Introduction
Recruiting and retaining doctors in rural Australia remains a complex issue. Ensuring work-life balance is known to be effective in retention of rural GPs, yet mechanisms to assist with this have not been effective. The model explored in this research is a GP developed and implemented, deliberate team based care (DTBC) model, built from the ground up within a rural community. The model aims to deliver DTBC, allowing chronic care patients to be treated with a multi-discipline approach, reducing GP workload and providing a supportive environment for patients. The GP oversees case conferencing and provides care plans to the multidisciplinary team who work together to provide timely treatment and patient care: therefore reducing demands on the GP. Understanding the effectiveness of this model in a rural setting is key to identifying how we can reduce the burden on GPs in these underserved areas.

Methods
Semi-structured interviews were carried out with clinicians and administrators within the team. Interviews were transcribed and analysed using an iterative theming approach, using NVivo software.

Results
Key themes identified in understanding model effectiveness revolved around three aspects: model set up, team work and impact on patient outcomes. Themes relating to model set up were pre-existing relationships with health professionals and knowledge of clinical capabilities. Team work was evident by the themes: trust, open communication, belief in the model, holistic care and a cultural shift in medical practice. Impact on patient outcome themes were: patients receiving earlier than normal care, being known by people in the town and that patient health literacy and engagement in their own care was higher.

Discussion
The DTBC model draws on pre-existing health professionals within the community. The GP had a high level of trust across the team, leading to all practitioners having a voice which was heard and respected. Open communication in case conferencing meant team members had shared learning experiences which enhanced their own practice. Effective team work and care plans ensured treatment was received earlier than in normal care, improving patient outcomes. The holistic approach to patient care was enhanced by the rural community surrounding each patient.

Conclusions
Building DTBC from the ground up produces care which contains key elements needed for effective patient care. Being community based, it ensures holistic care occurs not only in healthcare centres but also within the town itself. As a model of care this shows promise to be effective in reducing GP load in these settings and providing greater sustainable wellbeing for the GP.

Lessons learned
This model of care requires mutual trust and respect across all health service providers to ensure knowledge sharing and a holistic approach. A cultural change in the current medical approach to GP patient care could facilitate this, ultimately reducing GP workload.

Limitations
This study explores the perspectives on DTBC of nine team members in one rural town.

Suggestions for future research
Future studies examining patient perspectives and health outcomes are important in understanding model effectiveness and contribution to improved GP sustainability in rural Australia.

The Community Health, Infrastructure and Resilience Fund Inc (CHIRF) is a health promotion charity that was formed in May 2016 by a group of Mallacoota residents when it became clear that the sole medical practice in the town, the Mallacoota Medical Centre (MMC), which at that time was operating with one general practitioner (GP), would collapse without solid community support; leaving the community without the services of GPs. Mallacoota has population of 1,036 residents that swells to 8,000 in peak holiday times. Forty-nine percent of its residents are aged 60-years and over. It is situated at the eastern tip of Victoria and is one of the state’s most geographically isolated communities (ABS-RA4 and MMM6). Mallacoota is the only community in Victoria without a public hospital or bush nursing centre or residential aged care services. The nearest hospital is NSW, with 1 hr. 45-minute travel time each way.

CHIRF's initial focus was to address Mallacoota's GP shortage and in partnership with the MMC it began a ‘Dr Search’ initiative in May 2016. With the successful recruitment in early 2018 of a second GP and the placement of a GP registrar, CHIRF commenced broadening its mission. It is now focussed on addressing the communities’ other significant unmet primary health care (PHC) needs including allied health services, medical equipment, building infrastructure and health workforce. To help secure funding for its expanded mission, CHIRF is partnering with other community groups, has expanded its geographical focus to include the Wilderness Sapphire Coast and has been lobbying elected representatives and funding bodies. CHIRF has secured funding for: building a new medical centre, establishing an after-hours medical service, improving mental health services and providing greater support in community for people living with chronic health conditions. In the longer-term, CHIRF is working to secure extended aged care services including a residential aged care facility and high care nursing services in Mallacoota. All CHIRF’s PHC strategies place the MMC as the service hub for coordination and delivery of services. CHIRF believes for a small, geographically remote town like Mallacoota, a medical practice hub model is the most economically efficient approach for delivering PHC services. CHIRF as a DGR charity has been able to access funding sources and funding streams that are not readily accessible to private medical practices.

CHIRF is also committed building the evidence base to support other geographically remote small rural communities to help strengthen locally PHC services. To support this, a research partnership was formed in early 2019 with the University of Newcastle and University of New England. This community-academic partnership has recently received funding to undertake an evaluation of Teen Clinics operating in medical centres in the region.

This presentation will discuss the challenges and benefits of adopting a community-led model to strengthen PHC services in small rural towns including sustainability and replicability issues. The experience of volunteers taking an active role in strengthening PHC services and the development of and the plans for the university – community partnership will also be covered.

1. Introduction
Hospital and health care is multifaceted, fragmented, busy and expensive. As we age, our health needs become more complex, entwined with our broader social and community needs. Today, older people suffer a disproportionate amount of harm in the health system, often in ways unrelated to their illnesses.
The Institute for Healthcare Improvement (IHI) developed an age-friendly health system 4Ms Framework. The 4Ms—What Matters, Medication, Mentation, and Mobility—are the core issues that drive all care and decision making with older people.

The Better Care Victoria (BCV) Building an Age-Friendly Indigo Health System project aims to develop an age-friendly approach to the care of older people in rural communities based on the IHI 4Ms Framework.

2. Theory/Methods
The first stage of the project was to assess whether the IHI 4Ms Framework can be generalized to Australian rural health conditions through an independent, integrative review of rural health research and a review by clinical experts, including older people.

3. Results
Twenty-four articles addressing the review criteria were identified, and data extracted. Articles were assessed against the NHMRC Levels of Evidence hierarchy. The articles were diverse in their settings, populations of interest and models of care. The outcomes identified for older adults were also wide-ranging. Evidence existed for all four elements of the 4M model within the rural geriatric care literature. Importantly, other evidence, not an immediate ‘logical’ fit with the model, was also identified.

Sixteen clinical experts, including hospital, community and residential aged care health professionals and older people, convened to review the relevance, generalisability and feasibility of the 4Ms Framework and the integrative review.

4. Discussions
The IHI 4Ms Framework is a relevant, concise approach to synthesis common elements in rural health research. Overall, clinical experts provided good support for the model with the additions recommended through the iterative review. However, there were a low number of studies undertaken in rural settings. Such studies were of a low-level evidence. Importantly, there was little evidence relating to actual views of older adults regarding their health care needs.

5. Conclusions (comprising key findings)
The IHI 4Ms Framework provides a suitable approach to the care of older people in rural settings with minor adjustments to the interventions within ‘mentation’. The next stage of the project is to assess current models of evidence-based care against the draft Age-Friendly Indigo framework.

6. Limitations
The scarcity of rural health research is both a limitation and of concern. Rural clinical practice is often not evaluated, limiting the availability of evidence for existing clinical practice.

7. Suggestions for future research
Further research in rural health care is essential. It must clearly define rurality. It is also essential to undertake research on the health and social care needs and preferences of older people, carers and family.