Findings, progress, and lessons learned during the first 3 years of a student-led interprofessional health clinic in regional Australia

ABSTRACT

We describe the establishment and operation of a student-led interprofessional chronic disease prevention and management clinic in regional Australia. Our aim was twofold. First, to report on service delivery, student placement, and health outcome data; and second, to discuss key lessons learned during the first 3½ years of clinic operations. Between July 2019 and December 2022, 146 (79.3%) clinic participants completed the 4-month program and participated in an average of 48.4 occasions of service (total 7,060). The clinic supported 1,060 clinical placement weeks across 147 health students. There was a significant improvement across health measures reported at program completion, with the largest changes observed for the 6-min walk test and preference-adjusted quality of life. Nine key challenges and lessons were identified that affected operations and service delivery, which should be of interest to healthcare teams considering establishing an interprofessional student-led clinic.

KEYWORDS:

• Chronic disease
• interprofessional care
• Nursing and allied Health
• regional
• rural and remote
• student-led

Introduction

Australians living in regional communities (defined as non-urban, rural, and remote areas) experience poorer health outcomes compared with those living in metropolitan areas, including higher rates of hospitalization, chronic disease, injury, and premature death (Australian Institute of Health and Welfare [AIHW], 2020b). Although health needs are greater in regional Australia, there exists a maldistribution of the health workforce with fewer health professionals relative to the population (AIHW, 2020a; Colman, 2022; Department of Health [DOH], 2022). These human resource shortages limit regional Australians’ access to quality health care and contribute to the higher burden of chronic diseases (National Rural Health Alliance [NRHA], 2021). Innovative models of care that address chronic disease prevention and offer important educational experiences for health professionals in-training are therefore a priority in regional Australia (Smith et al., 2022).

There is growing acknowledgment of the importance of interprofessional collaborative practice to deliver quality health care (Lutfiyya et al., 2019; Wei et al., 2022), including for chronic disease management (Southerland et al., 2016) and in regional settings (Frakes et al., 2014; Martin et al., 2021; Pullon et al., 2016). A key skill for future health professionals is the ability to work effectively as part of an interprofessional team. Interprofessional education, defined as occasions when two or more professions learn from, with, and about each other to improve collaboration and quality of care (World Health Organisation [WHO], 2010), is a useful means of preparing health workers for interprofessional collaborative practice (Jones & Jones, 2011; Martin et al., 2021). Interprofessional education can be delivered to health students via clinical simulation, problem-based learning, group, and classroom activities, and work-integrated learning (Olson & Bialocerkowski, 2014). Service-learning models, where students engage in experiential learning activities in a local community, are a useful way to deliver interprofessional education while contributing to community health needs (Forbes et al., 2020; Hopkins et al., 2022). Although there is emerging evidence for the effectiveness of interprofessional service-learning models to support chronic disease prevention and management (Forbes et al., 2020; Kent et al., 2016; Lai et al., 2015), these models vary in the extent that interprofessional practice and education is core to service delivery (Hopkins et al., 2022); there is limited evidence in regional, rural, or remote settings in Australia (Frakes et al., 2014; Martin et al., 2021).

We describe the establishment and operation of a student-led interprofessional chronic disease prevention and management clinic in a regional community in Southern Queensland, Australia. The aim was, first, to report on service delivery, student placement, and health outcome data, and second, to discuss lessons learned from the first 3½ years of clinic operations. Sharing such insights may enable healthcare teams of existing or prospective student-led interprofessional clinics to proactively manage risks, anticipate potential issues, and optimize service delivery systems.

Background

The Health and Wellness Clinic (HaWC)

Southern Queensland Rural Health (SQRH) is one of the 19 University Departments of Rural Health located across Australia. Established in 2019 as an SQRH initiative, the Toowoomba Health and Wellness Clinic (HaWC) is a student-led interprofessional nursing and allied health service providing a holistic, client-centered, goal-orientated program for people with low to rising risk of chronic disease. The program aims to change individual health trajectories, thereby reducing chronic disease risk and the potential future burden on local health services. On referral by a General Practitioner (GP), eligible participants are required to meet at least two inclusion criteria:

• Hypertension ≥140/90 mmHg;

• Body Mass Index (BMI) ≥25 kg/m²;

• High cholesterol (GP referral and/or currently medicated);

• High blood glucose levels (GP referred);

• Physical activity less than the Physical Activity Guidelines set out by the Australian DOH (2021) and,

• Consuming less than two servings of fruit and five of vegetables per day.

