The Rural Private Therapy Project
Table of Contents
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Background
DisabilityCare Australia will deliver better outcomes for people with disability and their carers
(disability service users) by taking a more sustainable and equitable approach to supporting service users. This approach aligns with the United Nations Convention on the Rights of
Persons with Disabilities (CRPD). In December 2012 the Australian Government Department of
Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) funded 73 projects to develop practical ways for people with disability, their carers, and the disability sector to prepare for the transition to DisabilityCare Australia.
The Rural Private Therapy Project
There is less access to allied health professionals (therapists) in rural areas resulting in a high level of unmet need. Little is known about the capacity of the private therapy sector to meet the growing demand in a significantly changing disability sector. Funded by FaHCSIA, the aim of the Rural Private Therapy Project was to develop a framework to assist rural private therapists to provide ongoing, high quality and accessible therapy to rural disability service users.
Therapists included in this project are occupational and physiotherapists, speech pathologists and psychologists.
The Rural Private Therapy Project was conducted by the Wobbly Hub and Double Spokes
(WH&DS) team at the Faculty of Health Sciences, The University of Sydney. WH&DS is a four year (2010-2014) program of research funded by the National Health and Medical Research
Council in partnership with NSW Family and Community Services, Ageing Disability and Home
Care (ADHC) Western Region. The WH&DS project is designed to enhance therapy service delivery to disability service users in rural and remote communities.
As part of the WH&DS work, in mid 2012, 63 private therapists were among 199 therapists working in western NSW who completed a Rural Therapists’ Retention Survey. Analysis of this data suggested the potential of the rural private therapy workforce to deliver therapy services under DisabilityCare Australia.
Consultation and Development of the Framework
Since January 2013, the Rural Private Therapy Project team has built on the WH&DS work by conducting a literature review on rural private therapy service delivery and conducting focus groups and interviews with 28 rural private therapists working in western NSW. The information gained from the survey, literature review,focus groups and interviews was used to develop a first draft of the rural private therapy framework. The draft framework was refined via two rounds
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of online feedback from participating rural private therapists, representatives of national peak allied health organisations, national peak disability organisations, and national rural Medicare
Locals.
Online and face-to-face consultations were then conducted with rural disability service users to further refine the framework. Feedback from all participants was combined to develop the final framework: Enabling High Quality, Sustainable and Accessible Services: A Framework for Rural
Private Therapists.
Therapists and service users who participated in the development of the framework indicated that the autonomy and workforce stability of private therapists means they have the potential to provide flexible, creative and responsive services in rural areas. Furthermore, they are often better positioned to develop long-term collaborative relationships with service users and their communities. Although there is clearly great potential for rural private therapists to provide valuable services, participants noted that they are often constrained by time limitations and inflexible funding and service systems.
The framework presented in this document provides guidance for the development of policies, systems and models of practice that maximise the potential of rural private therapists to provide high quality, sustainable and accessible services. Implementation of the framework has the potential to create an environment that will encourage the growth of private therapy services through DisabilityCare Australia that are responsive to the diverse needs of rural disability service users. This document briefly describes the components of the framework.
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The Framework
Drawing on contemporary research and practice, this framework is informed by the following principles:
therapy interventions should be based on the goals identified by disability service users and inclusive of best practice;
the goals and outcomes achieved through therapy interventions should be sustainable for disability service users within their community;
disability service users should have access to therapy regardless of where they live.
This figure illustrates the framework arising from the project, which is further detailed below one component at a time.
The framework provides a description of the contextual features that “frame” and shape the therapy process. These “framing” elements include the rural context and ‘rural proofed’ policy.
Within this context service users, therapists, communities and the disability sector “engage” in a therapy pathway involving shared responsibility and collaborative approaches. Engagement in
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this pathway facilitates enhanced capacity. Additionally the framework highlights the factors that
“enable” the capacity to meet the needs and goals of service users in their rural communities.
These enablers are networks, resources and processes, influenced by four main drivers: time, cost, opportunity and motivation.
Elements of the framework – FRAMING
Rural Context
Rural context encompasses socio-cultural and socio-economic factors. Socio-cultural factors include the demographic profile of a community, the community values or “spirit”, and the “way things are done ” within a rural community.
Although there are some commonalities in the values rural people hold and the way they go about their lives, there is also great diversity within and between communities and contexts.
