Healthy ageing in rural and remote Australia: challenges to overcome

Abstract

Thousands of remote Australians aged over 65 are flown by aeromedical teams to hospitals with illnesses that could have been prevented through increased country health services.

A Royal Flying Doctor Service (RFDS) study of 23,377 older remote residents transferred by air to hospital found heart, injury, and digestive illness triggered preventable hospital stays.

The Barkly and Alice Springs regions in the Northern Territory, the Kimberley in Western Australia, and Bourke to Coonamble in NSW had the highest preventable heart conditions.

Hospitalisation of remote stroke patients was found to be 1.5 times higher than for city residents, but less than 8% of the nation’s stroke rehabilitation services are rurally based.

RFDS Chief Executive Dr Martin Laverty said “The population of remote Australia is getting older, but the Nation is yet to work out how to support people to age and stay in the bush.

“Neurological conditions of ageing - dementia and Alzheimer’s - will significantly increase within the bush in a decade. Without new investment, existing country services won’t cope.”

The RFDS report that examined reasons for RFDS transfer by air of people aged over 65 and reasons for attendance at RFDS country health clinics found:
• rates of all cancers are higher in rural and remote areas than in cities, but country areas lack reasonable access to oncology, haematology and palliative care;

• Falls of older people are key reasons for RFDS air transfer, but too few country physiotherapists and occupational therapists exist for injury rehabilitation;

• Absence of aged care services in remote areas correlates with increase in transfer by air of older remote residents for preventable hospital stays.

The RFDS report calls for expanded cancer care in rural and remote areas, together with increased cardiac and injury rehabilitation, expanded dementia and aged care services.

Full text

HEALTHY AGEING IN RURAL
AND REMOTE AUSTRALIA:
CHALLENGES TO OVERCOME
Research Report | December 2018
Fergus W Gardiner, Lauren Gale, Lara Bishop, Martin Laverty

2ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Acknowledgments
This report has been prepared by the Royal Flying Doctor Service Research and Policy Unit using data and
evidence from multiple sources. The report has benefited from review by academic experts, and several
RoyalFlying Doctor Service staff. We are grateful for their assistance and would like to acknowledge the
external experts and internal staff.
Published by
Royal Flying Doctor Service of Australia
Level 2, 10–12 Brisbane Avenue
Barton ACT 2600
Australia
ABN 74 438 059 643
Tel: (02) 6269 5500
Corresponding author: Fergus Gardiner; Royal Flying Doctor Service; (02) 6269 5500; Fergus.gardiner@rfds.org.au
Suggested citation: Gardiner, F. W., Gale, L., Bishop, L., Laverty, M. (2018). Healthy ageing in rural and remote Australia:
challengesto overcome. Canberra, Australia, The Royal Flying Doctor Service
© 2018 Royal Flying Doctor Service of Australia

3
Commitment to Indigenous Reconciliation
The Royal Flying Doctor Service of Australia (RFDS) respects and acknowledges Aboriginal and Torres Strait
Islander peoples as the first Australians and our vision for reconciliation is a culture that strives for unity,
equityand respect between Aboriginal and Torres Strait Islander peoples and other Australians. The RFDS
iscommitted to improved health outcomes and access to health services for all Aboriginal and Torres Strait
Islander Australians, and our Reconciliation Action Plan (RAP) outlines our intentions to use research and
policy to drive improvement. RFDS research and policy reports include Indigenous data as part of a broader
effort to improve health outcomes and access to health services for Indigenous Australians as a contribution
tothe ‘Close the Gap’ campaign. This research and policy report contributes to the aims of the RAP.
Royal Flying Doctor Service Research and Policy Unit
In mid-2015, the RFDS established a Research and Policy Unit, located in Canberra. The Unit’s role is to
gather evidence about, and recommend solutions to, improving health outcomes and health service access
for patients and communities cared for by RFDS programs. The Research and Policy Unit can be contacted
by phone on (02) 6269 5500 or by email at enquiries@rfds.org.au.
Notes about this report
Use of the term ‘Indigenous’
The term ‘Aboriginal and Torres Strait Islander peoples’ is preferred in RFDS publications when referring tothe
separate Indigenous peoples of Australia. However, the term ‘Indigenous Australians’ is used interchangeably
with ‘Aboriginal and Torres Strait Islander peoples’ in order to assist readability.
Data limitations
Data in RFDS reports come from a number of different administrative datasets and surveys, all of which have
limitations that should be considered when interpreting the results.
LOOKING AHEAD: RESPONDING TO THE HEALTH NEEDS OF COUNTRY AUSTRALIA IN 2028  THE CENTENARY YEAR OF THE RFDS

4ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Contents
Acknowledgments 2
Commitment to Indigenous Reconciliation 3
Royal Flying Doctor Service Research and Policy Unit 3
Notes about this report 3
Tables 5
Figures 5
Abbreviations 6
Foreword 7
Executive summary 8
Chapter 1: Introduction 10
1.1.1 Australia’s health 10
1.1.2 Rural and remote health 12
1.1.3 Older persons’ health 12
1.1.4 Rural and remote older persons’ health 13
1.2 Report aims and research questions 14
Chapter 2: Methods 15
2.1 Defining rural and remote Australia 15
2.2 Defining older Australians 15
2.3 Setting 16
2.4 Design and participants 16
2.5 Data sources 16
2.6 Statistical analysis 16
Chapter 3: Epidemiology of RFDS patients aged 65 or older in rural and remote Australia 17
3.1 RFDS aeromedical epidemiology trends in people aged 65 or older 18
3.2 RFDS primary health epidemiology trends in people aged 65 or older 21
3.3 RFDS combined aeromedical and primary health epidemiology trends inpeople aged 65 or older 22
Chapter 4: Services available for older rural and remote Australians 23
4.1 Health care services in rural and remote Australia 24
4.1.1 Hospitals, emergency departments and general practitioners in remoteAustralia 24
4.2 Treatment and management of chronic conditions 27
4.2.1 Injury prevention and older persons rehabilitation 27
4.2.2 Cardiovascular disease 30
4.2.2.1 Coronary heart disease 30
4.2.2.2 Stroke 32
4.2.3 Services for neoplasms—cancer 34
4.3 Aged care facilities 34
Chapter 5: Discussion and Recommendations 36
5.1 Health care for ageing Australians in rural and remote areas 37
5.2 Stroke services 37
5.3 Access to oncology services 37
5.4 Cardiac rehabilitation 37

5HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
5.5 Responding to dementia 39
5.6 Aged care services 39
5.7 Conclusion and recommendation 40
Chapter 6: Conclusion and future research interventions 41
References 42
Tables
Table 3.1 RFDS aeromedical retrievals for patients aged 65 and older, diagnosis
by gender and probability 19
Table 3.2 RFDS aeromedical retrieval Indigenous patients aged 65 and older, patient
diagnosis by gender and probability 20
Table 3.3 RFDS Queensland primary health patient (>65 years old) diagnosisandcount 21
Table 4.1 Remote and very remote population hospital service coverage by SA3 25
Table 4.2 Remote and very remote population emergency department coverage by SA3 26
Table 4.3 Remote and very remote population general practitioner coverage by SA3 27
Table 4.4 Highest rates: Preventable hospitalisation rate—heart failure, by SA3 31
Table 4.5 Lowest rates: Preventable hospitalisation rate—heart failure, by SA3 31
Figures
Figure 1.1 Distribution of total population aged 65 years or older in 2016 per SA3 11
Figure 1.2 Distribution of Indigenous population aged 65 years or older in2016perSA3 11
Figure 1.3 Disability-adjusted life years by age and geographical location 13
Figure 3.1 RFDS aeromedical retrievals by Indigenous status, by location (July 2014 – June 2017) 18
Figure 3.2 RFDS aeromedical retrievals for patients aged 65 and older, diagnosisbygender
and percentage 19
Figure 3.3 RFDS aeromedical retrievals for Indigenous patients aged 65 and older, patient
diagnosis by gender and percentage 20
Figure 3.4 RFDS Queensland primary health care patient (>65 years old) diagnosis type
and percentage 22
Figure 4.1 Variables that contribute to increased falls risk in older Australians 28
Figure 4.2 Non-RFDS physiotherapist provision for patients aged 65 years or older in remote
and very remote Australia 2016–17* 29
Figure 4.3 Non-RFDS occupational therapist provision for patients aged 65 years or older in
remote and very remote Australia 2016–17* 30
Figure 4.4 Number of strokes (>65 years old) in 2017 and corresponding strokeunitprovision 33
Figure 4.5 Areas in greatest need of aged care services per 100,000 population 35

6ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Abbreviations
ABS Australian Bureau of Statistics
ACAR Aged Care Approvals Round
ACS acute coronary syndrome
AHPRA Australian Health Practitioner Regulation Agency
AIHW Australian Institute of Health and Welfare
ASGS Australian Statistical Geography Standard
AUD Australian dollar
CABG coronary artery bypass graft
CHD coronary heart disease
COACH Coaching patients On Achieving Cardiovascular Health
COAG Council of Australian Governments
COPD chronic obstructive pulmonary disease
CR cardiac rehabilitation
CT computed tomography
CVD cardiovascular disease
Cwlth Commonwealth
DALY disability-adjusted life years
DM diabetes mellitus
FIM Functional Independence Measure
GP general practitioner
HT hypertension
iCCNet Integrated Cardiovascular Clinical Network
ICD International Statistical Classification of Diseases and Related Health Problems
MBS Medicare Benefits Schedule
MI myocardial infarction
NATSIFACP National Aboriginal and Torres Strait Islander Flexible Aged Care Program
ORH Operational Research in Health
PBS Pharmaceutical Benefits Scheme
PCI percutaneous coronary interventions
PEs primary evacuations
RAP Reconciliation Action Plan
RFDS Royal Flying Doctor Service
SA3 Statistical Area Level 3
SPOT Service Planning and Operational Tool

7HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Abbreviations
ABS Australian Bureau of Statistics
ACAR Aged Care Approvals Round
ACS acute coronary syndrome
AHPRA Australian Health Practitioner Regulation Agency
AIHW Australian Institute of Health and Welfare
ASGS Australian Statistical Geography Standard
AUD Australian dollar
CABG coronary artery bypass graft
CHD coronary heart disease
COACH Coaching patients On Achieving Cardiovascular Health
COAG Council of Australian Governments
COPD chronic obstructive pulmonary disease
CR cardiac rehabilitation
CT computed tomography
CVD cardiovascular disease
Cwlth Commonwealth
DALY disability-adjusted life years
DM diabetes mellitus
FIM Functional Independence Measure
GP general practitioner
HT hypertension
iCCNet Integrated Cardiovascular Clinical Network
ICD International Statistical Classification of Diseases and Related Health Problems
MBS Medicare Benefits Schedule
MI myocardial infarction
NATSIFACP National Aboriginal and Torres Strait Islander Flexible Aged Care Program
ORH Operational Research in Health
PBS Pharmaceutical Benefits Scheme
PCI percutaneous coronary interventions
PEs primary evacuations
RAP Reconciliation Action Plan
RFDS Royal Flying Doctor Service
SA3 Statistical Area Level 3
SPOT Service Planning and Operational Tool
Foreword
The Hon Ken Wyatt AM, MP
Minister for Indigenous Health
Minister for Senior Australians and Aged Care
On average, Australians are living longer and are healthier than ever before, however, our ageing
population means rising numbers of people with chronic conditions and increased need for
health services for older Australians.
Aged care is vitally important for rural and remote areas, where the challenge of essential
rehabilitation and aged care services means many country Australians are being relocated to
major cities and towns, often far removed from family and friends.
Higher rates of illness experienced by some First Nations people increases the country city
disparity, as they make up a large percentage of the population in remote areas.
I welcome this research report from the Royal Flying Doctor Service, which looks closely into
current health service access for older Australians living in country areas.
The treatment and management of chronic disease requires integrated care that involves
collaboration and coordination between service providers and services across primary,
secondary and tertiary care settings.
This paper is a step in the right direction, analysing national clinical data from RFDS aeromedical
retrievals of older persons, to make preventative recommendations, to improve health outcomes
for older Australians in the bush.
There is no quick fix but the RFDS’ push for targeted, innovative services for managing chronic
heart disease, cancer and neurological illness will improve results for senior Australians in the
rural and remote areas and lead to a better quality of life in their later years.
I encourage the careful consideration of this report, to ensure that health services for country
Australians are appropriate, well-targeted and responsive to changing needs
The Hon Ken Wyatt AM, MP
Minister for Indigenous Health
Minister for Senior Australians and Aged Care

8ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Executive summary
Overall, the Australian population is ageing. The 2018 median Australian age
was37.2, which is estimated to grow to a median age of 39.0 in the year 2028.
In 2018, people aged 65 years and over made up 15.6% of Australia’s population.
This is projected to increase to 22% in 2061 and to 25% in 2101. Aspeople live
longer, the prevalence of chronic diseases will increase, resulting inincreased
health service utilisation by older Australians.
Most of the population growth in older Australians will be concentrated in major cities in the next
10 years; however, the older population in rural and remote Australia is growing at a faster rate
(2.9% per year) compared to all other age groups in rural and remote areas (1.3%). To date there
has been very little information published on the health of older Australians in rural and remote
areas of our country. This report provides, for the first time, epidemiological data on older rural
and remote Australians who accessed Royal Flying Doctor Service (RFDS) aeromedical and
primary health care services, most often in areas where few other health services are available.
The RFDS conducted 23,377 aeromedical retrievals for patients aged 65 and older in the
threeyears between 1st July 2014 and 30th June 2017. This included 13,867 (59.3%) males and
9,445 (40.4%) females, with 18,252 (78.1%) being non-Indigenous people. The main reason for
anaeromedical retrieval was associated with diseases of the circulatory system (31.8%), injury
(12.8%), and diseases of the digestive system (9.2%). When comparing genders, maleswere
more likely (p<0.05) to have diseases of the circulatory system, abnormal clinical andlaboratory
findings, neoplasms and disease of the genitourinary system than females. Whereasfemales
weremore likely (p<0.05) than males to have injury and factors influencing healthstatus, such
asencountering health services in circumstances related to reproduction.
The RFDS also provides extensive primary health care services throughout Australia, including
general practitioner (GP) clinics in rural and remote areas. For example, the RFDS Queensland
Section provided 9,456 episodes of primary health care to patients aged 65 years or older between
1st of May 2016 and 31st May 2018 (2 years). This consisted of a total of 9,456 patient episodes.
The leading primary health care diagnoses included diseases of the circulatory system (19.4%),
diseases of the skin and subcutaneous tissue (14.8%), and diseases of the musculoskeletal system
and connective tissue (11.1%). Although more males sought treatment at these primary health care
clinics (p<0.05), female patients were more likely to receive treatment for diseases of the circulatory
system (p<0.05), diseases of the musculoskeletal system and connective tissue (p<0.05), abnormal
laboratory findings (p<0.05), and mental and behavioural disorders (p<0.05). Males, however, were
significantly more likely than females to be treated for diseases associated with blood and immune
disorders (p<0.05), although they were generally spread evenly throughout diagnostic categories.
The combined aeromedical and primary health care leading diagnosis included diseases of
thecirculatory system (28.3%), injury and poisoning (9.4%), and diseases of the skin and
subcutaneous system (4.7%).
Comparing to the broader Australian population, the three most common diagnoses following an
older person attending an emergency department included pain in throat and pain in chest
(i.e.chest pain), abdominal and pelvic pain, and cellulitis. The main reasons that older people
experienced hospitalisations were for diseases of the circulatory system, and injury and poisoning.

9HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
The treatment and management of chronic disease, and the key health issues the RFDS
responds to in rural and remote Australia, requires integrated care that involves collaboration
andcoordination between service providers and services across primary, secondary and
tertiarycare settings. However, the majority of health services are in metropolitan areas and
ruraland remote patients have limited access to other health care services, including specialist
andrehabilitation services, often requiring travel of more than 60 minutes. For example:
> Older people in rural and remote areas are more likely to suffer a stroke than those
inmajorcities, however the provision of stroke services in the bush is very poor;
> There are also significantly fewer physiotherapists and occupational therapists in rural
andremote areas to oversee injury rehabilitation following falls, a key reason for an RFDS
aeromedical retrieval of an older person;
> While the rates of all cancers are higher in rural and remote areas, there is a lack of access
tovarious oncology subspecialist treatments, such as medical and radiation oncology,
haematology and palliative care, and allied health services;
> The top diagnostic reason for a person aged over 65 to access RFDS aeromedical or
primaryhealth care services included in this report was for diseases of the circulatory system,
andparticularly cardiovascular disease. However, cardiac services, including cardiac
rehabilitation services and programs aimed at prevention are still dominantly located in
majorcities and inner regional areas; and,
> With the population of rural and remote areas ageing at a rate faster than any other in
Australia, dementia and neurological conditions are expected to increase significantly over
coming years, and there are not currently adequate services to respond.
When comparing the retrieval locations of patients aged 65 and older, many were from areas
oflow provision of aged care, thus resulting in many either staying in hospital or being admitted
to aged care facilities far removed from their communities. This situation has a significant impact
onolder people and their families, and often results in isolation when older people have to be
transferred into long-stay hospitalisation or residential aged care. There is also an increased
burden on emergency departments and geriatric evaluation and management units of hospitals.
Coupled with poor provision of aged care facilities in rural and remote areas, these gaps in
health care services may be leading to increased avoidable death rates in the bush.
The RFDS recommends the development by the Council of Australian Governments (COAG)
ofacoordinated National Healthy Ageing Strategy which identifies the health status and service
delivery challenges in rural and remote areas, and through locally appropriate solutions, focuses
onincreasing access to stroke services; injury rehabilitation services; cardiac rehabilitation
services; dementia services; and increasing the availability of local aged care places.

10 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Chapter 1: Introduction
> In 2016, life expectancy at birth in Australia was 80.4 years for males and
84.6years for females, with people aged 65 years and over in the year 2018
accounting for 15.6% of Australia’s population. As people live longer, they will
also develop and manage a greater prevalence of chronic disease, resulting in
increased health service utilisation.
> People aged 65 years and older are evenly distributed throughout Australia,
although the rate of disease burden increases with remoteness, with rural and
remote patients suffering from significantly more chronic disease than people
inmajor cities. This issue is compounded by fewer residential aged care places
available in rural and remote areas, with 38% of facilities in remote areas and
72% in very remote areas having fewer than 20 places.
1.1.1 Australia’s health
The Australian population life expectancy is expected to continue to grow, indicating
improvements in health.(1) In 2016, life expectancy at birth was 80.4 years for males and
84.6years for females. However, overall the Australian population is ageing—this is due to a
reduction in the ‘replacement of fertility’ (or average child per mother) combined with increasing
lifeexpectancy. The median age (the age that half the population is older than and half is
younger than) of the Australian population has increased by 3.0 years over the last two decades,
from 34years in 1995 to 37 years in 2015.(2) This figure is projected to increase to between
38.6years and 40.5 years in 2031 and to between 41.0 years and 44.5 years in 2061.(3)
The2018 median age was 37.2,(4) which is estimated to grow to a median age of 39 in 2028.
Inthe year 2018, people aged 65 years and over made up 15.6% of Australia’s population.(5)
This is projected to increase to 22% in 2061 and to 25% in 2101.(6) It is expected that as
peoplelive longer, they will also develop and manage a greater prevalence of chronic disease,
thusresulting in increased health service demand and utilisation.
Thirty-three percent (33%) of those aged 65 and older live in New South Wales, and 25% in
Victoria. The distribution of those aged 65 or older as a proportion of the total population differs
across the states, with 19% in Tasmania, 18% in South Australia, 16% in New South Wales,
15% in Queensland, and 7% in the Northern Territory.(5) However, the distribution by Statistical
Area Level 3 (SA3, as per the Australian Bureau of Statistics (ABS)) of the older population is
relatively even (Figures 1.1 and 1.2), although many live in major cities within these areas,
oftendue to service availability.(7, 8)

11HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Figure 1.1 Distribution of total population aged 65 years or older in 2016 per SA3
Source: Author's extrapolation from RFDS data
Figure 1.2 Distribution of Indigenous population aged 65 years or older
in2016perSA3
Source: Author's extrapolation from RFDS data
Low population High population
Low population High population

12 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
While the Australian population’s health is improving, resulting in increased life expectancy,
subsections of the Australian population, including rural and remote populations, still experience
increased morbidity and mortality as compared to major cities.(6)
1.1.2 Rural and remote health
Twenty-nine percent (29%) of the Australian population live in rural and remote areas, with 18%
living in inner regional areas, 8.9% in outer regional areas, 1.4% in remote areas and 0.9% in
very remote areas.(9) People living in rural and remote areas tend to have a lower life expectancy
and higher prevalence of disease and injury, coupled with poorer access to health services as
compared to major cities.(10, 11)
In 2015, age-standardised potentially avoidable death rates increased as remoteness increased,
withpeople living in very remote areas having a death rate over 2.5 times as high as people
living in major cities (256 per 100,000 population compared with 96 per 100,000 population).(11)
People living in rural and remote Australia have much higher DALYs (disability-adjusted life years)
compared to those living in major cities and inner regional areas. There are many potential
reasons for this, reflecting both social and geographical factors, such as reduced educational
and employment opportunities, income, and health care provision and thus access. As per
Gardiner et al.,(10) those living in rural and remote areas face more occupational and physical
risks, including farming and mining injury, transport accidents and potentially domestic violence.
This coupled with higher rates of tobacco smoking, drug use and alcohol misuse all contribute
to poorer health outcomes.(9-11)
The mortality rates and causes differ in rural and remote as compared to major cities.
In2009–11, rural and remote people had higher mortality rates (1.4 times) compared to people
inmajor cities, with coronary heart disease (CHD) being between 1.2 and 1.5 times more
prevalent in rural and remote areas. The 2016 Australian Health Status Report(9) demonstrated
that the rate of death due to land motor vehicle accidents was four times higher. The leading
comorbidity associated with cardiovascular disease (CVD) is diabetes mellitus (DM), with rural
and remote patients experiencing between 2.5 and 4 times higher prevalence. Of interest, in
2017 the Royal Flying Doctor Service (RFDS) conducted 7,696 aeromedical transfers for
predominately diseases of the circulatory system, with many of the patients having
comorbiditiessuch as hypertension (HT), and DM.(6)
1.1.3 Older persons’ health
Disease types impacting older Australians are different to disease types impacting younger
Australians. In 2018, the burden (DALY) from CHD was highest among older people aged 75–84
(13%), followed by dementia (7.7%), chronic obstructive pulmonary disease COPD (6.8%),
stroke(6.1%), and lung cancer (4.5%). Dementia was more prominent (15%) among older
people aged 85–94 and was the leading cause of disease burden among women aged 85–94.
CHD was the leading cause of burden (17%) among all older people aged 85–94. Stroke was
the third leading (8.6%) cause of burden in this age group, among both men and women. The
leading causes of burden among very old people (aged 95 and over) included dementia (21%),
CHD (19%), and stroke (9.2%) The top five also included infections and injuries (3.1%), which
can be more hazardous to a person’s health in older age.
Dementia and neurological conditions are expected to significantly increase during the next
10years.(6) One of the main reasons for the increase in neurological disorders is longer life
expectancy. People live longer and, accordingly, suffer dementia more often than several
decades ago. Because neurological disorders are more prevalent in older adults and people are
living longer (because of decreases in the number of deaths from CVD and cancer), there is an
unprecedented increase in the number of people affected by neurological disorders.(12)

13HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
1.1.4 Rural and remote older persons’ health
The prevalence of disease and the causes of death differ among population groups, including
differences by age, gender, ethnicity and remoteness. The reasons for this are driven by
variations in the population’s characteristics, including illness and risk factors, and access to
health services in rural and remote Australia.(1) The mortality rates in rural and remote Australia
are significantly higher compared to major cities, with these disparities increased by the higher
rates of illness among Aboriginal and Torres Strait Islander people, who make up the majority
ofthe population in remote areas of Australia.(6)
As discussed, Australians are living longer and are healthier than ever before. Some groups,
however, continue to face disadvantage that affects both their mental and physical health
andtheir opportunities for social and economic engagement within their communities.
The Aged Care Act 1997 (Cwlth) defines some populations as ‘people with special needs’—
people with particular care needs that should be taken into consideration. Two of these groups
include people from Aboriginal and Torres Strait Islander communities, and those who live in
ruralor remote areas, both of which are of central focus to the RFDS.
The rates of disease burden increase with both remoteness and age. Based on 2011 data,(13)
thedisease burden in rural and remote areas was higher than major cities, as detailed in
Figure1.3. This issue is compounded by fewer residential aged care places available in rural
andremote areas, with 38% of facilities in remote areas and 72% in very remote areas having
fewer than 20places. Older Australians in remote or very remote areas accounted for 0.7%
ofpeople aged65 and over in permanent residential aged care.(13)
Figure 1.3 Disability-adjusted life years by age and geographical location
1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
DALY
Age group (years)
70–74 75–79 80–84 85+
65–69
Rate ratio
Remote
Outer regions
Major cities
Inner regional
Very remote
Rate Ratio
1.7
1.6
1.5
1.4
1.3
1.2
1.1
1.0
Source: Australian Institute of Health and Welfare. Older Australia at a glance. Canberra, Australia: AIHW, 2017.

