Mildura, Latji Latji/Barkindji Country, Wodonga, Dhudhuroa/WayWurru Country

For the past two years in northeastern Victoria, community paramedics have been quietly reshaping how healthcare is delivered to traditionally underserved regional communities in the region.

The Community Paramedicine at Clinic (CP@clinic) Program, a joint initiative between La Trobe University and McMaster University in Canada, is enabling paramedics operating out of Mildura and Wodonga to use their knowledge and skills beyond emergency health responses to focus on preventative and rehabilitative health. McMaster University has a well-established and evidence-based CP@clinic program. In its first international adaptation, the program was initially piloted in Australia in collaboration with La Trobe University and Sunraysia Community Health Services (SCHS) in 2022, and later with Gateway Health in Albury-Wodonga.

CP@clinic provides free community clinics led by paramedics, who undertake chronic disease screening, health education and onward referrals. The model improves access to care, increases quality of life, eases pressure on ambulance services, hospital emergency departments and GP clinics, and improves overall health literacy in the community.

At present there are two paramedics working at each of the Victorian health services who provide easy walk-in access to healthcare, and their impact has been immediate and much welcomed by the public and other primary and allied health professionals.

Professor Evelien Spelten, from the Violet Vines Marshman Centre for Rural Health Research at La Trobe University and community paramedicine program coordinator, first heard about the CP@clinic model while on a study program for La Trobe with McMaster University. She was introduced via Professor Peter O’Meara. During the trip she met with Dr Gina Agarwal, a professor in the university’s Department of Family Medicine whose team has led the development and evaluation of the CP@clinic program, which now extends across Canada.

“I thought, actually that would fit really well with some of the challenges that we see in rural health, so I managed to persuade the then CEO of Sunraysia Community Health Services, Simone Heald, to consider this as a possible intervention … Simone is a very committed innovator in community health.”

Discussions with then Victorian Chief Paramedic Officer Alan Eade, paramedics and SCHS began the process of mapping out how the model would work and the potential barriers to implementation.

Dr Ruth Hardman, a post-doctoral researcher with SCHS, said initial funding piggybacked off the governmental financial support that was provided during the COVID-19 pandemic to enable non-traditional workforces to support more vulnerable populations during the pandemic.

Clinics were set up around the Mildura local government area in community spaces targeting older and economically vulnerable adults with chronic health conditions where people already felt safe and where there was easy walk-in access.

“We ran a pilot trial which started in August 2022, then we did data-gathering around health conditions, GP access, healthcare access, things like that. In July last year, we did a series of interviews with participants and with paramedics, and we put together a report that is published on that trial,” Dr Hardman said.

From there, they received a four-year $1.4 million Innovative Models of Care grant, a federally funded Department of Health grant that allows for long-term evaluation. It supports rural and remote regions where there are health workforce shortages and a need for more creative ways of using the available health workforce. With the support of community health services, who fund paramedic salaries, the grant has enabled expansion across Mildura region and now, in collaboration with Gateway Health, to set up clinics in and around Wodonga. Two more community health organisations are due to join the program.

“The idea is to do these small clinics at these different locations, and often they're linked up to things like food relief or other community support services,” Dr Hardman said.

“For the paramedics, it's about connecting them with the resources that are available. They go in there, do the assessments and a lot of health promotion and health education looking at things like blood pressure and diabetes risk, but also linking them up with services.”

Dr Hardman said because more than a third of the initial cohort didn't have a GP, connecting them with healthcare services was vital. Because SCHS is a holistic community health clinic employing health professionals across different disciplines, there was a range of services and referral options available, including drug and alcohol, mental health, Aboriginal health support, refugee health, chronic disease and diabetes.

“It has a very wide range of different services, and I would say they have been absolutely embraced by the community health service because they do outreach. I think that's where paramedics are great at being out in places and being the first person out in those sorts of environments. They're able to really connect and draw people in.

“The clinical staff within the community health centre really like the fact that they've got paramedics and that they can connect them to people and care-coordinate them in a way that that wasn't happening previously.” Ambulance Victoria (AV) paramedic Travis Coombes, who grew up in Mildura, was the first paramedic employed at SCHS in 2022. After 13 years on-road with AV, he wanted to move into a different role beyond emergency response and the shift work involved.

“And after doing a bit of research into what the community paramedic role was about, it was definitely something that really interested me in trying to focus more on preventative health than dealing with things once they get to a crisis point.”

At present there are eight clinics operating in Mildura and surrounding towns, staffed by Travis and new graduate paramedic Courtney Orwell, each with different challenges, different ways of life, and different socioeconomic and cultural dynamics, with each clinic individually adapted to the specific needs of each community. Some operate weekly and others fortnightly, both in open-access community spaces and retirement villages.