Clinic services are tailored to participant needs around the main pillars of Movement, Nutrition, Behaviour Change, and Social Connection. The multifaceted program includes comprehensive health assessments, land, and aqua-based exercise programs, health education sessions, individual and group consultations, and food preparation demonstrations. Services are delivered by physiotherapy, exercise physiology, dietetics, psychology, social work, and nursing students under the supervision of clinical educators. The program includes an interprofessional intake assessment, interprofessional case conferences, progress review sessions, and activities to ensure that participants are equipped to independently manage health goals outside of the clinic. The structured component of the program – and focus of this study – lasted 4 months. Follow-up contact occurs at 6 and 12 months following program completion.

Methods

Ethical approval was granted by the University of Queensland Human Research Ethics Committee for patient data collected prior to (2022/HE000928), and after January 2022 (2022/HE000076).

Service delivery and student placements

Individual-level data were collected for all participants from July 2019 to December 2022 Demographic data were summarized. Information on student discipline and placement duration was extracted for all students. Health disciplines were summarized.

Health outcomes

Health measures were collected at program commencement and completion. Participant anthropometrics (weight, BMI, and waist circumference) were measured in the clinic by staff and students but were at times self-reported by participants during COVID-19 pandemic-related restrictions, which necessitated telehealth appointments. Functional exercise capacity was measured using the standardized 6-min Walk Test (6MWT; Enright, 2003). Quality of life was measured using the Assessment of Quality of Life (AQoL)-8D instrument, a validated multi-attribute utility tool (Richardson et al., 2014). All data were normally distributed (Shapiro-Wilk). Repeated measures t tests were used to compare mean scores at intake and program completion (IBM SPSS Statistics v.26).

Challenges and lessons learned

The authors of this study comprise members of the SQRH senior leadership and HaWC clinic governance teams. Identified challenges and lessons learned during the first 3½ years since the clinic was established were based on our collective experiences as well as wider feedback provided by participants, staff, and students. Feedback from participants and students was synthesized from anonymous internal evaluation surveys, and staff feedback was documented in regular reflection workshops. The authors reviewed these internal feedback mechanisms, and jointly developed the list of challenges and lessons learned.

Results

Participant demographics

A total of 146 (79.3%) participants completed the 4-month program out of the 184 who commenced (Table 1).

Table 1. Demographic information.

	Commenced n = 184 (%)	Completed n = 146 (%)
Age (years)
<45	20 (10.8)	13 (9.0)
45–54	34 (18.6)	25(17.1)
55–64	49 (26.4)	36 (24.6)
65–74	63 (34.3)	57 (39.0)
75+	18 (9.9)	15 (1.3)
	Average = 60.1	Average = 61.7
Sex
Male	56 (30.4)	44 (3.1)
Female	128 (69.6)	102 (69.9)
Other	-	-
Aboriginal and/or Torres Strait Islander Status
Yes	9 (4.9)	4 (2.73)

Service delivery

Clinic participants received on average 48.4 occasions of service, with a majority attending in-person (in-person: 95.2%; telehealth: 4.8%; Table 2). There was a relatively even split of group and individual occasions of service (group: 50.5%; individual: 49.5%).

Table 2. Occasions of service (OOS) delivered for participants who completed the program (n = 146).