This diversity should be acknowledged and respected. The values within each community shape an understanding of what is important to that community and how things will be done within it. Rural context also includes social features and processes within communities such as the roles of local government and businesses and the importance of local “champions”.
Socio-economic factors relate to the perceived and actual wealth of the community which is, at least in part, based on local resources and industries (e.g., farming, mining, service sector).
Some rural areas are more economically prosperous than others. Disability service users may be further economically disadvantaged due to difficulties accessing employment, housing and transportation which may be limited or overpriced. Overall, rural communities tend to have lower socio-economic status than metropolitan areas and this affects the resources available to support disability service users and, at the individual level, their ability to pay for private therapy.
The therapist, disability service users, and community members require an understanding of the complex socio-cultural and socio-economic factors impacting on the rural areas in which they live and work.
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‘Rural Proofed’ Policy
High quality, sustainable and accessible rural private therapy occurs in policy contexts. Living and working in rural areas results in particular challenges that are often overlooked by metropolitan-based policy makers. For example, both rural private therapists and rural disability service users may incur additional costs to cover travel time compared with their metropolitan counterparts.
It is essential therefore that DisabilityCare
Australia policy is ‘rural-proofed’ 1 to ensure that rural disability service users and therapists are not disadvantaged. There will be a need to ensure policy is “rural-proofed” across various departments and organisations that impact on the delivery of therapy services to people with a disability. Federal and State Government Departments; Local Government; Professional
Associations and Disability Peak organisations will all need to consider the impact of policy on rural service users and therapy providers.
‘Rural proofing’ involves developing mechanisms to ensure that rural people are consulted about the implications of, and have ongoing input into, policy decisions.
Elements of the framework – ENGAGING
Preparedness
For the therapy service to be high quality, sustainable and accessible the service user, therapist, community and sector must be adequately prepared prior to embarking on the therapy pathway. Preparation will vary from person to person and community to community.
There are many factors influencing this including the place of the person in the community over time, the nature of the disability, the goals, resources and facilities the service user requires. Other factors include gender, culture and social status.
1
Swindlehurst, H. (2005). Rural proofing for health: A toolkit for primary care organisations . UK: Institute of Rural Health
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Preparedness of the service user:
In entering the therapy pathway, the service user brings with them knowledge of their unique situation, their goals and aspirations. They contribute to the process a range of personal strengths and resources, as well as knowledge of their local community, and the formal and informal networks that they can draw on for support. To access therapy services the service user will need knowledge of the potential benefits of therapy, how to find and access therapy services, and an understanding of how best to engage with a therapist to maximise therapy outcomes. Additionally the person may bring an understanding of their individual DisabilityCare
Australia funding package and how it could be used to help them meet their goals. Disability service users may already possess this knowledge or they may need to be supported with additional information, or the assistance of others, to engage in the therapy process.
Preparedness of the therapist:
In working with any service user, a therapist brings professional and discipline specific skills and knowledge. Depending on the needs and goals of the service user, the therapist may need to supplement her or his professional competence by accessing additional support and information. The therapist needs to be prepared to work in a way that is consistent with current best practices in disability services. For example, to work with a service user who wants to join a local community sporting group, the therapist may need to think about the barriers and facilitators to participation (as defined by the World Health Organisation International
Classification of Functioning, Disability and Health). Similarly, to assist a service user with a significant intellectual impairment to live independently, the therapist may need to consider issues around dignity of risk (as outlined in the United Nations CRPD).
Preparedness of the community:
The disability service user and therapist live, work and engage in the therapy pathway within the context of a local community. The community plays an important role in supporting the service user to meet their goals through the therapy process. Preparedness of the community involves recognising the importance of and access to facilities and resources for all community members, including those with disability. It is also important that communities create mechanisms for ensuring service users have a voice and that their participation is actively promoted and valued. Communities may already be engaged in these activities and possess the knowledge required to support and promote the participation of service users, or they may require information and assistance to do so.
