentally vulnerable on one or more domains.

• Australian Early Development Census – 2015 results by communities • Issue of concern in priority matrix • Stakeholder consultation and feedback

Early childhood development is perceived to be an issue across the CSAPHN region. Other Population Health Factors Socio-demographic disadvantage • High rate of single parent families in the Mid North, Yorke Peninsula and Riverland • Homelessness is not well recognised or documented throughout the region • Affordability of health care for disadvantaged people

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• • • • • •

PHIDU analysis of ABS Census 2011 PHIDU analysis of births and deaths registry data PHIDU analysis of DSS data The Kirby Institute, 2015 Stakeholder consultation and feedback Issues of concern in priority matrix

Outcomes of the health needs analysis • Health literacy is perceived to be an issue across the entirety of the CSAPHN catchment. Of particular concern are those areas identified as being of low English proficiency and where there are high rates of disadvantage. • Concentration of disadvantage in Peterborough, Coober Pedy, Port Pirie, the APY lands and other remote Aboriginal communities. Perinatal health • Infant mortality highest in the APY lands, followed by Port Augusta and Murray Bridge • Child mortality rates are generally below metropolitan rates, but not reported for many areas due to low numbers • Higher proportions of both low birthweight babies and mothers who smoked during pregnancy exist in Port Augusta, followed by the Outback region. Pregnancy smoking rates also high in Peterborough and Ceduna. Disability and carers • Higher proportion of people with a disability living in country SA than metropolitan Adelaide. Sexual Health • Aboriginal and Torres Strait Islander populations have higher rates of blood borne virus and sexually transmissible infections, including HIV, Hepatitis C, Hepatitis B, gonorrhea, chlamydia and syphilis.

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Outcomes of the health needs analysis Mental Health Appropriately Support People with or at risk of mild mental illness through development and/ or commissioning of low intensity mental health services

**The statistics and issues reported throughout this section are heavily influenced by socio-economic disadvantage and population structure, especially where there is a high proportion of Aboriginal and Torres Strait Islander residents

Remote, rural and regional communities face a range of stressors unique to living outside of a metropolitan centres. Generally demographics reveal lower socioeconomic status, reduced access to services, difficulties retaining a health workforce, greater exposure to natural disasters, increased distance between communities, reduced access to transport and fewer employment opportunities all of which influence mental health. Mental Health and Psychological Distress Mental health conditions are self-reported in high proportions across the region, generally increasing in prevalence with increasing remoteness. The highest rates within the Country SA region were for the following areas, all of which were above the state average • Lower North • Mid North • Yorke Peninsula • Limestone Coast. Psychological distress can have a significant impact on an individual’s life and correlates with numerous mental health disorders. Furthermore, increased psychological distress is strongly associated with numerous factors unique to country region. Within the Country SA catchment all SA3 regions had rates of self-reported psychological distress higher than the state average but one (Outback-North and East). This is in contrast to the 2014-2015 figures when only had three SA3’s recorded

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• Leading issue in priority matrix • Key area of concern in stakeholder consultation and feedback • SAMSS survey of residents aggregated by SA3 • Characteristics of people using mental health services and prescription medication, 2015 ABS • SA Health Hospital Separations data 2015-16 • Estimated resident population 2016. • ATAPS MDS data 2015-16 • AIHW: Healthy Communities: Hospitalisations for mental health conditions and intentional self-harm

Outcomes of the health needs analysis rates higher than the state average. The highest rates of psychological distress within the country SA region are: • Gawler –Two Wells • Murray and Mallee • Mid North Diagnosed vs Undiagnosed Mental Illness Low proportions of reported mental illness in the Outback North and East (SA3) contradict the high rates of hospitalisations for mental health related conditions. This suggests rates of undiagnosed mental illness rather than lower occurrence. Low Intensity Services Delivered For the 2016 period, commissioned Low Intensity services saw 133 clients. Within the region, approximately 111,949 persons are identified as at-risk, equating to 0.1% of the target population receiving services. Support Region specific, cross sectoral approaches for children and young people with, or at risk of mental illness, including those with severe mental illness being managed in primary care

Youth Mental Health Service aims to better engage young people and work with them to develop the skills and supports they need to manage mental health distress and enjoy the best health possible. Youth Mental Health Service provides a range of services to young people with mental health issues, including: • mental health assessment and care planning • individual therapy, group work and family work • Care Coordination • in-patient care including step-down care • physical assessment • alcohol and other drugs assessment

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Outcomes of the health needs analysis • co-care with GPs, partner agencies and other service providers • consultation and liaison services to support youth and community services • referrals to other services/agencies as appropriate Child 0-11 years Mental Health 1 in 7 young people aged 4-17 years were assessed as having had a mental health disorder(s) in the previous 12 months. The main treatment services utilized for the younger child cohorts were psychological therapies. ABS census statistics highlighted 19.3% of this age cohort as accessing MBS subsidised mental health-related services, which is equal to the national proportion. Non PHN commissioned services targeting this age cohort include Child and Adolescent Mental Health Service (CAMHS) whom currently have 11 country based services in the region (for children 0-15 years). Youth 12-24 years Mental Health Headspace For youth aged 12-24 years, Headspace is the predominant mental health service provider across the region. Headspace is the National Youth Mental Health Foundation providing early intervention mental health services to 12-25 year olds, along with assistance in promoting young peoples’ wellbeing. Headspace undertakes a range of activities to increase the awareness of services and how to access them