14 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Indigenous Australians continue to face disadvantage in areas of education, income, employment
and housing. The relationship between these social determinants and both mental and physical
health is well established. Indigenous Australians of all ages face substantial health issues.
Thispopulation has a higher mortality rate and a lower life expectancy, reflected in the younger
ageprofile of Indigenous Australians—in 2016, just 4% (31,000) of the Indigenous population
wereaged 65 and over compared with 15% (3.7 million) of the non-Indigenous population.(6)
1.2 Report aims and research questions
To date there has been very little information communicated on rural and remote older persons’
health. This report aims to provide epidemiology data on aeromedical retrievals for older rural
and remote Australians who accessed the RFDS between the years 2014 and 2017. As such,
this report has the following primary research questions:
> What are the leading RFDS aeromedical retrieval and primary health care diagnoses
forolderrural and remote Australians?
> What services are available for older rural and remote Australians and does this differ
byremoteness?

15HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Chapter 2: Methods
> Older persons were defined as >65 years old. This age was used rather
than >75 years old due to the higher prevalence of disease in rural and remote
communities, coupled with higher rates of disadvantaged groups, thus leading
to reduced life expectancies.
> The whole geography of Australia was included, including major cities, rural,
andremote areas. The term ‘rural and remote’ was defined as all areas outside
Australia’s major cities.
> The design of this report was to determine the epidemiology trends in older
persons living in rural and remote Australia, who accessed the RFDS primary
healthcare and aeromedical retrieval services.
> Data used included patient data from RFDS databases, and external
Department of Health and clinical registration databases.
2.1 Defining rural and remote Australia
The 2016 Australian Census counted 23.4 million people living in Australia, which was an
increase of 8.8% since the 2011 census.(14) Indigenous Australians comprise approximately 2.8%
(n=649,171)(14) of the total Australian population, although comprise almost half of the rural and
remote population.(15) Non-Indigenous Australians most commonly live in major cities. Based on
recent census data,(14) the leading non-Indigenous ancestry was English (36.0%), followed by
Irish (11.0%), Scottish (9.3%), and Chinese (5.6%).
Rural and remote parts of Australia encompass the majority of Australia’s landmass,(15) however
based on 2013 estimates, almost 71% of the population (n=16,678,000) resided in Australia’s
major cities. A little over 27% (n=6,342,000) of Australians resided in regional areas with just
2.3% (n=540,300) living in remote or very remote Australia.(16)
2.2 Defining older Australians
In the latest Australian Institute of Health and Welfare (AIHW) report, older persons were defined
as those who were >75 years old.(1) However, consistent with broader literature, this report
defines older persons as >65 years old, due to the higher prevalence of disease in rural and
remote communities, coupled with higher rates of disadvantaged groups, thus leading to reduced
age life expectancies. As such, this report uses the 65-year-old threshold for the wider rural and
remote population. It should be noted however, that publications focusing on Indigenous health
normally use a >55-year-old threshold to define older Indigenous populations.(17)

16 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
2.3 Setting
The RFDS operates a 24-hour, seven-days-a-week (24/7) aeromedical retrieval service,
supported by a 24/7 telehealth system, to people who live, work or travel in rural and remote
regions of Australia, are unable to access normal medical services, and who experience a
medical emergency requiring definitive care in a tertiary hospital. The RFDS also provides
extensive primary healthcare services throughout Australia including, although not limited to,
GPand nursing clinics. The types of services differ in response to configuration of other local
health services in particular operating regions.
The RFDS services from which these data have been drawn were provided in rural and remote
areas, with the term ‘rural and remote’ including all areas outside Australia’s major cities. This
includes areas that are classified as inner and outer regional (RA2 and RA3 respectively) and
remote or very remote (RA4 and RA5 respectively) under the Australian Statistical Geography
Standard (ASGS).(18) 1
2.4 Design and participants
The study is a cross-sectional study based on prospective collected patient data for RFDS
retrievals from 1 July 2014 to 30 June 2017 (3 years) and from Queensland RFDS primary
healthcare clinics from 1 May 2016 to 31 May 2018 (2 years). Although patient data was
collected for all age-groups, this analysis only included those patients aged ≥65 years.
2.5 Data sources
To determine healthcare service provision, we used ABS census, and Health Direct data
sources,(19) and then inputted them into the RFDS Service Planning and Operational Tool (SPOT)
todetermine population coverage. SPOT is designed for exploring healthcare coverage in
remote and very remote Australia. Working from a geographic distribution of ‘demand’ and
asetof healthcare facilities that provide cover for a range of services, SPOT calculates the
proportion ofdemand covered by those facilities within a user-specified drive time. Demand is
represented by population levels in different categories (e.g. mental health services) as well as
some specific RFDS demand types (retrievals).
In addition to Health Direct data sources,(19) we also used RFDS clinical databases,
to provide data on non-MBS medical service provision (such as the location and number of
RFDS primaryhealthcare clinics provided throughout Australia). This was completed in addition
to thecollecting of patient demographic information, medical history, diagnosis, location,
serviceprovider and type, and extensive information concerning patient treatment.
2.6 Statistical analysis
A combination of descriptive statistics, t-test, and Chi-square analysis was used in data analysis,
with significance determined at p<0.05. All analyses were performed using the statistical
software package R version 3.5.1.
1 The ASGS allocates one of seven remoteness categories to an area (major cities, inner regional, outer regional, remote, very
remote, migratory-offshore-shipping, and no usual address), based on its distance from a range of population centres. Each of
these remoteness categories are also defined by population characteristics. The remoteness structure of the ASGS uses the same
principles of the earlier remoteness classification system—the Australian Standard Geographical Classification System Remoteness
Areas (ASGC-RA)—which was formerly used to define remoteness structure. Although the ASGS remoteness areas have been
defined using a different base unit, the remoteness areas from the ASGC and the ASGS are generally comparable, according to the
Australian Bureau of Statistics (ABS). The Modified Monash Model uses the ASGS-RA as a base, and further differentiates areas in
inner and outer regional Australia based on local town size. The Modified Monash Model was developed to recognize the
challenges in attracting health workers to more remote and smaller communities(18) and improves categorisation of metropolitan,
regional, rural and remote areas according to both geographical remoteness and town size. It is a tool often used to inform health
resource allocation by government policymakers. The Modified Monash Model was not used in this report, as it concerns
workforce incentives to promote clinicians to relocate to rural and remote areas. The ASGS-RA was used in this report, as it
provides good classification as it pertains to resource allocation per 100,000 population.

17HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Chapter 3: Epidemiology of RFDS
patients aged 65 or older in rural and
remote Australia
> The RFDS provided 23,377 aeromedical retrievals nationally for patients
aged65 and older between 2014 and 2017.
> The combined aeromedical and primary healthcare leading diagnoses included
diseases of the circulatory system (28.3%), injury and poisoning (9.4%), and
diseases of the skin and subcutaneous system (4.7%).
> Consistently, the three most common diagnoses following an older person
attending an emergency department included pain in throat and pain in chest
(i.e. chest pain), abdominal and pelvic pain, and cellulitis. The main reasons that
older people experienced hospitalisations included diseases of the circulatory
system, and injury and poisoning.
> While rural and remote older persons’ diagnostic data appears to be consistent
with general Australian trends, there is a higher chronic disease prevalence at a
younger age in rural and remote areas (65 years old), as compared to major
cities (70 years old), as well as more avoidable deaths.

18 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
3.1 RFDS aeromedical epidemiology trends in people aged 65 or older
The RFDS provided 23,377 (32.8%) aeromedical retrievals for patients aged 65 and older between
2014 and 2017, with 13,867 (59.3%) males and 9,445 (40.4%) females. This included 1,690
Indigenous patients (7.2%), consisting of 762 (45.1%) male and 928 (54.9%) female patients.
These results indicated that non-Indigenous males were more likely (p<0.05) to receive an RFDS
aeromedical retrieval, whereas Indigenous females were more likely (p<0.05), indicating a reversal
in ethnicity gender trends. As detailed in Figure 3.1, the majority of Indigenous patients were
retrieved from remote areas of Australia.
Figure 3.1 RFDS aeromedical retrievals by Indigenous status, by location
(July 2014 – June 2017)
Note: The majority (85.3%) of the Indigenous status was recorded throughout Australia. However, Queensland RFDS did not routinely
collect Indigenous or non-Indigenous status, with 3,231 patients missing (35%) this data. As such, they were excluded from Figure 3.1.
Thus Figure 3.1 does not reflect Queensland Indigenous or non-Indigenous retrievals.
The main reasons for an RFDS aeromedical retrieval for a patient over 65 between 2014 and
2017 were associated with diseases of the circulatory system (31.8%), injury (12.8%), and
diseases of the digestive system (9.2%), as detailed in Figure 3.2. When comparing genders,
males were more likely (p<0.05) to have diseases of the circulatory system, abnormal clinical
andlaboratory findings, neoplasms and disease of the genitourinary system. Females were more
likely (p<0.05) to have injury, factors influencing health status and contact with health services.
Further detail is provided in Table 3.1.
Red: Indigenous patient evacuations
Blue: Non Indigenous

19HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Figure 3.2 RFDS aeromedical retrievals for patients aged 65 and older,
diagnosisbygender and percentage
Males
Females
Population
Percentage
Males
Females
Population
0 10.0 20.0 30.0 40.0
Factors influencng
health status and contact
with health services
Symptoms, signs and abnormal
clinical and labratory findings,
not elsewhere classified
Diseases of the
digestive system
Diseases of the
circulatory system
Injury (including
poisoning)
7.8
6.8
7.2
8.2
9.2
9.1
9.4
7.7
8.5
12.8
27.7
31.8
34.0
16.4
10.4
Table 3.1 RFDS aeromedical retrievals for patients aged 65 and older, diagnosis by
gender and probability
Diagnosis (ICD chapter) Male (%) Female (%) Probability Interpretation
Disease of the circulatory system (9) 4,826 (34.0) 2,617 (27.7) <0.05 Significantly more males
Injury (19) 1,439 (10.4) 1,549 (16.4) <0.05 Significantly more females
Disease of the digestive system (11) 1,257 (9.1) 893 (9.4) >0.05 Populations the same
Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified (18)
1,187 (8.6) 724 (7.7) <0.05 Significantly more males
Factors influencing health status and
contact with health services (21)
949 (6.8) 741 (7.8) <0.05 Significantly more females
Diseases of the respiratory system (10) 724 (5.2) 533 (5.6) >0.05 Populations the same
Repatriation (coded as 55) 662 (4.8) 530 (5.6) <0.05 Significantly more females
Neoplasms (2) 710 (5.1) 419 (4.4) <0.05 Significantly more males
Diseases of the genitourinary system (14) 639 (4.6) 323 (3.4) <0.05 Significantly more males
Diseases of the musculoskeletal system and
connective tissue (13)
257 (1.8) 192 (2.0) >0.05 Populations the same
Total 13,867 (59.3) 9,445 (40.4) <0.05 Significantly more males
Note: ICD refers to the International Statistical Classification of Diseases and Related Health Problems
The main reason for an aeromedical retrieval for an Indigenous patient was for diseases of the
circulatory system (25.7%), followed by diseases of the respiratory system (13.7%), and injury
(11.1%), as detailed in Figure 3.3. Of interest, although Indigenous females were more likely to
require an RFDS aeromedical retrieval, the differences in disease by gender were non-significant
(p>0.05) indicating no statistical differences in disease rates between Indigenous genders. This
is detailed in Table 3.2.

