Stepped care in rural and remote communities

As GPs are often the only constant clinicians in these communities, they provide essential continuity in places where other service providers can change or rotate. For this reason, it’s particularly important to understand that stepped care in rural and remote communities is centred on the GP, including the:

• GP and consumer relationship
• GP mental health treatment planning
• GP delivery of psychological interventions (Focussed Psychological Strategies in which the GP is trained)
• GP’s role as coordinator of multiple fragmented services
• GP telehealth referrals (psychiatry, psychology).

Telehealth plays an essential role in rural and remote communities, as it offers residents the ability to access services that might not be available locally.

Stepped care and early intervention is critical in rural and remote communities, because if the right level of care is not provided and the consumer’s condition worsens, they may experience:

• long waitlists
• the need to travel hundreds of kilometres
• the need to rely on RFDS, retrieval services, or fly-in psychiatrists
• disruption to family, work and culture
• higher costs.

All of the following can be undertaken via telehealth:

• psychological therapy via video
• psychiatry assessment and review
• suicide risk follow-up
• digital mental health programs
• digital mental health coaching models.

Therefore, consider using telehealth across all steps (ie from low-intensity support to non-GP specialist input), or a blend of telehealth with face-to-face (which could include home visits, and consultations at community locations). 

Challenges of telehealth in rural and remote communities

For some consumers, telehealth can also present challenges, if they have:

• limited or non-existent internet access
• lack of private spaces
• the need to ensure culturally safe, locally informed and community-led care, particularly for Aboriginal and Torres Strait Islander peoples
• a preference for face-to-face sessions in crisis or complex care needs
• fears about confidentiality and privacy in small communities where everyone knows everyone.

One of the major challenges of providing stepped care in rural and remote areas is achieving the right balance between these two competing principles:

• prioritising access and continuity over service availability
• basing a consumer’s stepped care on their needs and risks, rather than what is locally available.

Consequently, you need to ensure that consumers receive timely and ongoing support from the resources that are available, while continuing to identify, or wait for, services that provide the level of support they require.

To help overcome this challenge:

• remain flexible:
  • consider adopting flexible pathways and varying the periods of time at each step
• proactively manage wait times for other services by providing the consumer with interim supports and check-ins, and conduct active follow-ups rather than just passive referrals
  • take a consumer to the next level of care (step up) by, for example, increasing the frequency and duration of sessions and/or referring them to other available service providers

• consider alternatives, such as telehealth, GP FPS sessions, evidence-based digital interventions, or referral to Rural Generalists with Mental Health Advanced Specialised Training
  • use community-based options:
  • integrate allied health as necessary and partner with local services and communities
  • use community, peer, and informal supports
  • use shared care and case conferencing
• develop clear crisis escalation plans, particularly if the consumer lives a long way from acute services.

When living in a rural or remote town, it’s possible to feel quite separated from the larger society, and consequently, it’s common for people to feel isolated or disconnected12. Loneliness and isolation affect approximately 35% of rural Australians13, and social isolation has been linked to poor health behaviours, mental illness, emotional distress, suicide, the development of dementia and premature death14.

GPs who work in rural and remote areas are in a position to recognise social isolation early, and provide low-intensity and accessible supports.

If you are concerned that a consumer is facing social isolation, you could ask them about their:

• frequency of social contact
• how they maintain connection to family, community and Country
• support networks

You could also:

• provide psychoeducation about how social isolation affects health and wellbeing
• consider community-based and culturally led supports where appropriate
• refer to appropriate community and allied health supports if available
• book in regular follow-ups
• make sure the consumer understands what support and care is in place for them, what is going to happen next, and what follow-up appointments are needed.