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Outcomes of the health needs analysis among young people, their families, friends and the broader community. Headspace has five operational centres in the Country SA region • Port Augusta • Berri • Murray Bridge • Mount Gambier • Whyalla An additional Headspace outreach service is currently being developed in Mt Barker Correspondingly, ABS census statistics reported 11.4% of the youth cohort were accessing MBS subsidised mental healthrelated services, which was slightly below the national proportions. Child and Youth Mental Health Services Delivered Across the five Headspace centres, there were a reported 7,012 occasions of service, addressing the needs of 1,496 young people with approximately 978 new clients. Child and Youth ATAPS services were delivered across five of the eleven Country SA regions (Adelaide Hills, Lower North, Eyre Peninsula, Fleurieu- Kangaroo Island and Murray and Mallee) • For the 0-11 age cohort, 32 services were provided to 10 patients overall, 10.6 occasions of service per client.

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Outcomes of the health needs analysis • For the 12-24 age cohort, 1,722 services were provided to 466 patients overall, 3.6 occasions of service per client. Mental health support specifically targeting youth and younger people is limited across the Country SA region. Key reasons include: • Clients experience considerable waiting periods due to low service availability • Limited number of practitioners, specifically skilled in youth mental health. • Difficulties retaining rural/regional workforce Resilience in rural and remote communities and increased stigma around mental health Address service gaps in the provision of psychological therapies for people in rural and remote areas and other under-serviced and/or hard to reach populations

Psychological Therapies and ATAPS Psychological therapies are delivered to mild to moderate groups within the stepped care approach, services commissioned under this level of intervention within a stepped care approach must be evidence based for the population group being targeted The Country SA PHN had Psychological therapies delivered by mental health professionals to 3,190 clients, equating to 4.8% of the estimated population with mild to moderate mental health needs. For ATAPs, the Adelaide Hills region reported the highest occasions of service for clients at 4.4, followed by the Murray and Mallee (4.2) and Limestone Coast (4.1). The lowest occasions of service was in the Mid North with 2.6 sessions per client.

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Outcomes of the health needs analysis Better Access (MBS) The Better Access initiative aims to improve treatment and management of mental illness within the community. The billing of all mental health provided services by either a GP or an Allied Mental Health professional was highest in the Gawler- Two Wells region and lowest in the Mid North, with 2.3 and 1.1 sessions per client respectively.

Commission primary mental health care services for people with severe mental illness being managed in primary care, including clinical care

∙

GP Mental Health: For the CSAPHN, GP mental health sessions ranged between 1.1 sessions per client in the Adelaide Hills to 1.4 sessions per client in the Lower North.

∙

Allied Mental Health: For the CSAPHN, Allied mental health sessions ranged between 3.1 sessions per client in the Adelaide Hills to 3.1 sessions per client in the Outback - North and East. However, the Eyre Peninsula, Lower North, Mid North and Yorke Peninsula had no recorded sessions.

∙

GP Mental Health Care Plans:The preparation of GP mental Health care plans per 1,000 population was highest in the Gawler- Two Wells region, followed by Fleurieu – Kangaroo Island. Correspondingly, the Mid North and Outback – North and East had the lowest rate of preparation per 1,000 population.

Mental Health Related Hospital Separations Mental health hospitalisations are a method for measuring unmet health need due to the acute nature of a hospitalization being a proxy of the gap between known prevalence and

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• Leading issue in priority matrix • Key area of concern in stakeholder consultation and feedback • SAMSS survey of residents aggregated by SA3

Outcomes of the health needs analysis coordination for people with severe and complex mental illness

available/suitable treatment options. If client needs escalate beyond service availability or appropriateness, they become visible as acute hospital admissions (and potentially also drug and alcohol, and self-harm hospitalisations). The highest average annual rate of mental health related hospital admissions was in • Outback North and East SA3 • Murray and Mallee SA3 • Mid North SA3. Females were admitted to hospital for mental health issues slightly more often than males. The Murray and Mallee region had the highest proportion of admissions for both males and females in the region, followed by the Outback-North and East and the Mid North regions Specific mental health conditions were varied in type of admissions across the CSAPHN. These are summarized by SA3 below: • Schizophrenia and other psychotic disorders rates were highest in Outback North and East followed by Murray/Mallee and Eyre Peninsula and South West • Depressive Disorders rates were highest in the Mid North, followed by Murray and Mallee, and Outback North and East • Post-Traumatic Stress Disorder and other Stress Disorders were highest in Murray and Mallee and Mid NorthAnxiety Disorders rates were overall highest in females in the, Yorke Peninsula, Mid North and Fleurieu Peninsula – Kangaroo Island.