20 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Figure 3.3 RFDS aeromedical retrievals for Indigenous patients aged 65 and older,
patient diagnosis by gender and percentage
Males
Females
Total
Percentage
Diseases of the
respiratory system
Injury
Symptoms, signs and abnormal
clinical and labratory findings,
not elsewhere classified
Disease of the
digestive system
Diseases of the
circulatory system
0 5.0 10.0 15.0 20.0 25.0 30.0
7.8
9.8
8.7
9.9
11.1
9.4
12.4
8.9
11.0
13.7
24.7
25.7
26.9
12.9
14.7
Note: Although acute myocardial infarction (MI) is a disease of the circulatory system, where possible the most detailed ICD
classification was used.
Table 3.2 RFDS aeromedical retrieval Indigenous patients aged 65 and older,
patient diagnosis by gender and probability
Diagnosis (ICD chapter) Male (%) Female (%) Probability Interpretation
Disease of the circulatory system (9) 205 (26.9) 229 (24.7) >0.05 Populations the same
Diseases of the respiratory system (10) 112 (14.7) 120 (12.9) >0.05 Populations the same
Injury (19) 72 (9.4) 115 (12.4) >0.05 Populations the same
Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified (18)
84 (11.0) 83 (8.9) >0.05 Populations the same
Disease of the digestive system (11) 75 (9.8) 72 (7.8) >0.05 Populations the same
Diseases of the genitourinary system (14) 41 (5.4) 65 (7.0) >0.05 Populations the same
Certain infectious and parasitic diseases (1) 31 (4.1) 47 (5.1) >0.05 Populations the same
Diseases of the skin and subcutaneous
tissue (12)
33 (4.3) 26 (2.8) >0.05 Populations the same
Endocrine, nutritional and metabolic
diseases (4)
15 (2.0) 26 (2.8) >0.05 Populations the same
Neoplasms (2) 16 (2.1) 24 (2.6) >0.05 Populations the same
Total 762 (45.1) 928 (54.9) <0.05 Significantly more females
overall

21HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
3.2 RFDS primary health epidemiology trends in people aged 65 or older
The RFDS provides extensive primary health care services throughout Australia, including,
althoughnot limited to, GP clinics. The types of services provided differ in response to
configuration of other local health services in particular operating regions. The RFDS
QueenslandSection Primary Healthcare Service treated 37,563 patients from 1st of May 2016
untilthe 31stMay 2018 (2years), including general practice patients (n=31,610), medical specialist
outreach patients (n=5.931), and programs such as the Medicare Rural and Remote Medical
Benefits Scheme Clinic (n=14), Men’s Business program (n=2), and Child Health New Directions
program (n=3). There was a total of 9,456 patient episodes for patients over 65, including
significantly (p<0.05) more male patients, with 5,378 (57%) males and 4,077 (43%) females.
Therewere 1,663 (18%) Indigenous patients, with 733 (44%) males and 930 (56%) female
patients. This indicates that female Indigenous patients aged >65 years of age were more likely
(p<0.05) than Indigenous males of thesame age group to access RFDS primary health care.
The leading diagnoses included diseases of the circulatory system (19.4%), diseases of the skin
and subcutaneous tissue (14.8%), and diseases of the musculoskeletal system and connective
tissue (11.1%) (Table 3.3). Although more males sought treatment at the primary health care
clinics (p<0.05), female patients were more likely to receive treatment for diseases of the
circulatory system (p<0.05), disease of the musculoskeletal system and connective tissue
(p<0.05), abnormal laboratory findings (p<0.05), and mental and behavioural disorders (p<0.05).
Males, however, were significantly more likely to be treated for diseases associated with blood
andimmune disorders (p<0.05), although they were generally spread eventually throughout
treatment diagnosis. These results are detailed in Figure 3.3.
These findings in part reflect Australia-wide primary health care data that indicated that in
2013–14 the most common principal diagnoses among people aged 65 and over were diseases of
the circulatory system, and injury, poisoning and certain other consequence of external causes.(13)
The strength of the results presented within this report is that they provide clear primary health
care data on rural and remote patients age 65 or older. This has previously been a limitation of
population-wide diagnostic data.
Table 3.3 RFDS Queensland primary health patient (>65 years old)
diagnosisandcount
ICD Code Description Total (%)
Diseases of the circulatory system 1,832 (19.4)
Diseases of the skin and subcutaneous tissue 1,399 (14.8)
Diseases of the musculoskeletal system and connective tissue 1,045 (11.1)
Factors influencing health status and contact with health services 1,016 (10.7)
Endocrine, nutritional and metabolic diseases 743 (7.9)
Diseases of the respiratory system 640 (6.8)
Diseases of the digestive system 540 (5.7)
Diseases of the genitourinary system 525 (5.6)
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 466 (4.9)
Mental and behavioural disorders 204 (2.2)
Diseases of the eye and adnexa 204 (2.2)
Diseases of the nervous system 180 (1.9)
Neoplasms 162 (1.7)
Diseases of blood and blood-forming organs and certain disorders involving the immune mechanism 155 (1.6)
Diseases of the ear and mastoid process 151 (1.6)
Injury, poisoning and certain other consequences of external causes 102 (1.1)
Certain infectious and parasitic diseases 85 (0.9)
Total 9,456
Note: Factors influencing health status and contact with health services includes care involving dialysis, use of rehabilitation services,
radiotherapy, chemotherapy and palliative care.

22 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Figure 3.4 RFDS Queensland primary health care patient (>65 years old) diagnosis
type and percentage
Males
Females
Total
Percentage
Factors influencing health
status and contact
health services
Endocrine, nutritional,
and metabolic disease
Diseases of the
circulatory system
0 5.0 10.0 15.0 20.0 25.0
8.3
7.5
7.8
10.7
11.1
10.6
11.6
10.3
11.1
14.8
18.1
19.4
13.7
14.9
14.7
Diseases of the
musculoskeletal system
and corrective tissue
Diseases of the skin and
subcutaneous tissue
3.3 RFDS combined aeromedical and primary health epidemiology trends
inpeople aged 65 or older
The combined aeromedical and primary health care leading diagnoses included diseases
ofthecirculatory system (28.3%), injury and poisoning (9.4%), and diseases of the skin
andsubcutaneous system (4.7%). These results need to be interpreted with caution, as the
aeromedical data spanned 3 years, whereas the primary health care data spanned 2 years.
This is the first comprehensive epidemiology of rural and remote patients within Australia which
allows comparisons to Australia-wide estimates. Unfortunately, the literature does not specifically
detail the leading primary health care diagnoses of older people living in metropolitan areas, thus
making comparisons difficult. However, these findings are consistent with Australia-wide prevalence
reports.(13) The three most common diagnoses following an older person (>65 years old) attending
anemergency department, included pain in throat and pain in chest (i.e. chest pain), abdominal
andpelvic pain, and cellulitis. The main reasons that older people (>65 years old) experienced
hospitalisations included diseases of the circulatory system, and injury and poisoning.(13)
These results indicate that preventative and rehabilitation services are needed in the rural and
remote older persons population, to help reduce the prevalence of both aeromedical and primary
health care presentations related to the circulatory system and injuries. This should also include
targeted programs for older males in reducing CVD risk factors, and programs targeting older
females in reducing injury risks.

23HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Chapter 4: Services available for older
rural and remote Australians
> There are significant shortages of essential health services in rural and
remote Australia, including insufficient hospital, emergency department,
andgeneral practitioner provision.
> To access basic treatments, rural and remote patients are required to
travelmore than 60 minutes, which is often not feasible for older people.
> The provision of rehabilitation services in rural and remote areas is
significantly lower than major cities. This is concerning considering
thehighrates of falls in the older rural and remote population.
> The provision of cardiac services is poor in rural and remote areas.
Thisincludes reduced access to physical activity programs, nutritional
programs, and specialist medical and cardiac rehabilitation programs.
This is concerning given the high rates of heart failure and its comorbidities,
suchasrenal disease, DM and pulmonary disease, in older rural and
remotepopulations.
> Stroke rates are high amongst older people in rural and remote areas,
however stroke rehabilitation provision is poor.
> The incidence of all cancers is higher for people in regional areas, with
asignificantly higher incidence of bowel cancer, melanoma (associated
withsun exposure) and prostate cancer. However, the majority of cancer
treatment facilities are located in major cities.
> Aged care within Australia is considered high need with rural and remote
areas consistently under-serviced per 100,000 population.

24 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
This chapter details the provision of essential health services needed to manage the most
common conditions experienced by those over 65, including those RFDS is seeing in rural
andremote populations. It will be demonstrated that there are significant shortages of essential
health services in rural and remote Australia,(6) including those most needed by older people.
This is concerning as these populations have increased chronic disease prevalence, and
increased morbidity and mortality.(20, 21)
Reduced accessibility to health and welfare services may be one reason for the lower life
expectancy in rural and remote populations as compared to those living in major cities.
As the majority of Indigenous Australians live in rural and remote areas, reduced access could
alsobe areason for the difference in Indigenous and non-Indigenous disease prevalence,
asthemajority of non-Indigenous live in major cities. In 2014–15, nearly one quarter of
Indigenous people (24%) reported problems accessing service providers; this proportion
increased to 1 in 3 (33%) for Indigenous people living in remote or very remote areas.
As well, the rate of hospitalisations forIndigenous Australians that were potentially preventable
isaround 3.4 times that for non-Indigenous Australians. Older Indigenous people have poorer
healthand higher rates of disability than other older Australians. In the 2011 census, older
Aboriginal and Torres Strait Islander people were almost three times as likely as older non-
Indigenous people toneed helpwith self-care, mobility or communication tasks.(13)
4.1 Health care services in rural and remote Australia
4.1.1 Hospitals, emergency departments and general practitioners in
remoteAustralia
Hospitals, emergency departments, and GP services are an important component of a
contemporary health care system and of importance to rural and remote populations.
Achievingequitable access to hospital services is very important and a significant issue for
ruralcommunities. The majority of health care services are located in major cities in Australia,(6)
withthe majority of remote older patients required to travel more than 60 minutes to access
hospital services. Table4.1 indicates the remote communities with the poorest coverage of
hospital services bypopulation, with the poorest coverage including West Arnhem,
Albany and the Goldfields.

25HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Table 4.1 Remote and very remote population hospital service coverage by SA3
Region (SA3)
Total population
2016*
Covered within
60 minutes**
Population
covered %***
Daly - Tiwi - West Arnhem 14,666 618 4.2%
Albany 3,156 930 29.5%
Goldfields 7,042 3,500 49.7%
Katherine 20,791 10,612 51.0%
Barkly 6,203 3,506 56.5%
East Pilbara 25,991 14,880 57.3%
Bowen Basin - North 10,589 6,076 57.4%
Outback - North and East 11,433 6,785 59.3%
Central Highlands (Qld) 9,239 5,492 59.4%
East Arnhem 7,560 4,529 59.9%
Moree - Narrabri 2,812 1,735 61.7%
Port Douglas - Daintree 675 435 64.4%
Mid West 9,908 6,473 65.3%
Wheat Belt - North 8,414 5,538 65.8%
Wheat Belt - South 5,235 3,674 70.2%
Alice Springs 39,689 28,233 71.1%
Biloela 1,572 1,142 72.6%
Broken Hill and Far West 2,585 1,890 73.1%
Lower Murray 2,207 1,620 73.4%
Charters Towers - Ayr - Ingham 6,536 4,827 73.9%
* The population and service provision only include those within remote and very remote areas, all others are excluded. Please also
note, that this only includes mainland Australia.
** This is calculated using geographical mapping using average motor vehicle (bus, car, and motorbike) drive times based on average
road speeds. Implies the population has access to motor vehicle transport.
*** This percentage includes those covered with a 60-minute drive time. It does not consider clinic or hospital wait times or whether the
clinic or hospital has patient workload capacity.
As with hospital services, emergency department provision in remote areas is poor.
This makes any emergency medical evacuation by road difficult, thus requiring RFDS
aeromedical evacuation. This is reflected in the high number of older populations suffering
injuries(e.g. as a result of a fall) that required emergency retrieval in the past two years.
Table 4.2 indicates the remote communities with the poorest coverage of emergency
departments by population, withthe poorest coverage including West Arnhem,
Kuranda and Albany.