	No. OOS	% OOS
Type of OOS
Triage/intake/review/transition session	920	13.0
Physiological assessment session	487	6.9
Health education session	761	10.8
Group exercise session	2,475	35.1
Nursing session	172	2.4
Dietetics session	534	7.6
Physiotherapy session	359	5.1
Exercise physiology session	424	6.0
Social work session	275	3.9
Psychology session	513	7.3
6- or 12-month review session	140	2.0
Group or individual appointment
Group	3,568	50.5
Individual	3,492	49.5
Delivery method
Face to face	6,719	95.2
Telehealth	341	4.8

Student placements

Nursing and allied health students completed 147 placements and 1,060 weeks of clinical placement (Table 3). The average placement duration was 7.2 weeks, although this varied considerably between disciplines. Over the 3½ years of clinic operations, the staffing profile varied, however generally included a clinic coordinator and administration support staff as well as nursing, dietetics, physiotherapy, exercise physiology, social work, and psychology clinical educators.

Table 3. Student placement disciplines and duration.

Discipline	No. placements (%)	No. placement weeks (%)	Mean placement weeks
Dietetics	30 (20)	193 (18)	6.4
Exercise Physiology	42 (29)	268 (25)	6.4
Nursing	29 (20)	137 (13)	4.7
Physiotherapy	23 (16)	114 (11)	5.0
Psychology	16 (11)	246 (23)	15.4
Social Work	7 (5)	102 (10)	14.6
Total	147 (100)	1,060 (100)	7.2

Health outcomes

Participants who completed the program recorded improvements in anthropometric, aerobic, and quality-of-life outcomes (Table 4). Medium-to-large effect sizes were found for reduction in waist circumference (d = 0.67), increases in meters walked in 6 min (d = 0.71), and preference-adjusted quality of life (d = 0.84; Lakens, 2013).

Table 4. Changes to health measures at program commencement and completion.

Health measure	Status	N*	Intake Mean (SD)	Transition Mean (SD)	Mean change (95% CI)†	p value §	Effect size Cohen’s d
Weight (kg)	Commenced	181	103.40 (25.97)	102.49 (24.98)	−1.52 (−2.13, −0.91)	<.001	0.42
	Completed	135	104.01 (25.66)
BMI (kg/m^2)	Commenced	179	37.77 (9.19)	37.55 (8.80)	−0.52 (−0.77, −0.28)	<.001	0.36
	Completed	135	38.07 (9.04)
Waist circumference (cm)	Commenced	164	114.13 (18.20)	109.05 (16.67)	−4.60 (−5.87, −3.34)	<.001	0.67
	Completed	117	113.61 (17.67)
6MWT (m)	Commenced	161	381.00 (101.27)	433.66 (120.13)	52.36 (38.62, 66.08)	<.001	0.71
	Completed	114	381.31 (103.05)
AQoL-Physical (worst = 0, best = 100)	Commenced	179	62.56 (16.37)	69.84 (16.28)	6.21 (4.52, 7.89)	<.001	0.61
	Completed	141	63.63 (15.82)
AQoL-Psychosocial (worst = 0, best = 100)	Commenced	179	61.91 (17.73)	71.00 (16.53)	6.52 (4.79, 8.25)	<.001	0.61
	Completed	141	64.48 (17.39)
AQoL-Quality-Adjusted Utility (worst = 0, best = 1)	Commenced	183	0.510 (0.211)	0.646 (0.220)	0.112 (0.090, 0.135)	<.001	0.84
	Completed	142	0.534 (0.209)

*N= commenced refers to participants who had a valid measurement at intake (regardless of whether they finished the program). N= completed includes participants who had a valid measurement at intake and transition.

† Refers to the mean change between intake and transition scores for participants who completed the program.

§ p value refers to whether the mean difference between intake and transition scores for participants who completed the program are statistically significant. p < .05 was considered statistically significant.

Lessons learned

Nine key themes and challenges associated with HaWC service delivery were identified. Where relevant, refinements or fundamental changes to healthcare practices have been made. In other cases, challenges remain, and workarounds are in effect until the solutions are implemented (Table 5).

Table 5. Nine key challenges and lessons from HaWC implementation.

