To help the underserved is to learn

Coledale Student-led Clinic is a boon for education and the community. 

In the February issue of Nursing Review, Kathy Bell, CEO of the Australian Primary Health Care Nurses Association, posed concerns about access to quality healthcare for the aged, rural populations, and people with chronic diseases.

She also described the current institutional and legislative barriers facing Australian primary healthcare nurses in areas such as prescribing. She specifically asked, “How can we rise to these challenges?”

Nursing at the University of New England has taken on the challenge.

In March 2013, UNE Nursing, in partnership with Hunter New England Health and NSW Justice Health, established the UNE/Coledale Student-led Clinic to address the shortage of rural clinical training opportunities whilst providing a community service in a priority health area.

The clinic

The Coledale Community Centre, in West Tamworth, NSW, was selected as the site because of its fit with the philosophy and goals of the project. Coledale is a community of 3000 Indigenous and non-Indigenous residents with high rates of unemployment, domestic violence, crime and unmet health needs. Additionally, with the severe shortage of GPs in the Tamworth region, about 4000 individuals have no access to healthcare.

The specific aim of the clinic is to provide learning opportunities for students whilst building health access, literacy and equity for the local community. Under the UNE banner, multiple agencies operating out of the centre have been working together to integrate services within the context of a one-stop clinic led by nursing students. The centre operates under a clinical training grant funded by Health Workforce Australia.

In less than a year, the clinic has expanded its operations from one to three days a week. Students have helped hundreds of community members receive free drop-in help with health checks, disease screening, treatments, prescriptions, education, reading, writing, housing, employment, exercise, diet, social activities, financial planning, smoking cessation, rehabilitation and health coaching.

Whilst the tangible savings for the health system to date are significant, there have also been immeasurable benefits such as helping community members change their lifestyle and adhere to treatments. Students have also organised a number of health promotion events, such as birth certificate registration, women’s health, family fun, and eye and ear screening for elementary school children.

Students are working with individuals and families who would not otherwise get help, due to lack of availability of health and wellness practitioners, long waiting lists, transport and financial issues, and avoidance of services dues to stigma and previous negative experiences. Community residents are drawn to working with students because of their approachability, the unlimited time they can devote to each person and their willingness to learn. The holistic approach to primary health includes physical, spiritual, occupational, social, and emotional wellbeing. Within this mutually beneficial environment, opportunities exist to diminish barriers to health, improve community relations and make Coledale a healthier place for all.

Student-led principles are key to the success of the clinic. Students recognise the intrinsic value of all people and their right to health, wellbeing and high-quality help. As future healthcare professionals, they strive to understand the social determinants of health, the principles of primary healthcare and the importance of socially responsive health promotion.

Student vision at Coledale is based on community priorities as determined through extensive communication with residents, community groups and other professionals. Based on this foundation, the students create and maintain an interdisciplinary approach to provide integrated and timely services to Coledale’s underserved population.

The UNE/Coledale Student-led Clinic provides an invaluable and sustainable link between students, healthcare professionals, community-based organisations, the university and the community. The community benefits by learning to self-manage health and wellbeing. The students benefit by gaining practical experience in an interdisciplinary setting and through exposure to a community with unique and severe health needs.

Model of Care

The clinic’s approach is underpinned by The New England 4G Framework of Guided Self-health, which is based on the highly successful United Kingdom National Health Service initiative Improving Access to Psychological Therapies. The curriculum has now been expanded to include physical health conditions.

The 4G framework is based on cognitive-behavioral therapy – the most effective non-pharmacological, evidenced-based treatment for consequences of mental and physical health conditions. Students use the 4G approach to:

• Gather information to detect, assess, and measure health problems
• Generate a health action plan with the client
• Give health information and print-based or internet evidence-based (EB)self-health treatment packages
• Guide use of EB therapies using eHealth follow-up and measures.