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• Characteristics of people using mental health services and prescription medication, 2015 ABS • SA Health Hospital Separations data 2015-16 • Estimated resident population 2016. • ATAPS MDS data 2015-16 • AIHW: Healthy Communities: Hospitalisations for mental health conditions and intentional self-harm

Outcomes of the health needs analysis Mental Health related hospitalisations • In the Country SA PHN region, 5,430 hospitalisations and 48,525 bed days were recorded for mental health related hospitalisations. • Anxiety and stress disorder related admissions made up 23% of all mental health hospitalisations, followed by depressive episodes (19.7%), and drug and alcohol use (15.9%). Of the 48,525 bed days recorded, 19.9% were for schizophrenia and delusional disorders, 17.7% for depressive disorders, and 17.2% for bipolar and mood disorders. Psychiatry The state average for MBS Psychiatry services is 5.8 sessions per client. For the CSAPHN, only the Adelaide Hills (6.6 sessions per client) was above the state average, while all other SA3s were below the state average. The lowest average services for MBS Psychiatry was the Eyre Peninsula and South West (average 2.9 sessions per client), followed by ∙ Outback North and East (3.1 sessions per client), and ∙ Murray and Mallee (3.2 sessions per client). Clinical Psychology The stage average for MBS Clinical Psychology services was 4.3 sessions per client. For CSAPHN, access to MBS Clinical Psychology services ranged between an average of 3.5 sessions per client in Outback North and East to an average of 4.4 sessions per client in Adelaide Hills. SA3 regions with the lowest average services were • Limestone Coast,

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Outcomes of the health needs analysis • Yorke Peninsula, • Murray and Mallee • Outback North and East. Clinical Care Coordination The Country SA PHN commissioned Triple C services saw 500 clients (3.3%) with severe and complex mental illness, equating to 3.1% of the estimated population with a severe or complex mental illness. Encourage and promote a regional approach to suicide prevention

Rates of self-harm and suicide increase with remoteness suggesting that there are very significant mental health issues to be addressed in rural and remote areas. Across all states and territories, the suicide rate was lower in capital cities compared to regional areas, in 2015 however the rate was similar across SA, this was due to the suicide rate increasing in Adelaide and decreasing in the country SA region. • The highest rate of suicide deaths in Australia was for men in the 85 years plus age bracket with 39.3 deaths per 100,000 in 2015. This rate was higher than the age-specific suicide rate observed in all other age groups, with the next highest age-specific rates being in the 40-54 year age groups. • In 2013-14, 882 hospitalisations and 2,810 bed days were due to Intentional Self Harm in South Australia. Country SA PHN Region In Country SA, from 2015 to 2016 rates of suicide have decreased across all age groups but the 24-44 age cohort, which have increased by 8%. Approximately 504 Suicides

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• ABS - Suicides, Australia, 2010 • SA Health Hospital Separations 2015-16 • NCIS – Intentional Self Harm Fatalities in Specified South Australia Local Government Areas (2007-2015) • Stakeholder consultation (Data Australian Bureau of Statistics (ABS) Catalogue 3303.0 Cause of Death Australia, 2015

Outcomes of the health needs analysis (2007-2015) and 1,830 Suicide attempts were reported within the Country SA PHN region between 2013 and 2016. The highest rate of suicide was in Eyre Peninsula and South West. Yorke Peninsula and Murray and Mallee, while the highest attempt rates were found in the Limestone Coast, Murray and Mallee and Eyre Peninsula and South West regions. The Outback North East- additionally experienced high rates of suicide, however limited data is available through their LGAs. Males in the Country SA region accounted for 79% of all deaths by suicide, a ratio of more than 3:1. However females accounted for the highest rates of suicide attempts. ABS statistics (2001-2010) show males in South Australia completed suicide at a rate (1.8 per 10,000) three times than that of females (0.5 per 10,000). With slightly higher rates for males in ‘Rest of SA’ (1.9 per 10,000) and slightly lower rates for females in ‘Rest of SA’ (0.4 per 10,000). Hospital Separations for Intentional Self-Harm Females are more likely to be hospitalized than males for intentional self-harm. 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. The most common mechanism used for suicide was asphyxiation (Hanging) compared to Poisoning in most cases of attempt. Areas above the CSAPHN annual average rate were: • Eyre Peninsula and South West • Yorke Peninsula

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Outcomes of the health needs analysis • Limestone Coast • Lower North • Outback North and East. Suicide Prevention/ aftercare services delivered Over the 2013-2016 time frame 840 males and 1393 females were identified through intentional self-harm hospital separations. Within the overall catchment the Murray Bridge (Murray Mallee) followed closely by Whyalla (Eyre Peninsula and South West. Additionally, for the reporting period 511 people were followed up by a PHN commissioned service following a recent suicide attempt. Enhance and better intergrate Aboriginal and Torres Strait Islander mental health services at a local level

Mental Health is a significant issue for Aboriginal South Australians. The third leading cause of death in South Australia, and the second highest when compared to other jurisdictions is the classification of External causes (V01–Y98) which incorporates Intentional self-harm. Aboriginal and Torres Strait Islander Mental Health The age-standardised rate of mental health disease burden of Indigenous Australians was highest in remote areas, while inner regional areas had the lowest rate of total disease burden for Aboriginal and Torres Strait people. Furthermore, mental health & substance use disorders were the leading contributor to overall disease burden in Major cities, Inner regional, and Outer regional areas. For those Aboriginal and Torres Strait Islander people who reported psychological distress in 2012-13: • 71.5% did not see a health professional in Inner Regional areas