#	Theme	Challenge	Lesson learned and/or solution implemented	Status
1	Referral and recruitment	Attracting and recruiting a sufficient number of participants for the program.	Growing community awareness of the health benefits conferred by the clinic and changes to triage (below) have contributed to increasing numbers for intake. Self-initiated referrals predominate, though a GP referral is required.	Resolved. Continuous monitoring/refinement.
2	Triage assessment and program suitability	Frequent and time-consuming phone conversations with the referring GP to evaluate program eligibility regarding relevant clinical measures and potential long-term commitment.	An in-person interprofessional interview and biopsychosocial needs analysis with qualified clinical educators and students has replaced the previous model. Prior to program intake, participants are given the opportunity to tour the clinic, meet the team of clinical educators and students, and in doing so are exposed to the level of engagement expected over the 16-week intensive program.	Resolved. Continuous monitoring/refinement.
3	Method of program intake	Student availability under a “rolling intake” model was inconsistent affecting the participant experience and staffing for the program.	Participants are no longer able to continuously enroll into the program. Rather, two blocks aligning with each semester comprising 25 places annually (i.e., total 50 per year) has been adopted. Social connections are now maintained long after the formal component of the program concludes under the new arrangement.	Resolved. Continuous monitoring/refinement.
4	Requirement for structured group education	Group education sessions were voluntary leading to reduced engagement.	Education sessions are integral to the core program and participants have to actively disenroll from sessions. The new “opt out” approach has enabled a higher proportion of participants to add not only new skills, but also knowledge to their toolkit for sustainable health behavior change. Smaller group and telehealth catch-up sessions have been introduced.	Resolved. Continuous monitoring/refinement.
5	Clinic software and data management	Proprietary clinic software is not designed nor suitable for interprofessional education and collaborative practice.	Clinic software has been modified to meet program requirements. Customisations have enhanced interprofessional data sharing, yet also contributed to instability in functionality (e.g., errors, slow down, missing data). Data collection, extraction and exporting for research purposes has been suboptimal, creating a requirement for excessive manual handling of data.	Not resolved. Whilst system stability has, to an extent been achieved, alternative software and further investigations to optimize data capture and recording are ongoing.
6	Transition to a telehealth model	In-person clinic activities had to be transferred into telehealth format during the COVID-19 lockdown.	All enrolled participants were invited to bring a preferred device (e.g., laptop, tablet) to the clinic in the leadup to lockdown. They were assisted by staff and students with the installation of the required software programs to enable HaWC program continuation via teleconsultation. Participants increased their skills in telehealth technology use and continue to apply them, however a small proportion opted out.	Resolved. Continuous monitoring and refinement.
7	Student allocation to interprofessional placements	Communicating with stakeholders about the benefit of a bespoke interprofessional placement opportunity, which still meets overall university program and discipline-specific requirements.	Each health discipline requires students to undertake placement to enhance evidence-based skills, knowledge and competencies. A tactful approach to redress traditional perspectives toward discipline-specific learning requirements has been taken. This has involved higher levels of negotiation, information sharing and clarification of how interprofessional education can add value to pedagogy and all health disciplines involved.	Not resolved. As interprofessional education and collaborative practice is proving to be the future and recommended direction for providing an optimal healthcare experience, it is likely that a placement of this kind becomes standard rather than the exception.
8	Incorporation of formal interprofessional education into student experience	Students on placement in the clinic were not provided formal interprofessional learning modules (available to other SQRH-supported placements), recognizing the additional opportunities available when working in a truly interprofessional environment.	Southern Queensland Rural Health (SQRH) coordinates a formal interprofessional learning course, an initiative that provides students with the knowledge and range of skills to become part of an interprofessional, practice ready, health workforce. The course is now delivered in modified form to students undertaking HaWC placement, contributing to a holistic educational experience, ensuring program inclusivity.	Resolved. Continuous monitoring and refinement.
9	Role of nursing in interprofessional clinic setting	There was a mismatch between nursing student placement requirements and the program.	Nursing student placements are undertaken primarily during initial program phases involving holistic health assessments (i.e., within interprofessional triage and intake), and specific cardiac reviews for participants determined to have a higher risk of heart disease. Additional placement opportunities are also offered toward the end of the program, during progress reviews and transitioning to completion of the intensive part of the program.	Resolved. Continuous monitoring and refinement.