The model is strategically aligned with the agendas of the Australian Health Care Reform Alliance, the Department of Health, and New South Wales Health by:

• increasing access to integrated help
• providing efficient treatments that work in a primary health setting  and promote optimization of one’s own health
• increasing health literacy and community engagement
• initiating new ways of working towards workforce development
• use of eHealth
• addressing key areas of chronic and preventable disease self-management and mental health
• liaising with Medicare locals to fill the gap in primary care needs of rural populations

This model also represents value for money because as a student training ground, services are delivered at no cost and student learning is beyond value.

Outcomes

Routine assessment and outcome data is collected on each contact. The measures used are commensurate with a national and international database. Residents are able to track and manage their own health records if they wish. The tests and results conducted on site are explained and can be kept and accessed by the person receiving care. With increased health literacy, individuals can understand and make health decisions based on immediate feedback. For example, monitoring blood glucose before and after exercise or meals and understanding food labels and packages enables individuals to make informed choices.

A few examples highlight the range of everyday clinic scenarios. A man had been coming to the centre bi-weekly for wound care. When the clinic commenced, students investigated why the wound was not healing.  They discovered poor nutrition due to dental problems. Inaccessibility to dental care combined with fear of needles kept this man from gaining help. Students were able to find and arrange dental care, work with the man’s needle phobia and help him understand and select nutritious foods, which resulted in his long-standing wound healing.

Meanwhile, a woman and her baby came to the centre to escape a fight with her partner; a chat with a student uncovered the domestic violence concerns. Students engaged the Aboriginal counselor and the Staying Home Leaving Violence co-ordinator, who helped the woman consider her options. A health check uncovered a punctured ear drum and infection for the woman, and a highly contagious skin disease for her baby. Also, a pregnancy test was positive. Instruction and prescriptions were delivered on the spot, with ongoing follow up and counseling.

On birth registration day, students helped 278 individuals gain a free certificate. It was subsequently reported that it was the first time in the history of local elementary school enrolments that all children had a birth certificate. The ear and eye screening day revealed 60 students, out of nearly 300, with significant vision or hearing impairments that were probably affecting their learning or contributing to bullying. Students were able to discover the issues, attend to them, and teach kids and others to recognise problems and their implications.

In addition to these examples, case records to date reveal positive reversal of life-threatening conditions including renal failure, heart attacks, diabetic coma, bowel obstruction and gangrene. Scabies, lice, impetigo, whooping cough, fresh puncture wounds, as well as a range of other infectious and chronic disease conditions have been treated and are monitored.

New frontiers

As the palpable buzz of activities and success continues, each week more volunteers and agencies join the team. To meet community demands, students will now operate five days a week, with extended evening programs. A local laboratory plans to set up in the clinic and train community residents in blood collection; an optometrist wants to provide testing and free glasses; Work for the Dole will supply additional staffing; a food bank and sustainable garden program will enhance the Soup Kitchen; respite care will enable folks to drop off loved ones and get a break; a student dental service van will provide basic oral treatments; and our treasured Aboriginal nurse practitioner with prescribing rights will be pushing practice boundaries and expanding her formulary on a trial basis.

The internet system will soon be updated to enable specialists to beam in their consultations and bulk bill whilst students do the heavy lifting of pre-assessment, treatment and follow up. Further expansions will bring in more students from social work, medicine, law, pharmacy, sports science, criminology, art and education. Organisers envision a strengthening of inter-agency and inter-professional partnerships across the higher education, health and community sectors.

The HWA clinical training grant has offered a unique opportunity to think anew about how a range of vital community services can be offered more effectively and innovatively. Under the umbrella of a community outreach plan, we are working to refresh the current workforce and prepare developing workers to enact state-of-the-art, research-based help.

We believe that our community-governed, student-led model, which has developed and grown organically, can be adapted across Australia. We agree with Kathy Bell’s call for nurses to expand their role in primary healthcare and welcome her and all to visit our centre.

Cynthia Stuhlmiller is professor, school of health at the University of New England.

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