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Outcomes of the health needs analysis • 77% did not see a health professional in Outer Regional • 83% did not see a health professional in Remote areas • 81.2% did not see a health professional in Very remote areas Culturally Appropriate mental health services delivered The Country SA PHN delivered Culturally appropriate services to 586 clients in the 2016-2017 reporting period, equating to 3 percent of the total Aboriginal and Torres Strait Islander population. The highest average annual rate for Aboriginal and Torres Strait Islander hospital separations was in the Murray/Mallee (SA3), Eyre Peninsula and South West (SA3) and Yorke Peninsula (SA3). Overall, mental illness and substance use resulted in 35 life-years lost due to burden of disease among the Indigenous population, making it the highest non-fatal burden of disease. Indigenous Suicide Prevention • Aboriginal and Torres Strait Islander South Australians completed suicide at a rate more than twice that of non-Indigenous South Australians, at 25.5 deaths to 12.5 per 100,000 respectively. Suicide was the second leading cause of death among Aboriginal and Torres Strait Islander men at a rate of 39.2 per 100,000

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Outcomes of the health needs analysis Aboriginal and Torres Strait Islander Drug and Alcohol Aboriginal and Torres Strait Islander people, of whom 70 per cent live in rural Australia, were 1.7 times more likely to have used illicit drugs recently compared to the general population. The highest average annual rate of AOD separations as the primary diagnosis for Aboriginal and Torres Strait Islander was the in the Yorke Peninsula SA3, other areas with high proportions included: • Murray and Mallee, • Lower North, and • Eyre Peninsula and South West

Alcohol and Other Drugs Drug and Alcohol is a relatively new field for the PHN, with commissioning beginning July 2016. The PHN strategic vision for Drug and Alcohol treatment aligns to the National Drug Strategy aiming to contribute to ensuring safe, healthy and resilient communities through minimising alcohol, tobacco and other drug related health, social and economic harms. • Prevalence of Lifetime illicit drug use ranged from 8% in the South East to 18% in the Outback North and East, while state prevalence was 14%. • Prevalence of recent methamphetamine use was highest in South Outback South Australia (4%) whilst state-wide prevalence was 2%. • Alcohol accounted for the highest proportion of AOD ED presentations, AOD hospital separations, specialised AOD treatment episodes, and reason for contacting ADIS. The South East SA4 particularly

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• • • •

Drug and Alcohol Stakeholder Survey SA Health Hospital Separations 2013-14 and 2014-15 Estimated resident population 2014. Estimated resident population Aboriginal and Torres Strait Islander 2011 • IHW 2016. Australian Burden of Disease Study: impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011 • Identifying the Gaps: Report on SA Drug and Alcohol Services Planning, DASSA • Drug and Alcohol Use among Select South Australian At-Risk Groups, NCETA, 2017

Outcomes of the health needs analysis accounted for 54% of the Country SA PHNs AOD ED presentations. â&#x20AC;˘ The Country PHN SA3 area will the highest prevalence of monthly risky drinking were Adelaide Hills (43%), Barossa (40% and Outback North and East (35%) â&#x20AC;˘ The highest prevalence of recent cannabis use was found in the Gawler- Two Wells and Barossa regions both 18% Alcohol and drug related hospital separations The highest annual rate of separations for Drug and Alcohol related primary diagnosis was the Outback North and East (SA3), for both males and females. Other notably high rates were in the Murray and Mallee, Eyre Peninsula and Mid North. Some high SA3 rates were driven by specific Local Government Areas. Coober Pedy (within Outback North and East SA3) had the highest rate of female drug and alcohol separations and Peterborough (within Mid North SA3) had the highest rate of male drug and alcohol separations. Withdrawal Management The actual number of withdrawal beds in Country SA was short of the estimated number by 17 beds (11% of the optimal). This shortfall is greater in percentage terms than in Metropolitan Adelaide. Furthermore, the actual number of withdrawal management separations in Country SA was short of the estimated optimal number by 654 (23% of the estimated optimal).

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Outcomes of the health needs analysis Residential Rehabilitation The actual number of residential rehabilitation beds fell short of the estimated optimal number (38% of the estimated optimal). This shortfall is a little less than that in Metropolitan Adelaide in percentage terms. Furthermore, the actual number of residential rehabilitation separations fell short of the estimated optimal number (24% of optimal). This shortfall was similar to that in Metropolitan Adelaide in percentage terms. *The DASSA data compiled the estimated optimal vs actual number of withdrawal management and residential rehabilitation beds for Country SA and Metropolitan Adelaide. Rurality and Drug Use â&#x20AC;˘ The 2013 NDSHS shows that the proportion of those who recently used an illicit drug varies with use increasing with growing rurality: Remote/Very Remote areas (18.7 per cent), Outer Regional (16.7 per cent) Inner Regional (14.1 per cent), and Major Cities (14.9 per cent). People living in Remote and Very Remote areas were twice as likely as people in Major Cities to have recently used illicit methamphetamines or amphetamines. Furthermore, the proportion of South Australians who had consumed alcohol at levels that increased their risk of disease or injury over a lifetime was higher in the country regions of the state (17% vs. 20%) â&#x20AC;˘ Illicit use of Ice (or crystal methamphetamine) has more than doubled, from 22% in 2010 to 50% in