“For all the public ones, we’re there every week and we make sure that the times stay the same every week and people can just drop in whenever they want. On average, we see between six to 12 people per clinic every week. Sessions roughly go for about 45 minutes for an initial private consult and 15 minutes for those returning, and so all our clinics are set up with a private consult room. People can walk in, no appointments, just come in for a health check, and if they've got any problems, they can come and chat to us. That gives us a better understanding of the context. They might suggest that they're doing it tough and we can try and help them.”

There are nine key diagnostic areas in the CP@clinic database, with health assessments including risk factors for diabetes, hypertension, cholesterol, falls, and heart disease, as well as lifestyle factors, financial security, and mental health, to determine if there is a chronic disease or a predisposition to chronic disease that is not being managed or is hindered by individual financial hardship. This enables the paramedics to set them on the path to longer-term health management and continuity of care through referrals to other clinicians.

Travis said one of the greatest benefits was in seeing people take an interest in and gaining a better understanding of their overall health and wellbeing.

“A lot of people hadn't been to a doctor in two or three years and now they're seeing us on a regular basis. They're exercising more, they're interacting with other people more, and coming to one of our clinics actually becomes a social outing for them because they wouldn't have had that otherwise; they'd just be staying at home.

“We've got a guy who's a Type 2 diabetic, and he stopped drinking soft drink. That was a massive win. Prior to coming to see us, he didn't have a GP, he didn't have a diabetes educator. There were so many other things that he didn't have any assistance with, and now he's got the medicine he needs and is getting so much better health-wise and also interaction-wise.

“Everywhere we go, people are extremely thankful for us being there, and they're totally on board, and it's a real change in my working aspect - that before you would just pick up people and take them to the hospital, that was it. Here you get to see them every week, and it's seeing the changes in them, and they're so happy with things now.”

The initiative is also fostering greater community connection and social cohesion, with visitors to the clinics - many of whom are socially isolated - forming friendship groups in what have become truly communal spaces.

The public health and social benefits of the SCHS experience are being mirrored at Gateway Health in Wodonga, where fellow AV paramedics Lauren Rudd and Alicia Turnbull have set up three walk-in clinics in the town itself, and one each in Corryong, Wangaratta and Chiltern. The pair undertake the same health assessments and provide the same referral pathways, and are also building the interpersonal connections that have often been lacking, particularly for vulnerable populations.

“It's not just meant to be about the medical side of things; it's about social connection. We've opened up six clinics so far, most of them piggyback off existing programs such as food shares in neighbourhood houses, exercise groups and craft groups, where people are already coming in for food or social connection,” Lauren said.

She said through the clinics they had been able to pick up a number of previously undiagnosed health conditions among people who either lacked the financial means or were unsure how to navigate the health system and weren’t connected to GPs or other health providers, including hypertension, diabetes, and mental health issues.

“It's very complex, they don't know that there's free counselling available or bulk billing,” Lauren said. “They can't afford to see a GP so they haven't seen a GP in a long time, so we've got a massive resource folder and we can refer them into these services at Gateway Health. It's such a fantastic service in itself with all of its specialised services.”

The last clinic the pair set up in Wodonga is in a 46-unit low-income public housing block. The block had a community centre that residents had been unable to access since the pandemic.

“We got in, we've had it cleaned by the Department of Housing and we get the key and open it up,” Alicia said. “People come in, and the residents who have been quite socially isolated and have kept to themselves are loving it. Gateway Health funds some catering, so they're bringing sandwiches and slices, people are coming in and they're getting their health check and they're having a sandwich, having a social connection and then leaving, and that's been really special, just really addressing that social isolation that they've all had since COVID.

“The manager at the Corryong Foodshare wrote a beautiful email to our boss thanking us because we actually had a very unwell client we had to call an ambulance for. They said that the client wouldn't be alive if it wasn't for us because we recognised that he was ill. He was in to get some food from the Foodshare and we assessed him and called the ambulance. There was just one single officer at Corryong and it would have taken an hour to get a backup from Tallangatta to drive, so we actually drove the ambulance in, being also employed by Ambulance Victoria.”

And while the CP@clinics have been overwhelmingly welcomed by the communities in which they operate, many locals fear that the program will be short-lived.

“When I walk into a clinic and I talk to people who've attended, their very first question is, and this has happened multiple times, when is this going to stop? Is this going to stay? People in rural areas are so used to doing pilot after pilot of something that then disappears,” Professor Spelten said.

“It's so ingrained in their perception of how healthcare is provided that you know they rave about the service, but they always ask that question. It breaks my heart. And I think that's pretty fundamental in how we deliver healthcare and that's part of why La Trobe is involved as well because it's about health equity, especially in the rural context.

“The evidence is everywhere that it works. And we have now been given four years to build up and consolidate that evidence.”