Tullamore

The 4Ts: A primary care model for rural communities and their clinicians

[Amelia Haigh - 4Ts Project Lead]

The Four T’s model is a single employer model providing whole of healthcare in small rural communities.  The Four Ts are four small rural communities in Central New South Wales. The towns are Tottenham, Tullamore, Trundle and Trangie with  approximately less than 1,500 people in each town. All four communities are situated very closely within about 30 to 45 minutes of each other and in less than two hours from the nearest base hospital.

[Dr Shannon Nott - Rural Director Medical Services, Western NSW LHD]

The Four Ts is an ecosystem of one practice across multiple communities where our staff, our key clinicians, our administrative staff are able to work together to meet the community's need. It takes away that administrative burden, it takes away the challenges of running a business and it allows us to bring in people who are experts in providing care and focus on patients.

[Amelia Haigh - 4Ts Project Lead]

Essentially what that has meant for the four communities of Tottenham, Tullamore, Trundle and Trangie has access to a primary care clinic co-located with their local Multipurpose Health Service. The primary care clinics operate just like a GP practice with a GP, a primary care nurse an administration staff member and also a medical centre manager. This network services across all of those communities and there's telehealth support where the doctor might not be available on site.

[Dr Shannon Nott - Rural Director Medical Services, Western NSW LHD]

It's been a really, rewarding experience working under this current model.

[Dr Jason Maher - 4Ts Rural Generalist (Trundle)

It is a little bit different in management, but in reality when you're sitting down with your patient and exploring their health issues it's just like any other general practice really.

I like it that I do get a little bit of work in within the hospital as well and in the emergency department and I get to have the resources of the hospital which is really helpful for a GP so we get those resources we can admit our patients if we need to it's a very, very good place to work in that regard too.

[Dr Shannon Nott - Rural Director Medical Services, Western NSW LHD]

So what we want to be able to do through this program is not only provide fantastic care for our patients but also a model of care that clinicians and the top clinicians across our country want to work in.

[Dr Mark Grey - 4Ts Rural Generalist (Trundle)]

It harks back to the Golden Age of medicine in a lot of ways where you're looking after people from the cradle to the grave and you're feeling a welcome part and an important part of the community by providing those services.

[Dr Ash Labib - 4Ts Rural Generalist (Trangie)]

Then we came and test the country. Once you choose the country, you taste it, you love it and you stay with it, like me, I'm in 22 years. The people, the people here are friendly, warming. The life the life is like it's quiet, it's not rushing like the city so we like it.

[Dr Jason Maher - 4Ts Rural Generalist (Trundle)

On a daily basis I don't have strangers coming in to talk with me about their health issues, I have people that matter to me and that is the most gratifying part of my job. But it's living in the community that attracted me to come back from the coast and living in the city to live and work within a small community, it's a lovely place to live and it's a lovely place to bring up children as well, so that was the big draw card for me.

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I came here as a new grad and I've stayed on since. I've always  enjoyed working here - one of the other reasons is that I met my husband in my new grad year - and the team environment here and getting the things I get to do is second to none - you can't get to do it anywhere else.

You can Triage our here, you can canulate, venepuncture, IDCs, SPCs you name it - we can do it out here.

I am a ward nurse generally but obviously in a rural facility I am also an accident and emergency nurse, when there's a trauma or there's a need for it. 

I also do community nursing, we also have dialysis here at this facility, I've also done dialysis nursing and obviously we have palliative patients.  We have a lot of post rehab patients, so we do a lot of wound care.

The variety is on the of the things I enjoy the most about working here, also you have aged care, you have emergency and you have your normal everyday ward work, so every day is something different and you get to experience things you wouldn't see in the city as they would be swept away to a specialist unit.

I have so many more skills my friends wish they would have but don't, they don't get the opportunity with all the junior Doctors down there in the city.

My role is virtual outreach support to the nursing staff in the district, education sessions through the video conference we support the staff because they may have a question about a medication or a procedure.   For this month in May we have approximately a hundred virtual sessions offered.

When I started working here, they supported me for triage, like how to work in a rural ED. First of all if anything comes through the ED, how to handle that, I've done a vaccination course, advanced life support, so if something happens we can administer drugs.

We have excellent support from vCare which is the speciality emergency team based in Dubbo, and all the retrieval teams they can connect us with.

Here in Nyngan we are very lucky - we have the support of our managers and usually on call RN overnight.  