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Outcomes of the health needs analysis 2013. In 2013, people living in Remote and Very Remote areas were twice as likely as people in Major cities to have recently illicitly used methamphetamines or amphetamines. Aboriginal and Torres Strait Islander Drug and Alcohol Aboriginal and Torres Strait Islander people, of whom 70 per cent live in rural Australia, were 1.7 times more likely to have used illicit drugs recently compared to the general population. The highest average annual rate of AOD separations as the primary diagnosis for Aboriginal and Torres Strait Islander was the in the Yorke Peninsula SA3, other areas with high proportions included: • Murray and Mallee, • Lower North, and • Eyre Peninsula and South West The high rates experienced are primarily attributed to lack of services on the lands and lack of continuity of care from acute to community settings. Furthermore, Aboriginal and Torres Strait populations experience high comorbidities with mental health. A higher proportion of Aboriginal South Australians drank at levels that increased their risk of injury from a single occasion of drinking, and also drank at levels that increased their risk over a lifetime. • Nearly one quarter of Aboriginal South Australians aged 15 years and over had used at least illicit one substance in the past 12 months

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Outcomes of the health needs analysis Mental and substance use disorders accounted for 19% of the total burden of disease for Aboriginal and Torres Strait Islander persons, the highest of all categories. The high population of Aboriginal persons in regional SA suggests these figures would further increase in these communities. Additionally, 22% of mental health disease burden was attributed to alcohol use among indigenous Australians.

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Section 3 – Outcomes of the service needs analysis Outcomes of the service needs analysis Identified Need

Key Issue

Description of Evidence

Aboriginal Health **All needs and issues listed in the following sections also apply to Aboriginal and Torres Strait Islander people and communities, and there are often additional challenges to meeting these needs within these populations**

Concentration of population in remote locations and the need for cross-border care provision and coordination in the Ngaanyatjarra Pitjantjatjara Yankunytjatjara lands, including the Anangu Pitjantjatjara Yankunytjatjara lands of SA and the Central Desert crossing the jurisdictions of Western Australian and Northern Territory. Mobility of Aboriginal peoples to and from communities, across state boarders, and into metropolitan or regional centres, add to the challenges of care coordination and maintaining accurate health records Systemic disadvantage in Aboriginal populations increases challenges in chronic condition care and management. This is further exacerbated in remote locations. Poorly managed conditions are likely to result in increased frequent use of the acute care health system by individuals.

• Leading issue in priority matrix • PHIDU analysis of ABS Census 2011 and ERP 2013 • AIHW ‘Closing the Gap Clearinghouse’ Report: Effective strategies to strengthen the mental health and wellbeing of Aboriginal and Torres Strait Islander People reports significant rates of poor social and emotional wellbeing outcomes.(AIHW 2014b) • Consultation with and feedback from Aboriginal communities and health workers • CSAPHN service mapping – geographic distribution of ACCHOs • RDWA Indigenous Medical Outreach programs ((RDWA undated c, undated d) • PHIDU, August 2016 update

Communities struggle to respond appropriately to individuals with mental health episodes, especially in the after-hours period. Lack of culturally appropriate service provision

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Outcomes of the service needs analysis • No operational ACCHO in the Riverland, Mid North, Lower North or Yorke Peninsula despite sizeable Aboriginal populations in several LGA in these regions, including; o Berri Barmera (estimated at 605 residents or 5.8% of the total population in 2015) o Mount Remarkable (estimated at 113 residents or 4.1% of the total population in 2015) o Port Pirie (estimated at 655 residents or 3.7% of the total population in 2015), and o Yorke Peninsula (estimated at 421 residents or 3.8% of the total population in 2015). • ACCHOs and AMS need support to operate effectively and become more sustainable. • Existing GPs (including Royal Flying Doctor Service RFDS), pharmacists and other mainstream services may require ongoing cultural competency training and facilitation to engage with Aboriginal and Torres Strait Islander -specific providers. Aboriginal Workforce

Low numbers of Aboriginal and Torres Strait Islander health professionals, in the CSAPHN region including:

• Health Workforce Data 2015

• General Practitioners at a proportion to total of 0.7% compared to a proportion of 0.45% in SA. • Nurses and Midwives at proportion of 1.54% compared to a proportion of 0.8% in SA. • Allied Health Professionals at a proportion of 1.7% compared to 0.7% in SA. High employement rates for health professionals. Health Workforce

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Outcomes of the service needs analysis There is a continued difficulty in attracting, recruitmenting and retention of GPs and allied health professionals to rural and remote areas • All of region except Port Augusta, Port Pirie and areas of the Barossa, Hills and Fleurieu is considered a GP district of workforce shortage • GPs often responsible for ED and acute hospital services as well as primary health care via General Practice • Many localities with limited or no services • Rates of Podiatrists, Psychologists, Registered Nurses, Optometrists, Physiotherapists below state averages in all CSAPHN regions, despite higher rates of chronic disease and mental illness • Rates of GPs, Pharmacists and Dentists below state averages in nearly all CSAPHN regions. • Long wait times to see a practitioner • Ageing of the rural and remote health workforce.