26 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Table 4.2 Remote and very remote population emergency department coverage by SA3
Region
Total population
2016*
Covered within
60 minutes**
Population
covered %***
Daly - Tiwi - West Arnhem 14,666 525 3.6%
Tablelands (East) - Kuranda 1,335 308 23.1%
Albany 3,156 930 29.5%
Goldfields 7,042 3,500 49.7%
Katherine 20,791 10,612 51.0%
Central Highlands (Qld) 9,239 5,240 56.7%
Bowen Basin - North 10,589 6,075 57.4%
Outback - North and East 11,433 6,785 59.3%
East Arnhem 7,560 4,529 59.9%
Moree - Narrabri 2,812 1,735 61.7%
Port Douglas - Daintree 675 435 64.4%
Broken Hill and Far West 2,585 1,690 65.4%
Wheat Belt - North 8,414 5,538 65.8%
Barkly 6,203 4,151 66.9%
Lower Murray 2,207 1,497 67.8%
Wheat Belt - South 5,235 3,674 70.2%
Mid West 9,908 7,051 71.2%
Alice Springs 39,689 28,698 72.3%
Charters Towers - Ayr - Ingham 6,536 4,826 73.8%
Darling Downs (West) - Maranoa 13,737 10,649 77.5%
* The population and service provision only include those within remote and very remote areas, all others are excluded. Please also
note, that this only includes mainland Australia.
** This is calculated using geographical mapping using average motor vehicle (bus, car, and motorbike) drive times based on average
road speeds. Implies the population has access to motor vehicle transport.
*** This percentage includes those covered with a 60-minute drive time. It does not consider clinic or emergency department wait
times or whether the clinic or emergency department has patient workload capacity
Following a hospital admission and/or an emergency department presentation, many
olderpatients will be discharged home for follow-up care with their family, community, and,
ifavailable,their family doctor. This requires effective transition between care, as problems with
clinical handover can have a negative impact on patient outcomes.(22) The RFDS does extensive
inter-hospital transfers, with 70,342 patients transferred by road in 2016–17.(6) This is aimed,
inpart, at reducing patient transfer risks, through continuity of clinical care.
There are many factors that promote effective discharge planning for older patients as they
movefrom hospital to community care. This includes support network education and effective
communication between the acute care provider and the patient’s general practice. This has
long been identified as problematic,(23) with many finding rural and remote areas(6) are further
influenced by delayed and/or inaccurate communication which affects continuity of care and
contributes to adverse patient outcomes.(24) Watson et al.(22) found that of the 50 participants
in their study, 76% attended general practice follow-up within seven days. Those who were
not married (54% versus 84%) and non-drivers (53% versus 90%) were less likely to attend
a follow-up. This study was conducted in a major city, which generally has a high provision
of health care services, including GPs.(6) As the provision of GPs in rural and remote areas is
significantly less than metropolitan areas, coupled with geographical barriers to attendance,
it is likely that those who live rurally and remotely would be even less likely to attend follow-up
care following hospital discharge. Table 4.3 indicates the communities with the lowest provision
of GPs, requiring many patients to travel more than 60 minutes.
Table 4.3 Remote and very remote population general practitioner coverage by SA3

27HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Region
Total population
2016*
Covered within
60 minutes**
Population
covered %***
Broken Hill and Far West 2,585 514 19.9%
Albany 3,156 1,757 55.7%
East Arnhem 7,560 4,529 59.9%
Goldfields 7,042 4,374 62.1%
Moree - Narrabri 2,812 1,746 62.1%
Gascoyne 9,717 6,195 63.8%
Far North 19,934 13,909 69.8%
Outback - North and East 11,433 8,164 71.4%
Wheat Belt - South 5,235 3,842 73.4%
Lower Murray 2,207 1,629 73.8%
Charters Towers - Ayr - Ingham 6,536 4,837 74.0%
Wheat Belt - North 8,414 6,238 74.1%
Central Highlands (Qld) 9,239 6,921 74.9%
Daly - Tiwi - West Arnhem 14,666 11,517 78.5%
Kimberley 36,343 28,910 79.5%
Darling Downs (West) - Maranoa 13,737 11,071 80.6%
Biloela 1,572 1,272 80.9%
East Pilbara 25,991 21,082 81.1%
Mid West 9,908 8,098 81.7%
Outback - South 18,051 14,800 82.0%
* The population and service provision only include those within remote and very remote areas, all others are excluded. Please also
note, that this only includes mainland Australia.
** This is calculated using geographical mapping using average motor vehicle (bus, car, and motorbike) drive times based on average
road speeds. Implies the population has access to motor vehicle transport.
*** This percentage includes those covered with a 60-minute drive time. It does not consider clinic wait times or whether the clinic has
patient workload capacity.
4.2 Treatment and management of chronic conditions
The treatment and management of chronic disease requires integrated care that involves
collaboration and coordination between service providers and services across primary, secondary
and tertiary care settings. Integrated care should extend beyond a patient’s normal service provider
to include access to the wider medical community, inclusive of specialists including physicians,
hospitals, GPs, allied health and nursing providers and Indigenous Health Workers.
4.2.1 Injury prevention and older persons rehabilitation
Many RFDS aeromedical retrieval for patients 65 years or older are response to injuries,
specifically as a result of falls. Falls and fall-induced injuries in older people are common,
furtherraising injury burden and costs.(6, 25)
The rates of people aged 65 years or older living in the community and those in aged care
facilitiesor nursing homes who have a fall ranges from 30% to 50%, with half falling repeatedly.(25)
Fall rates rise with age, with functional impairment and disability common in those aged 90years
or older. Assuch, fall prevention is essential in the planning of effective injury prevention.
Generally,fall prevention consists of regular strength and balance training, nutritional interventions
(suchasvitamin D and calcium), medication review, hearing and vision intervention, and the
reduction ofhome-based hazards and management. The key factors that influence falls are
detailed in Figure 4.1. Of interest, many of the conditions that the RFDS treats in people aged
65years or older also have a direct impact on falls risk. This, coupled with the high rates
ofmedication and alcohol use in this age group and population, heightens the need for falls
andinjury reduction strategies.

28 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Figure 4.1 Variables that contribute to increased falls risk in older Australians
Ageing, disuse and medical
conditions such as:
Parkinson’s disease
Stroke
Arrhythmia
Hypotension
Depression
Epilepsy
Dementia
Eye diseases
Osteoarthrosis
Rheumatoid arthritis
Dizziness and vertigo
Peripheral neuropathy
Impairments:
Muscle function
Joint function
Vestibular system
Vision
Proprioception
Cognition
Alertness
Disabilities:
Static balance
Dynamic balance
Gait
Increased impact force by:
Thin soft tissues
Hard landing surface
Fall injury
Fall impact
Fall descent
Fall initiation
Alchohol and medication
use such as:
Sedatives
Hypnotics
Antidepressants
Antihypertensives
Multiple drugs
Environmental hazards
Source: Kannus, P., et al. Prevention of falls and consequent injuries in elderly people. The Lancet 2005;l366(9500): 1885–1893.(25)

29HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
The provision of allied health services, including physiotherapist and occupational therapist
rehabilitation services, in rural and remote areas is significantly lower than major cities even when
accounting for population differences,(26) as detailed in Figures 4.2 and 4.3. This lack of access
leads to older rural and remote patients spending more time as a hospital inpatient,(27) to receive
essential injury rehabilitation.(28-30)
Rehabilitation services aim to assist people with loss of function or ability due to injury or
diseasetoattain the highest possible level of independence (physically, psychologically,
sociallyand economically) following that incident or illness. This can be achieved through a
multidisciplinary teamconsisting of rehabilitation medicine physicians and nursing and allied
health professionals. Theprocess involves individual assessment, treatment, regular review,
discharge planning (if an inpatient), community integration and follow-up of people who are
referred to that service. Rehabilitation services are guided by principles including: leadership,
equitable access, interdisciplinary care teams, care coordination, patient-centred care,
evidence-based care, appropriate care settings and clinical process and outcomes.(31)
Whiletraditionally many rehabilitation services have been provided in the inpatient hospital
environment, it is recognised that there should be a far greater emphasis on ambulatory models
of care, both in disease management and also in the provision of rehabilitation after people have
suffered sudden or progressive onset of disabling conditions as a result of illness, injury or the
effects ofchronic disease.
Figure 4.2 Non-RFDS physiotherapist provision for patients aged 65 years or older
in remote and very remote Australia 2016–17*
* The physiotherapist service is not specific to older populations. i.e. the service may provide clinical support to multiple age groups.
Source: Author's extrapolation from RFDS data

30 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Figure 4.3 Non-RFDS occupational therapist provision for patients aged 65 years or
older in remote and very remote Australia 2016–17*
* The occupational therapist service is not specific to older populations. i.e. the service may provide clinical support to
multipleagegroups.
Source: Author's extrapolation from RFDS data
Figures 4.2 and 4.3 indicate that there are many rural and remote areas with no provision
ofphysiotherapist and occupational therapist rehabilitation services. As such, those patients
withthe highest clinical need have the lowest provision, which is potentially contributing to
thesignificantly poorer outcomes that rural and remote people have as compared to their
citycounterparts.(6, 32)
4.2.2 Cardiovascular disease
4.2.2.1 Coronary heart disease
Underlying CHD is the primary cause of heart failure, which is usually accompanied by a history
ofmyocardial infarction (MI, better known as heart attack). Other causes of heart failure, and by
extension CHD, include HT, idiopathic cardiomyopathy and valvular heart disease. The primary
riskfactors for these conditions include age (those aged 65 years or older at a heightened risk),
family history of CVD, history of smoking, poor diet, obesity, DM, high cholesterol, excessive
alcohol consumption and inadequate physical activity.(33) Rural and remote populations have
significantly higher rates of many of these risk factors, including obesity, DM, high cholesterol,
excessive alcohol consumption and poor diets due to high fresh food cost.(6) Rural and remote
people admitted to hospital with acute heart failure often have comorbidities with shared risk
factors, suchas renal disease, DM and pulmonary disease.(34) As such, it is not surprising that the
rates ofheart failure are highest in rural and remote Australia, as detailed in Tables 4.4 and 4.5.

31HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Table 4.4 Highest rates: Preventable hospitalisation rate—heart failure, by SA3
Area name (SA3) State Rate Hospitalisations Remoteness (RA)
Barkly NT 994 61 Very remote (RA5)
Kimberly WA 632 154 Very remote (RA5)
Alice Springs NT 554 167 Remote (RA4)
Mount Druitt NSW 437 350 Major city (RA1)
Bourke - Cobar - Coonamble NSW 429 137 Remote (RA4)
Port Douglas - Daintree Qld 424 50 Outer regional (RA3)
Katherine NT 400 58 Remote (RA4)
Wagga Wagga NSW 363 471 Inner regional (RA2)
Outback - South Qld 358 86 Very remote (RA5)
Griffith-Murrumbidgee (west) NSW 340 216 Outer regional (RA3)
Notes:
> Rates are age and sex standardised to the Australian population
> Rates are based on the number of hospitalisations in public and private hospitals (numerator) and people in
the geographical area (denominator)
> Analysis is based on the patient’s area of usual residence, not the place of hospitalisation
Sources: AIHW analysis of National Hospital Morbidity Database 2014–15 and ABS Estimated Resident Population 30th June 2014.(9)
Table 4.5 Lowest rates: Preventable hospitalisation rate—heart failure, by SA3
Area name (SA3) State Rate Hospitalisations Remoteness (RA)
Dural - Wisemans Ferry NSW 90 29 Major city (RA1)
Sherwood - Indooroopilly Qld 94 48 Major city (RA1)
Warringah NSW 95 220 Major city (RA1)
Launceston Tas 96 115 Major city (RA1)
Surf Coast - Bellarine Peninsula Vic 98 109 Major city (RA1)
Notes:
> Rates are age and sex standardised to the Australian population
> Rates are based on the number of hospitalisations in public and private hospitals (numerator) and people in
the geographical area (denominator)
> Analysis is based on the patient’s area of usual residence, not the place of hospitalisation
Sources: AIHW analysis of National Hospital Morbidity Database 2014–15 and ABS Estimated Resident Population 30th June 2014.(9)
Effective management of heart failure involves multidisciplinary care across the acute and
primary care sectors, and a combination of strategies, including:(35)
> Non-pharmacological approaches, such as physical activity programs, and fluid or
dietarymanagement;
> Pharmacotherapy, including diuretics, angiotensin-converting enzyme inhibitors
andbeta-blockers;
> Surgical procedures and supportive devices—for example, coronary artery bypass graft
surgery, or cardiac resynchronisation therapy with or without insertion of an implantable
cardiac defibrillator; and
> Cardiac rehabilitation services,(28, 29) such as cardiac rehabilitation and healthy livingprograms.
The provision of heart services are generally poor in rural and remote areas. This includes
reduced access to physical activity programs, nutritional programs, and specialist medical and
cardiac rehabilitation programs.(36) Pharmaceutical access is generally considered adequate as
compared to metropolitan areas.(6)

32 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
4.2.2.2 Stroke
Stroke is a common and a potentially debilitating condition. It is the second leading cause of
mortality and the third leading cause of morbidity. One in six people will have a stroke during
their lifetime. In Australia, currently, there are around 470,000 people living with this condition;
this is projected to reach 709,000 people in 2032. The financial cost of stroke is substantial
andamounts to $5 billion (AUD) per annum in Australia.(30) Rural and remote Australians are
19%more likely to suffer a stroke.(37)
According to AIHW 2009–10 estimates,(38) the age-adjusted stroke hospitalisation rate for
peopleliving in rural or remote areas (212 hospitalisations per 100,000 population) was 1.5
timeshigher that of people living in major cities (139 per 100,000). Furthermore, in 2006–10,
theage-adjusted stroke death rate was 34 per 100,000 population for people living metropolitan
areas compared with rates of 37 to 38 per 100,000 for people living in rural and remote areas.
Rehabilitation services for stroke survivors are provided across a range of care settings.
Theseinclude inpatient units, day hospitals, outpatient clinics, community centres, home-based
services and virtual clinics via telehealth.(39) Patient access to these services is impacted by
theiravailability within the patients community, and their suitability to the individual’s needs.
Recentdata(40) demonstrated that only 59% of patients with stroke received an assessment
forrehabilitation, and of these patients only 46% had a referral made for ongoing rehabilitation,
eventhough three quarters (75%) of those who had an assessment for rehabilitation had an
identified need for ongoing rehabilitation. These rates are significantly lower than the
recommendation that every patient with stroke be assessed for rehabilitation.(41)
Stroke rehabilitation provision is a problem in rural and remote areas, partially due to the
difficultyingetting appropriate medical intervention within the critical time period of three hours.
Based on arecent Stroke Foundation survey,(42) consisting of 121 eligible stroke rehabilitation
services, themajority (92.6%) of programs were from major cities with nine (7.4%) from rural
areas. Thisindicates that provision of stroke services is poor in rural areas, which is consistent
withrecent workforce provision reports,(6) and Figure 4.4, which details that most of the
provisionisinmajor cities or inner regional areas. The Stroke Foundation survey(42) also measured
patient outcomes, aimed at allowing health professionals to evaluate the effectiveness of their
rehabilitation therapies. Based on the audit, they found that the median Functional Independence
Measure (FIM) in rural patients was lower than that of metropolitan areas, with the urban median
FIM change following treatment equalling 20%, compared to the rural change rate of 17%.
Thisindicates that both provision and outcomes of stroke rehabilitation in the bush are worse
than that of metropolitan areas. This lack of provision would increase the rates of acute stroke
inrural and remote areas, thus leading to increased reliance on the RFDS aeromedical services.

33HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Figure 4.4 Number of strokes (>65 years old) in 2017 and corresponding
strokeunitprovision
Source: Stroke Foundation. No postcode untouched: Stroke in Australia. Melbourne, Australia: Stroke Foundation, 2017.(37)
As most of the provision of stroke services is in major cities, there is a reliance on regional
emergency departments to provide initial care, with many regional emergency departments
unable to provide time-critical therapies. Stroke patients need an assessment by a stroke
specialist to ensure a patient is suitable for treatment. Telemedicine provides those living in
ruraland regional areas with the opportunity to quickly access stroke specialists who can
correctly diagnose stroke and support clinicians on the ground to administer time-critical
thrombolysis treatment or arrange transfer to a comprehensive stroke centre for clot retrieval
treatment. Telemedicine services are now operating in limited areas, but more investment
isrequired todevelop a nationally coordinated stroke telemedicine network.
However, successful TeleStroke (which allows remote stroke neurologist access to patients)
delivery of care still requires the treating centre to complete a CT (computed tomography) scan
immediately, which is not always feasible due to many reasons, including the availability of skilled
technicians.(43) This limitation could be reduced using small portable CT scanners, which require
limited training, to rule out brain haemorrhage. In theory, TeleStroke could support regional
areasand the RFDS, via remote evaluation by a stroke neurologist before thrombolysis
treatment, thusreducing treatment times. A study by Shuaib et al.(43) concluded that portable
scanners, incoordination with telemedicine, can be used successfully in the evaluation
ofpatients in rural andremote regions that are not within timely reach of stroke experts
ordonothave available conventional imaging with CT scans.
• Stroke Unit Location

34 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
4.2.3 Services for neoplasms—cancer
The results of this report indicated that neoplasms were a prominent reason for older
ruralandremote patients seeking the RFDS aeromedical and primary health care services.
Ruralandremote cancer patients have reduced survival rates as compared to people in
majorcities, and are more likely to die within five years of diagnosis.(44) The main contributing
factors for poorsurvival include:(45)
> reduced availability of diagnostic and treatment services;
> delayed diagnosis;
> lower socioeconomic status;
> reduced rates of physical activity;
> increased rates of high-risk alcohol consumption;
> higher rates of smoking; and
> increased sun exposure.
The incidence of all cancers is higher for people in rural and remote areas, which may be partly
due to lifestyle factors. There is a significantly higher incidence of bowel cancer, melanoma
(associated with sun exposure) and prostate cancer. The incidence of cervical cancer, lung
cancer (associated with smoking) and cancer of unknown primary site are significantly higher
inthose living in remote areas compared to those in major cities. Rural men experience poorer
survival rates from prostate cancer than their urban counterparts due to reduced use of
diagnostic and treatment services.(46)
The majority of cancer treatment facilities are located in major cities. According to the National
RuralHealth Alliance, one third of patients diagnosed with cancer live outside metropolitan
areas, in areas that also have the lowest health care provision.(6) Cancer patients who live
furthest from a large treatment centre are at the highest risk of a poor treatment outcomes.(44)
Many rural and remote patients prefer to be treated near their community support network.
Thispreference to be treated close to their home and family should not compromise access
tohigh-quality care. There is a need to utilise new technologies such as tele-oncology to enable
improved access without compromising quality of care. Satisfaction with tele-oncology services
have been perceived as high among rural and remote patients.(47)
4.3 Aged care facilities
Aged care within Australia is considered a high need area.(48) This is in part due to the ageing
population and a growth in chronic diseases, such as neurological conditions, as people live
longer.(6) Provision can be poor in metropolitan areas, although rural and remote areas are
consistently under-serviced per 100,000 population.(6) There are fewer residential agedcare
placesavailable in remote and very remote areas, with 38% of facilities in remote areas and72%
in very remote areas having fewer than 20 places. Older Australians in remote or very remote areas
accounted for 0.7% of people aged 65 and over in permanent residential aged care.(13)
Most of the population growth in older Australians will be concentrated in major cities in
thenext10 years, however the older population in rural and remote Australia is growing at
afaster rate (2.9% per year) compared to all other age groups within rural and remote areas
(1.3%), thussupporting the belief that the population in rural and remote Australia is ageing.(49)
Thisgrowth has mainly been associated with the non-Indigenous population, although initial
dataindicates that the Indigenous population is ageing at a much faster rate than the
non-Indigenous population. This has implications for rural and remote population ageing,
giventhatthe majority of the Indigenous population resides outside of major cities.(6)

35HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Some 15% (112,000) of Indigenous Australians are aged 50 and over, yet less than 1% of
people in permanent residential aged care at 30 June 2015 identified as being Aboriginal or
Torres Strait Islander.(13) The age profile of Indigenous Australians in permanent residential aged
care was substantially younger than that of their non-Indigenous counterparts: 1 in 4 (26%)
Indigenous Australians were aged under 65 compared with fewer than 4% of non-Indigenous
Australians. To address the inequality older Indigenous Australians may face in accessing aged
care, some places and programs within the aged care system are specifically allocated for
people who identify as Aboriginal and Torres Strait Islander. Indigenous Australians can access
aged care services through the National Aboriginal and Torres Strait Islander Flexible Aged Care
Programme. At 30 June 2015, the program had 802 operational places, predominantly located
in rural and remote Australia.(13)
When comparing the retrieval locations of patients aged 65 and older, many were from areas of
low provision of aged care (as detailed in Figure 4.5), thus resulting in many either staying in
hospital or being admitted to aged care facilities far removed from their communities.(7) Figure 4.5,
details the provision of aged care services per 100,000 population based upon the Aged Care
Approvals Round (ACAR)2 recipients, which gives an indication of accredited aged care facilities.
Figure 4.5 Areas in greatest need of aged care services per 100,000 population
Source: Australian Government Department of Health. 2016–17 ACAR map. Canberra, Australia: Department of Health, 2016.(50)
Available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/ACAR-Map.
2 The Aged Care Approvals Round (ACAR) is a competitive application process that enables prospective and existing approved
providers of aged care to apply for a range of new Australian Government funded aged care places and financial assistance in
theform of a capital grant.

36 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
Chapter 5: Discussion
and Recommendations
> Older people who live in rural and remote areas are often required to travel more
than 60 minutes to access basic hospital, emergency department, and GP care.
It is vitally important that interventions be introduced aimed at increasing the
provision of essential health services in rural and remote areas, especially as
itrelates to an ageing population.
> Rural and remote people are much more likely to suffer a stroke than people in
major cities. Despite this statistic, the provision of stroke services in the bush is
poor. The use of small portable CT scanners in combination with TeleStroke
(remote stroke neurologist access) services is an example of a novel way to
reduce this imbalance.
> Rural and remote patients lack access to various oncology subspecialist
treatments, such as medical and radiation oncology, haematology and palliative
care, and allied health services. Tele-oncology services have been determined
as a cost-effective and clinically non-inferior alternative to traditional methods of
service delivery.
> Cardiac rehabilitation (CR) is the recommended ‘Gold Standard’ protocol for the
treatment of CVD. The COACH program is an example of a standardised
coaching program delivered by telephone and mail-out for people with or at high
risk of chronic disease. The COACH program (Coaching patients On Achieving
Cardiovascular Health) could be used in prevention and rehabilitation of CVD
patients who do not have access to metropolitan-based CR programs.
> The poor provision of aged care in the bush leads to older patients being
relocated to areas of higher provision.
> The RFDS recommends development by the Council of Australian Governments
(COAG) of a coordinated National Healthy Ageing Strategy that identifies the
particular needs of older people in rural and remote areas.

37HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
5.1 Health care for ageing Australians in rural and remote areas
The RFDS is essential to the provision of health care in rural and remote areas. The combined
aeromedical and primary health care leading diagnoses included diseases of the circulatory
system (28.3%), injury and poisoning (9.4%), and diseases of the skin and subcutaneous system
(4.7%). Beyond these RFDS services, many of these patients have limited access to other health
care services, including specialist and rehabilitation services, often requiring travel of more than
60 minutes.
The treatment and management of chronic disease, and the key health issues the RFDS responds
toin rural and remote Australia, requires integrated care that involves collaboration and coordination
between service providers and services across primary, secondary and tertiary care settings.
Unfortunately, within rural and remote areas there are still significant shortages of stroke services,
injury rehabilitation, cancer treatment services and CVD rehabilitation services. This coupled with
poor aged care provision may be leading to increased avoidable death rates in the bush.
5.2 Stroke services
Rural and remote people are much more likely to suffer a stroke then those in major cities,(1)
anddespite this statistic the provision of stroke services in the bush is poor.(6) The use of small
portable CT scanners in combination with TeleStroke services is an example of a novel way to
reduce this imbalance. New portable CT scanners allow for brain scanning with minimal training
and provide early thrombolysis treatment of acute ischaemic stroke. Research evaluating
TeleStroke demonstrates that it is effective, efficient and safe for treating acute ischaemic stroke.(43)
A small number of dedicated stroke specialists can manage a large population at risk provided
via TeleStroke. By having a CT scanner locally, many patients would avoid the need to be transported
to larger facilities, likely more than 500 kilometres away, for assessment, diagnosis and treatment.
This however would not reduce the need for locally based stroke rehabilitation services.
5.3 Access to oncology services
Rural and remote patients lack access to various oncology subspecialist treatments, such
asmedical and radiation oncology, haematology and palliative care and allied health services.
This is due to low workforce provision, and the long distances patients are required to travel,
with the majority of treatment options within major cities.(6, 47) This, in part, is believed to lead
toreduced rural and remote patient survival rates. An Australian study by Sabesan et al.(47)
measured the effectiveness of a service based at Townsville Cancer Centre (Queensland)
whichprovided routine and urgent medical oncology services to rural and remote communities
through videoconferencing. They concluded that participants were satisfied with the model
ofcare, and benefits included: effective communication between patients and specialists,
reducedtravel time and money expenditure, and superior specialist support for rural health
workers. Although tele-oncology services are not widespread, this study demonstrates the
potential ofbroadening to other rural and remote areas.
5.4 Cardiac rehabilitation
Cardiac rehabilitation (CR) is the recommended ‘Gold Standard’ protocol for the treatment of CVD.
The patient benefits associated with a CR program include reduced mortality, symptom relief,
smoking cessation, enhanced physical ability and improved psychological wellbeing.(51, 52)
Guidelines recommend CR for patients with acute coronary syndrome (ACS), and for patients
whohave received coronary revascularisation, including coronary artery bypass graft (CABG)
surgery or percutaneous coronary interventions (PCI), or valvular surgery.(52, 53) CR programs are
acost-effective and comprehensive approach to address CVD risk factors, and help restore an
individual’s physiological, psychological, nutritional and functional status.(54-57) CR programs have
shown reductions in morbidity and mortality by nearly 25% compared to conventional care.(58-60)
Cardiac services, including CR programs, health services with cardiac capacity, and programs
aimed at prevention, are mainly located in major cities and inner regional areas.

38 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
The Coaching patients On Achieving Cardiovascular Health (COACH) program was established
in 2009 with the aim of assisting people diagnosed with chronic diseases, specifically CVD, and
to reduce the risk of future complications, such as heart attack and stroke. The COACH program
is a standardised coaching program delivered by telephone and mail-out for people with or at
high risk of chronic disease. Trained health professionals (“coaches”) coach people to achieve
national recommended target levels for their particular risk factors and to take medications as
recommended by guidelines for the management of their particular medical condition or
conditions.(61) The program has been found to be better than usual primary health care in
reducing risk factors in two randomised control trials.(62, 63)
Another example of an effective program is the ProActive Heart program, which could either be
used by RFDS clinicians when referring patients for CR or embedded into current RFDS telehealth
services. ProActive Heart is delivered by trained health professionals termed “Health Coaches”
viathe telephone, as with the COACH program. The Health Coaches are based off-site which
provides flexibility around the translation of ProActive Heart into clinical practice, either utilising
telehealth lines or helplines available to CHD patients (such as the Heart Foundation’s Heartline
inAustralia) or through acute clinical settings. The intervention commences within two weeks
ofhospital discharge, and is delivered by study-trained health professionals over the course
ofupto10 30-minute scripted telephone health coaching sessions. Participants also receive
aProActiveHeart handbook and an educational resource to use during the coaching sessions.
Theintervention focuses on appropriate modification of CHD risk factors, compliance with
pharmacological management and management of psychosocial issues.
The development of a regionalised clinical cardiac support network in South Australia is
anotherexample of a program that has been developed to improve access to services for
peoplefrom remote and rural Australia with CVD.(64) Specifically, the South Australian Integrated
Cardiovascular Clinical Network (iCCNet) supports the capacity of primary care to manage
suspected MI by providing expert risk stratification, point-of-care troponin testing and
cardiologist-supported decision-making for people with suspected MI.(64) This program was
progressively implemented in non-metropolitan areas of South Australia from 2001 to 2008.
Itprovides rapid assessment of non-metropolitan patients, and, with the RFDS, facilitates timely
transport of patients to metropolitan hospitals to receive medical interventions such as coronary
angiography, percutaneous coronary intervention, CABG surgery and CR services. Researchers
evaluated the relationship between availability of the iCCNet service and mortality by reviewing
30-day death rates among patients with MI presenting to rural hospitals before and after the
clinical network implementation, and comparing and contrasting these with mortality rates
among primary MI presentations in metropolitan hospitals. The results demonstrated that the
immediate cardiac support provided through iCCNet was associated with a 22% odds ratio
in30-day mortality (p=0.007).(64) In addition, there was a strong association between network
support and transfer of patients to metropolitan hospitals (p<0.001), with lower mortality
observed among transferred patients. “These interventions closed the gap in mortality
betweenrural and metropolitan patients in South Australia”. (64)
The COACH program, the ProActive Heart program and the South Australian iCCNet are
examples of programs and initiatives that could implemented in rural and remote areas to
improve outcomes for people with CVD.

39HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
5.5 Responding to dementia
Dementia and neurological conditions are expected to significantly increase during the next 10 years.(6)
One of the main reasons for the increase in neurological disorders is longer life expectancy.
Peoplelive longer and, accordingly, suffer dementia more often than several decades ago.
Because neurological disorders are more prevalent in older adults and people are living longer
(because of decreases in the number of deaths from CVD and cancer), there is an unprecedented
increase in the number of people affected by neurological disorders.(12) This is an area of need,
which needs tobe considered in policy development. This is particularly the case in remote areas
where there are less services designed for neurological disease burden management.
5.6 Aged care services
The poor provision of aged care in the bush leads to older patients being relocated to areas
ofhigher provision. This has been highlighted by Bernoth et al.,(7) who stated that “participants
described how they believed their only option in obtaining aged care for their loved ones was
forthem to be uprooted from their communities to become totally, socially disconnected from
allthey knew and loved and forced into exile”. This study found that feelings of aloneness were
common, with many participants believing their loved ones died more quickly due to being
relocated from their rural and remote communities.(7) This situation is not unique, with respite
centres and palliative facilities in rural and remote areas, such as Tenant Creek and AliceSprings,
generally being at capacity and therefore not accessible to older people. As stated by Gibb
andDempsey,(8) “What is needed are respite and palliative care services in remote communities.
Thiswould mean that as people’s need for support services progresses to this stage, they can
remain close to family”.
The need to maintain social contact is an important social issue for older people,(65) with
socialconnectedness being based on relationships with family, friends and their community.(66)
Many of the RFDS older patients describe a strong sense of social connectedness with their
family, friends and rural communities, prior to their needing residential aged care following an
acute injury. Buckley and McCarthy state that little is known about social connectedness and
themeaning it has for an older person, although they contend that the more social ties an older
person has, the less socially isolated they feel.(66) By preventing older patients from remaining
within driving distance of their communities, we are reducing their social networks and increasing
their rates of isolation, both of which contribute to increased depression and anxiety.
Many not-for-profit or private providers have withdrawn their service provision in rural and remote
areas, due to the inability to deliver sustainable care services.(8) This could be due to the costs for
running aged care services in rural and remote areas that are not incurred in major cities, such as
the costs of purchasing and transporting food. These additional costs need to be formally budgeted
in government funding allocations to regional councils and Aboriginal controlled health organisations
that offer care services to older people and those living with a disability.(8)
The National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP),3
hasgenerally been acknowledged as a program that could be employed further in improving
residential and flexible care in rural and remote areas of Australia.(67) This model provides a viable
option that could result in sustainable ways of providing aged care in remote communities.
3 The National Aboriginal and Torres Strait Islander Flexible Aged Care Program funds organisations to provide culturally appropriate
aged care to older Aboriginal and Torres Strait Islander people close to home and community. Flexible aged care services can
deliver a mix of residential and home care services in accordance with the needs of the community. Services funded under the
Program are located mainly in rural and remote areas. The National Aboriginal and Torres Strait Islander Flexible Aged Care
Program is administered outside of the Aged Care Act 1997. For more information: https://agedcare.health.gov.au/sites/g/files/
net1426/f/documents/02_2017/natsifacp_guidelines_october_2016.pdf.

40 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
5.7 Conclusion and recommendation
People in rural and remote communities generally want to remain independent and in control of
how and where they live for as long as possible. They want to continue to be connected to their
families, friends and communities and to be able to exercise some measure of choice if they
require care—including the choice to age in their own communities. It is vitally important that
interventions be introduced aimed at targeting poor provision of the essential health services
outlined in this chapter in rural and remote areas, especially as it relates to an ageing population.
The RFDS recommends the development by the Council of Australian Governments (COAG)
ofacoordinated National Healthy Ageing Strategy which identifies the health status and service
delivery challenges in rural and remote areas, and through locally appropriate solutions, focuses
on increasing access to stroke services; injury rehabilitation services; CR services and dementia
services; and increasing the availability of local aged care places.

41HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
Chapter 6: Conclusion and future
research interventions
The provision of essential services for older rural and remote Australian patients
ispoor. This poor provision means patients are required to travel to receive acute
and chronic disease treatment, which for many is not realistic, based on personal
and geographical limitations.
This imbalance could be a contributing factor for the lower life expectancies in rural and remote
areas. As such, it is important that innovative models of care be implemented. This could include
telemedicine for injury, stroke and CHD rehabilitation, in addition to tele-oncology and remote
neurological specialist support (such as TeleStroke). It is hoped that by providing telemedicine
services to rural and remote communities, we can reduce the health imbalance of rural and remote
communities in a cost-effective and efficient manner. As such, future studies may wish to pilot test
telemedicine interventions aimed at older rural and remote populations, to determine whether the
clinical outcomes and patient perceived benefits are non-inferior to traditional methods of delivery.
By conducting a pilot study, most likely embedded in a current RFDS telemedicine service, we will
be able to determine benefits before an extensive Australian-wide implementation.