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Preparedness of the sector:
The disability sector is undergoing major changes with the introduction of DisabilityCare
Australia. Questions have been raised about the capacity of the current disability sector workforce to adequately meet the anticipated increased demand by service users for services including therapy. Rural areas face additional challenges due to difficulties in attracting and keeping therapists. Alternative ‘rural-proofed’ strategies for recruiting and retaining rural therapists are required including incentives to entice the ‘sleeper therapy workforce’ (i.e., qualified therapists who are currently not practicing) back into rural therapy practice. There is also a need to recognise and support the role of local, trained therapy facilitators who, along with the use of technology, can extend the reach of therapists based in regional towns or capital cities. Retention will be also improved by cross-sector networking between government, nongovernment and private sector therapists so that there is a supportive work environment for all therapists. Improvements in inter-therapist relationships are likely to result in improved therapy provision and outcomes for rural service users. All parts of the sector (government, nongovernment and private) require the flexibility to deliver alternative models of therapy service such as community capacity building approaches along with more traditional individual therapy models.
The pathway
The central section of the framework represents the planning and prioritising activities that facilitate rural private therapy interventions through DisabilityCare Australia.
The service user plays a central role in determining their individual therapy pathway.
Together, the service user and the rural private therapist share the responsibility to set priorities and agree on the approaches to meet the person’s goals. This is an active process that draws on and at the same time enhances the capacity of the service user and the therapist within their community and more broadly within the disability sector. Enhanced capacity means that each of the players (service user, therapist, community and sector) will develop knowledge, skills and resources that can be utilised in enabling active participation of people with a disability in the community.
Elements of the framework – ENABLING
Enabling Capacity
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The capacity of the service user, the therapist and the community is enabled and enhanced through the therapy process. In all, but particularly in rural and remote areas, the community in which the service user lives is integral to the achievement of the person’s goals. At the same time that the therapist and service user develop and build on existing skills and knowledge, the knowledge and capacity of the community is enhanced.
Transfer of knowledge between all components of the framework enables the capacity of service users, therapists, communities and the sector to be better prepared and better informed.
Components: Networks, Resources and Processes
Three components contribute to successful engagement in the therapy process and to enabling capacity from the perspective of both the therapist and the service user within their community. These components are: networks, resources and processes .
Knowledge is important across each of these components. Therapists, service users and their communities require knowledge about the networks, resources and processes that exist and how they can draw on and work within these. Additionally they may need knowledge about how these components can be built on to further enhance capacity.
Networks:
Rural private therapists and communities require access to networks that enhance their capacity to meet the goals of the service user. Existing formal and informal networks are enhanced through the use of flexible, varied and accessible methods. These networks can be a source of information and knowledge sharing and of emotional and/or practical support. It is important for the therapist, the service user, and the community to develop knowledge about existing networks and how they can be utilised. They may also require knowledge about how additional networks can be built to meet the needs of the service user.
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Resources:
Rural private therapists and communities require access to resources that enhance their capacity to meet the goals of the service user. Existing resources can be supplemented or enhanced with new and relevant resources that are affordable and easily accessible. The therapist, the service user, and their community will need knowledge of the resources that are available and how to utilise or develop these to meet the service user’s needs.
Processes:
These include the administrative processes such as referral procedures, payment arrangements, and reporting mechanisms required by a therapist to deliver therapy intervention to a service user within DisabilityCare Australia. In addition, the therapist should work with the service user and their local community to use local networks and funding opportunities and understand local regulations to enhance the participation and inclusion of the service user.
Drivers
There are facilitators and barriers to therapist, service user and community capacity that relate to the components of networks, resources and processes.
For each of the components, the primary drivers are time, cost, opportunity and motivation . These drivers are common to all therapists and communities regardless of where they are located; however they are often heightened by, and different as a result of, being located in a rural area.
For example, although time pressures and limited opportunities influence the ability of all therapists to conduct in-home equipment trials there are additional barriers in rural areas due to long distance travel and infrequent visits by equipment suppliers. These additional time and opportunity pressures impact on the ability of therapists to utilise resources to meet the goals of service users. Similarly the additional costs associated with travel to see a service user in a remote community may not be covered by government funding processes. This funding shortfall may influence the motivation of the rural private therapist to accept the referral as they would have to absorb any additional costs.
Solutions to these barriers at a policy, community and individual level will need to address the drivers of time, cost, opportunity and motivation. Addressing these drivers will result in effective
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strategies that enable capacity in relation to the components of networks, resources and processes and ultimately, smooth the therapy pathway for service users. The framework relies on feedback at all levels and throughout the therapy intervention process. Based on consultations with stakeholders, we recommend solutions relating to each of the components which address one or more of the four main drivers. These recommendations are outlined in the following section.