• Leading issue in priority matrix • HWA rates of health practitioners • DoH District of Workforce Shortage mapped via DoctorConnect • Key theme in all stakeholder engagement and feedback • NHSD and CSAPHN internal service mapping • SA Health inpatient data • HWA report: National Rural and Remote Health Workforce Innovation and Reform Strategy (HWA 2013) • RDWA Medical Outreach programs by specialty and location (RDWA undated a, undated b, undated c)

All of region apart from a few metropolitan periphery locations are considered a district of workforce shortage for Medical Specialists. Challenges in accessing business improvement and professional development opportunities for rural and remote practitioners. Impact on prescribing practices and medication management – especially for patients with chronic and complex conditions. Lack of connection and communication between various health providers both within and between rural communities.

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Outcomes of the service needs analysis Difficulty of acquiring accurate, comprehensive service data around allied health – particularly level and quality of outreach services. Chronic Disease Prevention High rates of chronic disease, high rates of potentially preventable hospitalisations due to chronic conditions, low rates of allied health professionals practicing in rural and remote areas.

• Leading issue in priority matrix • Key theme in all stakeholder engagement and feedback • HWA rates of health practitioners

Need for more sub-acute care options (e.g. nurse led clinics, support groups), especially outside of the major population centres. Education and awareness of risk factors and preventative measures for chronic disease must be maintained and improved in all communities, but especially those that are identified as being at higher risk. Support for rural and remote residents after an acute event to prevent relapse and/or rehospitalisation. Communities may not support ‘healthy lifestyles’ – built environment, community programs, information and resources Health Service Coordination and Integration Referral pathways can be unclear. Practitioners may not be aware of all referral options.

• Issue of importance in priority matrix • Key theme in ML and PHN stakeholder consultations • Issue highlighted by CHSA LHN

Having to travel long distances to access multiple consultations/treatment, patients are often unable to coordinate

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Outcomes of the service needs analysis appointments and/or face hardship in affording transport, accommodation, absence from home, etc. Gaps identified in discharge planning. Patients with complex conditions require care input from multiple practitioners, which is currently difficult to coordinate effectively in many regions. Palliative care • Palliative care options are perceived to be limited in smaller communities • Limited information available about current services and care pathways throughout the region. After Hours Services No/limited after hours sites in the Tatiara and upper South East regions. Reliance on country hospital EDs for after hours treatment in many country locations.

• CSAPHN internal service mapping database and listing of PIP practices. • After hours clinics and hospital ED locations mapped • Issue of importance in priority matrix • Key theme in stakeholder consultations

Many country hospital EDs do not have a doctor readily available for consultation. PIP scheme inadequate to fully resource some practices for necessary after hours operations. Difficulty in distinguishing need from service availability through MBS after hours billing rates. Ageing Population

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Outcomes of the service needs analysis Concentration of population in outer regional locations where age-specific services are more limited, especially the Fleurieu Peninsula, Yorke Peninsula and Mid North. Projected increases in aged population throughout the region, but particularly in the Riverland, Mallee and South East • Projected increasing demand for both home based and residential aged care services throughout the region • Projected increase in dementia diagnoses.

• • • • • •

Residential Aged Care Facility (RACFs) places • No RACF places in Robe or Mallala • Very low rate of RACF dementia specific places in the Outback, Adelaide Hills and Gawler. Requests for domestic assistance often related to social isolation. Gap in timely primary care services to RACFs leading to increased ED presentations of residents. Inadequate nursing workforce to support both in-home and residential aged care needs. As people age, they often have reduced access to private transportation. Lack of access to geriatricians throughout country SA. Community health allied health providers only able to support the most complex clients.

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Leading issue in priority matrix ABS Census 2011 and ERP 2013 (via PHIDU) CSAPHN service mapping Stakeholder consultation and feedback Department of Health Aged Care Data Warehouse Feedback from LHN Community Home Support staff

Outcomes of the service needs analysis Commonwealth Home Support Program • No CHSP places in many LGAs in the Mid North, Eyre Peninsula, Mallee and Fleurieu-Kangaroo Island • Referrals are effected by operation of MyAgedCare portal • Increase in complex clients requiring higher level of care than their current package can support • Increased numbers on waiting lists. Culturally and Linguistically Diverse Populations High rates of non-English speaking migrants in the Riverland, Mallee (specifically Murray Bridge) and South East regions. More recent arrivals clustered in the regional cities plus Naracoorte & Tatiara. Humanitarian visa holders most likely to settle in the South East.

• Issue of importance in priority matrix • PHIDU analysis of ABS Census 2011 • Department of Immigration and Citizenship Settlement Reporting • Health Performance Council scoping study (Principe 2015)

Presence of discrete communities with different cultural backgrounds in dispersed locations throughout the region • • • • •

Lower level of health service utilisation Populations ageing with lack of cultural specific services Language barriers Varying levels of health literacy Difficult to access interpreters outside of the metro area.

New arrivals – particularly humanitarian visa holders – need support to settle and integrate. Refugee experiences and cultural norms may result in poorer physical and mental health and form barriers to accessing and engaging with mainstream health services. CALD needs often not considered in service planning.

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Outcomes of the service needs analysis Transport No public transport throughout most of the region. Some local bus services operate with varying regularity. Residents of areas with no or limited public transport options face significant barriers to accessing timely primary health care and can have difficulty coordinating appointments.