42 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
References
1. Australian Institute of Health and Welfare. Australia’s health 2018. Australia’s health series no.
16. AUS 221. Canberra, Australia: AIHW, 2018.
2. Australian Bureau of Statistics. FEATURE ARTICLE: POPULATION BY AGE AND SEX,
AUSTRALIA, STATES AND TERRITORIES Canberra, Australia: Australian Bureau of Statistics,
2015 [Available from: http://www.abs.gov.au/ausstats/abs@.nsf/
featurearticlesbyCatalogue/7A40A407211F35F4CA257A2200120EAA?OpenDocument.
3. Australian Bureau of Statistics. 3222.0 - Population projections, Australia, 2012 (base) to 2101
Canberra, Australia: Australian Bureau of Statistics, ; 2013 [Available from: http://www.abs.gov.
au/ausstats/abs@.nsf/Latestproducts/3222.0Main%20Features32012%20(base)%20to%20
2101?opendocument&tabname=Summary&prodno=3222.0&issue=2012%20(base)%20to%20
2101&num=&view=.
4. Australian Bureau of Statistics. 3235.0 - Population by age and sex, regions of Australia, 2016
Canberra, Australia: Australian Bureau of Statistics,; 2017 [Available from: http://www.abs.gov.
au/ausstats/abs@.nsf/0/151AA7593B394934CA2573210018DA4A?Opendocument.
5. Australian Institute of Health and Welfare. Older Australia at a glance. Canberra, Australia:
AIHW, 2018.
6. Gardiner FW, Gale L, Ransom A, Laverty M. Looking ahead: responding to the health needs
ofcountry Australians in 2028- the centenary year of the RFDS. Canberra, Australia: The Royal
Flying Doctor Service 2018.
7. Bernoth M, Dietsch E, Davies C. Forced into exile: the traumatising impact of rural aged care
service inaccessibility. Rural and Remote Health. 2012;12:1924.
8. Gibb H, Dempsey D. Profiling capacity to support older people in remote communities to age
inplace. Darwin, Australia: Northern Institute 2017.
9. Australian Institute of Health and Welfare. Australia’s health 2016. Canberra, Australia: AIHW;
2016.
10. Gardiner FW, Bishop L, Gale L, Ransom A, Laverty M. The Royal Flying Doctor Service:
Responding to injuries in remote and rural Australia. Injury. 2018;In review.
11. Australian Institute of Health and Welfare. Australia’s health 2018: in brief. Cat. no. AUS 222.
Canberra, Australia: AIHW, ; 2018.
12. GBD 2015 Neurological Disorders Collaborator Group. Global, regional, and national burden
ofneurological disorders during 1990–2015: a systematic analysis for the Global Burden of
Disease Study 2015. Lancet Neurology. 2015;16(11):877-97.
13. Australian Institute of Health and Welfare. Older Australia at a glance. Canberra, Australia:
AIHW; 2017.
14. Australian Bureau of Statistics. Census of Population and Housing: Reflecting Australia - Stories
from the Census, 2016 Canberra, Australia: Australian Bureau of Statistics; 2017 [Available
from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20
Subject/2071.0~2016~Main%20Features~Snapshot%20of%20Australia,%202016~2.
15. Bishop L, Gale L, Laverty M. Responding to Injuries in Remote and Rural Australia. Canberra,
Australia: Royal Flying Doctor Service, ; 2016.
16. Garvan Research Foundation. Medical Research and Rural Health Garvan Report 2015.
Darlinghurst: Garvan Research Foundation; 2015.
17. Bishop L, Laverty M, Gale L. Providing aeromedical care to remote Indigenous communities.
Canberra, Australia: Royal Flying Doctor Service of Australia; 2016.
18. Australian Bureau of Statistics. Drought Canberr, Australia2918 [Available from: http://www.
bom.gov.au/climate/drought/.
19. Health Direct Australia. Who we are Canberra, Australia2018 [Available from: https://about.
healthdirect.gov.au/.

43HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
20. Gardiner FW, Nwose EU, Bwititi PT, Crockett J, Wang L. Blood glucose and pressure controls
in diabetic kidney disease: Narrative review of adherence, barriers and evidence of
achievement. Journal of diabetes and its complications. 2018;32(1):104-12.
21. Gardiner FW, Nwose EU, Bwititi PT, Crockett J, Wang L. Services aimed at achieving desirable
clinical outcomes in patients with chronic kidney disease and diabetes mellitus: A narrative
review. SAGE Open Medicine. 2017;5:2050312117740989.
22. Watson B, Tam CWM, Pellizzon B, Ban L, Doan H. General practitioner follow-up in older
patients after an emergency department admission. Aust Fam Physician. 2017;46(7):521-6.
23. Elizabeth M, Fiona G, Bernadette W, Dorothy J, Phillip D. Perspectives of clinical handover
processes: a multi-site survey across different health professionals. Journal of Clinical Nursing.
2016;25(1-2):80-91.
24. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in
communication and information transfer between hospital-based and primary care physicians:
Implications for patient safety and continuity of care. JAMA. 2007;297(8):831-41.
25. Kannus P, Sievänen H, Palvanen M, Järvinen T, Parkkari J. Prevention of falls and consequent
injuries in elderly people. The Lancet. 2005;366(9500):1885-93.
26. Gardiner FW, editor Flying Doctor Research in remote Australia: what’s the data telling us.
National Conferance for Rural and Remote Allied Health Professionals; 2018; Darwin SARRAH.
27. Gardiner C, Geldenhuys G, Gott M. Interventions to reduce social isolation and loneliness
among older people: an integrative review. Health & social care in the community.
2018;26(2):147-57.
28. Gardiner FW, Nwose EU, Regan E, Park BK, Bwititi PT, Crockett J, et al. Outpatient cardiac
rehabilitation: Patient perceived benefits and reasons for non-attendance. Collegian.
2018;Article in press.
29. Gardiner FW, Regan E, Nwose EU, Bwititi PT, Crockett J, Wang L. Outpatient cardiac
rehabilitation: Effects on patient improvement outcomes. Diabetes Metab Syndr.
2017;11(Suppl 2):S1025-S30.
30. Zhai S, Gardiner F, Neeman T, Jones B, Gawarikar Y. The Cost-Effectiveness of a Stroke Unit
inProviding Enhanced Patient Outcomes in an Australian Teaching Hospital. J Stroke
Cerebrovasc Dis. 2017;26(10):2362–8.
31. The Royal Australasian College of Physicians. Rehabilitation medicine physicians delivering
integrated care in the community. Sydney, Australia 2018.
32. Bishop L, Ransom A, Laverty M. Cardiovascular health in remote and rural communities.
Canberra, Australia: Royal Flying Doctor Service,; 2018.
33. Australian Institute of Health and Welfare. Cardiovascular disease, diabetes, and chronic kidney
disease – Australian facts: risk factors. Canberra, Australia; 2015.
34. Newton PJ, Davidson PM, Reid CM, Krum H, Hayward C, Sibbritt DW, et al. Acute heart failure
admissions in New South Wales and the Australian Capital Territory: the NSW HF Snapshot
Study. MJA. 2016;204(3):113.
35. National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand
(Chronic Heart Failure Guidelines Expert Writing Panel). Guidelines for the prevention, detection
and management of chronic heart failure in Australia. Australia; 2011.
36. Heart Foundation. Heart Maps Brisbane, Austrlaia: Heart Foundation,; 2018 [Available from:
https://www.heartfoundation.org.au/for-professionals/heart-maps/australian-heart-maps.
37. Stroke Foundation. No postcode untouched Stroke in Australia. Melbourne, Australia 2017.
38. Australian Institute of Health and Welfare. Stroke and its management in Australia: an update.
Canberra, Australia; 2013.
39. Stroke Foundation. Rehabilitation Stroke Services Framework Melbourne, Australia; 2013.
40. Stroke Foundation. National Stroke Audit Acute Services Report. Melbourne, Australia; 2017.
41. Australian Stroke Coalition Rehabilitation Working Group. Assessment for Rehabilitation:
Pathway and Decision-Making Tool. 2012.

44 ROYAL FLYING DOCTOR SERVICE OF AUSTRALIA
42. Stroke Foundation. National Stroke Audit Rehabilitation Services Report Melbourne,
Australia;2016.
43. Shuaib A, Khan K, Whittaker T, Amlani S, Crumley P. Introduction of portable computed
tomography scanners, in the treatment of acute stroke patients via telemedicine in remote
communities. International Journal of Stroke. 2010;5(2):62-6.
44. Jong KE, Smith DP, Yu XQ, O’Connell DL, Goldstein D, Armstrong BK. Remoteness of
residence and survival from cancer in New South Wales. MJA. 2004;180(12):618-22.
45. Craig U, Rebecca B, David G, Helen S, Stephen B, Patsy Y, et al. Mapping oncology services
inregional and rural Australia. Australian Journal of Rural Health. 2009;17(6):321-9.
46. Australian Institute of Health and Welfare. Cancer compendium: information and trends by
cancer type. Canberra, Asutralia; 2017.
47. Sabesan S, Simcox K, Marr I. Medical oncology clinics through videoconferencing: an
acceptable telehealth model for rural patients and health workers. Internal Medicine Journal.
2012;42(7):780-5.
48. Humphreys JS, Wakerman J, Wells R. What do we mean by sustainable rural health services?
Implications for rural health research. . Aust J Rural Health. 2006;14(1):33-5.
49. Davis S, Bartlett H. Healthy ageing in rural Australia: Issues and challenges. Australas J Ageing.
2008;27(2):56-60.
50. The Department of Health, cartographer 2016-17 ACAR Map. Canberra, Australia:
TheDeprtment of Health; 2016.
51. Cardiovascular diseases: World Health Organisation; 2013 [Available from:
http://www.who.int/cardiovascular_diseases/en/.
52. Piepoli MF, Corra U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, et al. Secondary
prevention through cardiac rehabilitation: from knowledge to implementation. A position paper
from the Cardiac Rehabilitation Section of the European Association of Cardiovascular
Prevention and Rehabilitation. European Journal of Cardiovascular Prevention and
Rehabilitation. 2010;17:1-17.
53. Aragam KG, Moscucci M, Smith DE, Riba AL, Zainea M, Chambers JL, et al. Trends and
disparities in referral to cardiac rehabilitation after percutaneous coronary intervention. Am Heart
J. 2011;161(3):544-51.
54. Papadakis S, Oldridge NB, Coyle D, Mayhew A, Reid RD, Beaton L, et al. Economic evaluation
ofcardiac rehabilitation: a systematic review. Eur J Cardiovasc Prev Rehabil. 2005;12(6):513-20.
55. Wenger NK. Current status of cardiac rehabilitation. J Am Coll Cardiol. 2008;51(17):1619-31.
56. Lavie CJ, Milani RV. Cardiac rehabilitation and exercise training in secondary coronary heart
disease prevention. Prog Cardiovasc Dis. 2011;53(6):397-403.
57. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, et al. Exercise-based cardiac
rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011;7(7):CD001800
58. Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention
programs for patients with coronary artery disease. Ann Intern Med. 2005;143(9):659-72.
59. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, et al. Exercise-based rehabilitation
for patients with coronary heart disease: systematic review and meta-analysis of randomized
controlled trials. Am J Med. 2004;116(10):682-92.
60. deVries H, Kemps HMC, vanEngen-Verheul MM, Kraaijenhagen RA, Peek N. Cardiac
rehabilitation and survival in a large representative community cohort of Dutch patients.
European Heart Journal. 2015.
61. Ski CF, Vale MJ, Bennett GR, Chalmers VL, McFarlane K, Jelinek VM, et al. Improving access
and equity in reducing cardiovascular risk: the Queensland Health model. MJA.
2015;202(3):148-53.
62. Vale MJ, Jeinek MV, Best JD, Santamaria JD. Coaching patients with coronary heart disease to
achieve the target cholesterol: a method to bridge the gap between evidence-based medicine
and the "real world"--randomized controlled trial. J Clin Epidemiol. 2002;55(3):245-52.

45HEALTHY AGEING IN RURAL AND REMOTE AUSTRALIA: CHALLENGES TO OVERCOME
63. Vale MJ, Jelinek MV, Best JD, Dart AM, E GL, Hare L, et al. Coaching patients On Achieving
Cardiovascular Health (COACH): a multicenter randomized trial in patients with coronary heart
disease. Arch Intern Med. 2003;163(22):2775-83.
64. Tideman PA, Tirimacco R, Senior DP, Setchell JJ, Huynh LT, Tavella R, et al. Impact of a
regionalised clinical cardiac support network on mortality among rural patients with myocardial
infarction. MJA. 2014;200(3).
65. Stanley M, Moyle W, Ballantyne A, Jaworski K, Corlis M, Oxlade D, et al. 'Nowadays you don't
even see your neighbours': loneliness in the everyday lives of older Australians. Health & social
care in the community. 2010;18(4):407-14.
66. Buckley C, McCarthy G. An exploration of social connectedness as perceived by older adults in
a long-term care setting in Ireland. Geriatric nursing (New York, NY). 2009;30(6):390-6.
67. The Department of Health. National Aboriginal and Torres Strait Islander Flexible Aged Care
Program (NATSIFACP) Guidelines. Canberra, Australia; 2016.