Because of the diverse nursing that I do I've always been able to do those extra courses whether it be palliative care, community nursing, dialysis.

We're using this technology and this education to improve, to help our nurses, support our nurses.

I've done lots of emergency courses through the district with training days on site here or just in Dubbo or in other towns and they've help further my skills give me that confidence to be in charge.

We do have more registered nurses starting, here - New Grads - which is also very enjoyable as you get to  help them and  you learn new things off them, things they are learning at uni or they have learned in other facilities, so the team is quite diverse but in a way it is very experienced and very strong.

Working in a small rural facility again, the team is not just the nurses on the ward, its actually the whole facility. I might ring a community nurses today to get an assessment with a patient that's being discharged tomorrow, I might actually speak to the front office staff about something particular about that patient, so actually everyone is involved because it is such a small community and a small facility so my whole team is everyone including the ambulance officers who walk through the door.

They're beautiful out here, I couldn't ask for a better team, they're all lovely, all supportive, you just couldn't find any, any team like it.

In a small rural facility everyone is dependent on eachother , its teamwork - if someone comes in ED everyone comes and helps you, they know what is there role and they support us in those situations, in every situation.

I had some free accommodation over at the units for 12 months and then I brought myself a house here in town - so I'm a permanents stayer.

There s no reason not to even if you don't stay out here forever the skills you'll learn in Western LHD will be transferable back in the city and the things you'll see you'll never see anywhere else.

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A multi-purpose is just a fantastic solution for rural towns. It means we can gather together all of the services for the town: aged care services, an emergency department, acute services, community health, and in some cases, general practice. And it's got the Commonwealth and the state together jointly funding and getting the community the services they need.

The inclusive nature of MPS's and that whole sense of a health community is what revitalises towns when they build an MPS. What the MPS is about is engaging with the communities and the key stakeholders very early on, which is all part of the planning. You'll find in these remote and rural towns, the town feels they own the hospital, the Health Service. It's an ownership that is really deep. Local people take huge pride in the health service, which is why with the MPS program, it's really critical that we talk to the community because, at the end of the day, it is their community, and they know better than any of us what their gaps are and what their service needs actually are. So that is a very fundamental but critical part of the MPS planning.

Where health districts really got a dream that with the new technology and the new drugs that are available, people that would have been admitted to an acute hospital five, ten years ago just don't need to be anymore. We really can care for them in their own hometown. So in every multipurpose of us, we're designing in first-class technology that means that an intensive us from Orange can look at a patient in Nyngan. A specialist respiratory physician can have a dialogue with a patient with asthma. Our new technology means that patients don't need to leave their hometown to receive specialist care.

The core services of an MPS are very clearly the provision of residential aged care for people. We need to make sure that the facility is actually designed to be like their home. Aging in your own community is a really important part of the model that an MPS allows you to do. So it means they don't have to leave their community, their town, their relatives, their friends. They can stay in an age where they should be, and that's in their local communities. So that is very different from a traditional hospital model because we're actually going all out to make this facility look like a home. The community is always made to feel welcome when they come through the doors. It's not as though it's a big, sterile environment.

MPS are developed and tailor-made to suit the local needs of their community, and in actual fact, they provide an integrated health community hub. So the MPS is used not only for inpatient services and the provision of aged care, but it's also used for a whole range of other health-related activities within the health service. That can range from enjoying a community garden through to participating with the community in gentle exercises through to caring for an acutely ill patient in an emergency department.

Yes, it's a great care facility, and being close to my son and his family. Most people that come in our doors, we know them, and it's like it's part of their home, really. Part of the strength of our model is to do home visits, and sometimes that's not possible, so we bring our clients into the hospital where they get care in a private and confidential way. They're quite happy to come here because they love the new MPS. I love the staff here as well. Everything's under one roof, and the fact that we can actually flex the beds to meet the needs of the day is what makes it work. So you can have an acute bed with a very sick patient in it that's recovering from an operation one day. The next day it might be a respite bed for a residential aged care patient from the community. So the fact that we can actually be responsive and adapting is what makes these services sustainable.

I'm really proud of multi-purpose services. I think they're a fantastic solution for every rural community. We've got nearly 20 multi-purpose services across the whole of our region. For every community, that looks different, and we commit to communities that we will design a service that's right for their community. So I think the multi-purpose services are a great solution, and every community should be excited to have one.