• Issue of importance in priority matrix • Extensive community engagement done via MLs and within PHNs • Report on transport options within the former Country South SA ML region

Services provided from centralised locations create a burden of cost, time and lost income on clients and client support or carers. The great majority of specialist services are accessed from Adelaide and, to a lesser extent, regional centers which are remote from populations in need. Significant travel cost (time and financial) is often required to facilitate simple follow up appointments of short duration. The issue is felt across the region, but accentuated the further the travel demand from Adelaide. Immunisation Lack of coordination between different providers (e.g. GP, local council, ACCHO clinic).

• Issue of importance in priority matrix • Concerns raised by immunisation nurses throughout the region

Uncertainty around the validity of ACIR data Health Information and Technology Very low uptake of ‘My Health Record’ by providers throughout the region despite a high level of GP registration and a moderate level of consumer registration.

• Issue of concern in priority matrix • DoH eHealth statistics • Country SA PHN General Practice and Allied Health survey (April 2016)

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Outcomes of the service needs analysis Change from ‘Personally Controlled Electronic Health Record’ to ‘My Health Record’ – impacts continued use by GPs and use and uptake by the general public. Low uptake of Telehealth. Electronic transfer of patient information between health providers is limited • High percentages of General Practices and allied health providers use fax to send referrals or clinical reports • Only 46% of General Practices and 22% of allied health providers employing secure messaging software to send information. • Allied Health providers are less likely than General Practice to use electronic patient records (61% vs. 96%) • General Practices and allied health providers are less likely to communicate electronically with local hospitals and pharmacies. Oral/Dental Health Low rate of dental practitioners in country SA.

• Issue of concern in priority matrix • HWA rates of health practitioners

Mental Health, Suicide and Alochol and Other Drugs General Mental Health, comorbidity and suicide prevention. Generally there is a workforce shortage across the region, particularly within programs designed to minimise costs for eligible patients. Psychologists are in high demand and yet are limited particularly in rural and remote areas. Where Psychologists are available, large gap payments prevent

• • • • • • • •

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Leading issue in priority matrix Recurring themes in ATAPS provider needs assessments DoH District of Workforce Shortage Drug and Alcohol Stakeholder Survey NCETA – Patterns and Prevalence & At-Risk groups AOD 2017 ATAPS referral rates CSAPHN ATAPS Provider evaluation report, 2016 Drug and Alcohol Stakeholder Survey, CSAPHN - 2016

Outcomes of the service needs analysis consumers from attending their services or extended waiting periods exist. Psychological Therapy service provision rates are lower than the state average across all regions, indicating an imbalance with service provision in the metropolitan area despite equal or greater need in many rural areas. Service is not provided at all in some areas, particularly for youth. Neither Psychological Therapies nor Clinical Care Coordination (MHNIP) services are consistently provided within all regions, despite most having some level of need, this is directly dependant on workforce availability in rural regions. Once more, where Psychological Therapies are provided, consumers are subject to high waiting periods.

• • • •

Areas with high rates of hospitalisation for mental health and low service capacity need resources to minimise the risk of both ‘well’ populations and ‘at risk’ populations, from requiring higher level services through unmet lower level need. Currently clients’ needs go unmet while waiting for services, leading to progression in illness in most cases. Further analysis to determine if the service capacity needs to increase, or is inappropriate would assist in closing this gap. A substantial benefit for the region, is its selection as one of the National Suicide Prevention Sites. This achievement will bring considerable funding and resources into the region with the sole purpose of addressing prevention and aftercare of suicide. Other areas in need of improvement or further analysis to improve the sector include

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SA Health Hospital Separations 2015-15 Estimated resident population 2014. MBS mental health providers ATAPS – DoH

Outcomes of the service needs analysis • Range and coordination of services to better address different stages and severities of mental illness along the continuum. • Service appropriateness - Areas with high female mental health admissions, and/or high Indigenous female mental health issues require more specific services for females and Indigenous females. • Lack of coordination for drug and alcohol co-morbid conditions such as mental health and suicide prevention. • Lack of service continuity for rural patients from acute to community care to facilitate a stepped care model • A structured stepped care approach is limited and fragmented due to limited access, lengthy waiting periods and often excessive travel required for care. For residential treatment, rural patients are left with no option but to relocate to metro areas for treatment. Alcohol and other Drugs Service gaps and comorbidity of Mental Health conditions with drug and alcohol is evident in the hospital separations for each region, correlating as high for both. Furthermore client needs go unmet while waiting for services • Stakeholder consultation indicated extensive waiting times – clients are unlikely to be re-motivated after waiting. Resulting in clients continuing to use illicit substances while they wait for a service. • Extensive waiting lists indicate service capacity unable to meet need. Aboriginal and Torres Strait Islander clients in more remote, dry zones have to travel to regional areas which aren’t dry to

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Outcomes of the service needs analysis withdraw/sober up. Stakeholders indicate this can cause issues, particularly when clients return back to their areas post rehabilitation. Clients are then lacking in follow-up and outreach back in the community. Areas with low service capacity and/or no outreach service, require additional hours or more providers to bring waiting times down, especially in areas where there are higher rates of drug and alcohol admissions, as well as mental health admissions.