Discussion

This study has described initial findings of a student-led interprofessional chronic disease prevention and management clinic in a regional community in Southern Queensland, Australia. Findings suggest that HaWC is contributing to improvements in individual health outcomes and overall quality of life. The largest improvements were associated with the submaximal exercise tolerance test, a measure of cardiovascular capacity, and preference-adjusted quality of life. Given that the program targets members of the community who require intervention to reduce chronic disease risk or progression, these results are encouraging, not only from our perspective as a relatively new student-led interprofessional health clinic but also for other health teams who may aim to establish a similar model of care.

This study adds more generally to the interprofessional education and collaborative practice literature (Forbes et al., 2020; Lutfiyya et al., 2019; Olson & Bialocerkowski, 2014; Pullon et al., 2016; Southerland et al., 2016; Wei et al., 2022; WHO, 2010), and more specifically to the paucity of research evaluating outcomes associated with student-led interprofessional health clinics in regional settings (Frakes et al., 2014; Martin et al., 2021). Indeed, over the 3 ½ years, several challenges and lessons covering various aspects of the HaWC program were identified, from referral, triage, and intake, through to student allocation and the timing and delivery of interprofessional education. Whilst two of the identified challenges continue to warrant further investigation, several challenges have been addressed, either as a result of the natural passage of time, as is the case with increasing clinic referrals due to growing community awareness, or via changes to program structure and service delivery systems. Changing the method of program intake from a rolling to a block intake model, for example, was one of the most important decisions made as a clinic team. According to staff and student feedback, continuity in contact among the same participant cohort has contributed to goal attainment, social cohesion, and ultimately improved health outcomes. Similar flow-on effects from each of the other changes implemented have been observed. Whilst service delivery has been enhanced as a result of these amendments, we continue to closely monitor activities and remain open to the idea of refinement in the face of new and existing challenges.

Conclusion

This study provides evidence that a student-led interprofessional nursing and allied health clinic in a regional Australian community has contributed positively to individual health outcomes in its first 3½ years of operation. Interprofessional healthcare teams may hereby reflect on the challenges and lessons learned to enhance service delivery. Future studies will report on physiological, behaviour change, and health student evaluation outcomes over a longer follow-up period.

Acknowledgments

The authors would like to acknowledge all staff at Southern Queensland Rural Health (SQRH) and the passionate interprofessional team of clinical educators and students at the Health and Wellness Clinic (HaWC) who have worked tirelessly since 2019 to deliver high-quality healthcare services.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This research received no external funding or sponsorship. All authors who completed this work are employed under the Australian Government’s Rural Health Multidisciplinary Training (RHMT) program. Award/Grant number not applicable.

Notes on contributors

Clara Walker

Clara Walker, is a Principal Project Officer at Southern Queensland Rural Health (SQRH). She is an Adjunct Research Fellow at the Centre for Health Research, University of Southern Queensland.

Bahram Sangelaji

Bahram Sangelaji, is a Senior Research Assistant at Southern Queensland Rural Health (SQRH). He is Adjunct Research Fellow at the Centre for Health Research, the University of Southern Queensland.

Dayle Osborn

Dayle Osborn, is the Health and Wellness Clinic Coordinator and Clinical Educator Nursing and Mental Health Nursing at Southern Queensland Rural Health (SQRH).

Nicola Cotter

Nicola Cotter, is Deputy Director (Darling Downs) at Southern Queensland Rural Health (SQRH). She has 15 years’ experience working as a Physiotherapist and Manager of multidisciplinary and interprofessional healthcare teams.

Geoff Argus

Geoff Argus, is the Director of Southern Queensland Rural Health (SQRH). He is an Associate Professor with The University of Queensland and Adjunct Associate Professor with the University of Southern Queensland. He is a Board Director with Australian Rural Health Education Network (ARHEN) and the National Rural Health Alliance (NRHA).

Adam Hulme

Adam Hulme, BSc Hons (ExSc), MA (Health Promot), PhD (Systems Epidemiol), is a Research Fellow and Senior Research Officer at Southern Queensland Rural Health (SQRH). He is a School Research Chair (University of Queensland), Deputy Chair of the Australian Rural Health Education Network (ARHEN) Research Staff Network and serves as an Associate Editor for the Australian Journal of Rural Health (official Journal of the National Rural Health Alliance.