This framework is built on the identification of facilitators, barriers and solutions to rural private therapy practice as identified by rural private therapists, rural disability service users and peak organisations. The approach is framed in a rural context including the need for ‘rural-proofed’ policy. The elements of the framework are dependent on the engagement of service users, therapists, community and the sector to provide a high quality sustainable and accessible therapy service. Attaining this service involves three components: networks, resources and processes taking into account four primary drivers: time, cost, opportunity and motivation.
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Recommendations based on Consultations
Recommendation 1: Network Solutions: Collaborative Digital Hub
The development of a collaborative digital hub: for example, a website, to provide a “one-stopinformationshop” for therapists, service users and their communities. A digital hub would reduce the time spent searching for information, provide opportunities for networking and information gathering, reduce therapists’ costs through the delivery of flexible professional development without the need for additional travel, and reduce the time spent away from directly working with service users.
The collaborative digital hub should:
Contain relevant, reliable, concise, well synthesized information about:
Therapy – e.g., what therapists do and where to find them
Disability – e.g., latest evidence-based information about person-centred and community inclusive therapy practice
DisabilityCare Australia policy and processes – e.g., provider registration; billing procedures
Be user friendly
Utilise quick and easy search mechanisms
Use intuitive / easy to follow navigation
Be available in accessible formats
Engage the community
Local users generate and update hub content
Link with existing local networks, resources and services
Host online community forums to showcase local initiatives
Facilitate partnerships and build relationships through sharing of information and ideas, challenges and solutions between therapists, between service users, between community members
Post answers to questions such as: Who do I ask about this? Where do I go to find that? Has anyone else experienced this? How did you get around that?
Support professional development
Develop multidisciplinary online ‘communities of practice’ to keep up-todate with colleagues, evidence-based practice and mentors;
Promote local professional development initiatives;
Tap into existing online professional development and training packages.
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Although stakeholders indicated that these features would ideally be located in a single location, for example, a collaborative digital hub, they are important in their own right. Strategies aimed at enhancing and enabling capacity in relation to networks should address these features, regardless of their mode of delivery.
Recommendation 2: Resource Solutions: Collaborative Community
Every rural community has resources that could be utilised by service users and therapists. We identify a number of strategies for enhancing knowledge, use and development of resources.
Information about these strategies should be fed into the digital hub. These strategies would address the drivers of time, cost and opportunity by consolidating information about existing resources and providing a platform for collaborative resource use.
Resource solutions involve:
An audit of existing local people, equipment, venues and resources with the potential to be shared:
teleconference/webconference/videoconference facilities
training and therapy venues
infrastructure/business tools (e.g., EFTPOS machines, accounting software)
therapy resources (e.g., assessment tools)
outreach arrangements (e.g., transportation for coordinated visits)
knowledge of local champions including therapy facilitators
sharing of administrative support staff
relevant publications/literature
Development of local strategies and arrangements for sharing existing and advocating for additional resources.
Recommendation 3: Process Solutions: Streamlined Systems
Through consultation with stakeholders we have identified that developing streamlined systems is critical to enhancing capacity. We recommend a range of features that should be included when designing streamlined systems. Streamlined systems address the drivers of time, cost and motivation and should provide:
Clear policies and procedures including:
DisabilityCare Australia information about eligibility and preferred provider criteria
Information about flexible individual funding arrangements
Support in tailoring private practice business models to meet
DisabilityCare Australia requirements
Flexible therapy remuneration arrangements and price guides
“Rural proofed” policy including:
Remuneration for rural travel / time
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Grants to support local community participation of rural service users
Incentives to encourage rural therapists to up-skill in disability
Support and funding for alternative rural therapy service delivery models, for example models that:
Use technology
Train local therapy facilitators
Provide flexible funding to enable community capacity-building.
These recommendations are grounded in the experiences of and have direct relevance to rural private therapists, rural disability service users and peak organisations. The recommendations and ongoing consultation and feedback with relevant stakeholders have the potential to build on the positive attributes and address many of the barriers and challenges to the successful implementation of DisabilityCare in rural Australia.
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