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References (in addition to health statistics made available to PHNs or publicly accessible)

ABS. (2011). Census of Population and Housing. Canberra: ABS. ABS. (2012). Australian Health Survey: Biomedical results for chronic disease. Canberra. AIHW. (2008). Rural, regional and remote health: indicators of health system performance. Canberra: AIHW. AIHW. (2014). Arthritis and other musculoskeletal conditions across the life stages. Arthritis series no. 18. Cat. no. PHE 173. Canberra: AIHW. AIHW. (2014). Mortality from asthma and COPD in Australia. Canberra: AIHW. AIHW. (2015). Cancer. Retrieved from Australian Institute of Health and Welfare: http://www.aihw.gov.au/cancer/ AIHW. (2015a, August). Chronic diseases. Retrieved from http://www.aihw.gov.au/chronicdiseases/ AIHW. (2015b). Cardiovascular disease, diabetes and chronic kidney disease - Australian facts: Prevalence and incidence. Canberra: AIHW. AIHW. (2015c). Diabetes. Canberra. AIHW. (2015d). Cardiovascular disease, diabetes and chronic kidney disease - Australian facts: Aboriginal and Torres Strait Islander people. Canberra: AIHW. AIHW. (2015e). The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Canberra: AIHW. AIHW. (2016). Aged Care. Retrieved from AIHW: http://www.aihw.gov.au/aged-care/ AIHW. (2016a). Arthritis and its comorbidities. Retrieved from AIHW Arthritis and musculoskeletal conditions: http://www.aihw.gov.au/arthritis-and-its-comorbidities/ AIHW. (2016b). Cancer Screening in Australia by Primary Health Network. Retrieved from AIHW Cancer data: http://www.aihw.gov.au/cancer-data/cancer-screening/ AIHW. (2016c). Risk factors to health. Retrieved from Risk factors, diseases & death: http://www.aihw.gov.au/risk-factors/ Australian Government Department of Health. (2015, May). health.gov.au. Retrieved from http://www.health.gov.au/internet/main/publishing.nsf/Content/chronic-disease

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Australian Government Department of Social Services. (2015, June 30). Preventing falls in the elderly. Retrieved from myagedcare: http://www.myagedcare.gov.au/healthy-andactive-ageing/preventing-falls-in-elderly Department of Health. (2014, Feb. 16). Australia's Physical Activity and Sedentary Behaviour Guidelines. Retrieved from health.gov.au: http://www.health.gov.au/internet/main/publishing.nsf/content/health-pubhlthstrateg-phys-act-guidelines#apaadult Egger, G., Donovaon, R., Swinburn, B., Giles-Corti, B., & Bull, F. (1999). Physical Activity Guidelines for Australians - Scientific Background Report. Canberra: Commonwealth Department of Health and Aged Care. Heart Foundation. (2014). Data and Statistics. Retrieved from Heart Foundation: http://www.heartfoundation.org.au/SiteCollectionDocuments/2014HeatMaps_PrevCVD _SA.pdf NHMRC. (1993). Dietary Guidelines for Australians. Retrieved from www.nhmrc.gov.au/publications/synopses/dietsyn.htm NHPA. (2016). My Healthy Communities: Immunisation rates for children in 2014-15. Retrieved from National Health Performance Authority: http://www.myhealthycommunities.gov.au/our-reports/immunisation-rates-forchildren/february-2016 NHPA. (2015). My Healthy Communities. Retrieved from National Health Performance Authority: http://www.myhealthycommunities.gov.au/primary-health-network/phn402 PHIDU. (2015). Social Health Atlas of Australia: South Australia. Data by Local Government Area: June 2015 Release. Adelaide: The University of Adelaide Population Research & Outcome Studies Unit. (2013). Health of South Australian Adults by South Australian Medicare Locals. The University of Adelaide. Unpublished. RDWA. (undated a). Outreach Services. Retrieved from Rural Doctors Workforce Agency: https://www.ruraldoc.com.au/outreach-services RDWA. (undated b). List of Services by Location. Retrieved from Rural Doctors Workforce Agency: https://www.ruraldoc.com.au/Media/Default/PDFs/Outreach%20List%20of%20Services. pdf RDWA. (undated c). Medical Outreach - Indigenous Chronic Disease. Retrieved from Rural Doctors Workforce Agency: https://www.ruraldoc.com.au/medical-outreach-indigenouschronic-disease RDWA. (undated d). Healthy Ears - Better Hearing - Better Listening. Retrieved from Rural Doctors Workforce Agency: https://www.ruraldoc.com.au/healthy-ears-better-hearingbetter-listening Country SA PHN Needs Assessment Report November 2017 Page 45 of 46

RDWA. (undated e). Visiting Optometrists Scheme. Retrieved from Rural Doctors Workforce Agency: https://www.ruraldoc.com.au/visiting-optometrists-scheme SA Health. (2015). Potentially Preventable Hospital Admissions - Country Residents 2011-12 to 2013-14. Data supplied to CSAPHN by SA Health. The Kirby Institute. (2015). HIV, viral hepatitis and sexually transmissible infections in Australia: Annual surveillance report 2015. Sydney: The Kirby Institute, UNSW. Wardliparingga Aboriginal Research Unit. (2016). South Australian Aboriginal Hearth and Stroke Plan: Gap analysis and Draft Recommendations. Adelaide: SAHMRI.

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