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Volume 12, Issue 3, December 2014 ADVANCES IN MENTAL HEALTH

Meeting unmet needs? The role of a rural mental health service for older people

Julie Henderson*, Mikaila M Crotty*, Jeffrey fuller* and lee Martinez+

School of Nursing and Midwifery, Flinders University, Adelaide, SA, Australia; +Centre for Rural Engagement, University of South Australia, Whyalla, SA, Australia

Abstract: Background: Rural and remote residents have been identified as a group with limited access to mental health services. Older rural people may experience additional problems due to lack of access to transport, limited oppor-tunities for social engagement and the stigma attached to mental illness. Aim: To explore the extent to which service providers, carers and consumers view the Older Persons’ Mental Health Service (OPMHS) as meeting the needs of older people with mental health problems in rural South Australia. Methods: Semi-structured interviews were conducted at 3 case study sites with 22 key informants from mental health teams and organisations providing care to older people and with 4 consumers and 5 carers. Results: The establishment of OPMHS clinicians at the sites studied led to increased access to specialist services for older people leading to earlier assessment and treatment of consumers. It has also led to greater service integration and knowledge sharing about older persons’ mental health. Participants identify ongoing service needs particularly for remote, CALD and Aboriginal populations and for after-hours crisis care. Conclusion: The localisation of services and attachment of specialist older persons’ clinicians to rural mental health teams has enhanced service delivery for older people through enabling case management within rural communities. There are however, ongoing service needs which need to be resolved.

Keywords: community mental health, rural health, older people, service access, service integration

This paper addresses the role of the Older Persons Mental Health Service (OPMHS) in

meeting the mental health needs of older, rural South Australians. OPMHS was established in 2010 in response to an anticipated increase in the percentage of the population aged 65 or over in country areas of South Australia (approxi-mately 66,000 people were aged over 65 in 2007) coupled with the extreme shortage or absence of specialist aged care mental health services. In 2007, older rural South Australian had access to three full time staff based in the metropolitan area providing a consultation and liaison service (Country Health SA, 2008). The establishment of the OPMHS service involved the placement of specialist OPMHS clinicians within rural mental health teams on a full or part time basis; estab-lishing a country governed specialist psychogeri-atric position; and moving the governance of the Older Persons Consultation and Liaison team 3 FTE positions based in Adelaide to Country Health SA (Country Health SA, 2008; Crotty, Henderson, Fuller, & Martinez, 2013). The service model sought to create a mental health service for older people living in rural South Australia with the goal of building the capacity

of community mental health teams using a con-sultation liaison model to work with people 65 years and over (45 years and over for Aboriginal and Torres Strait Islander peoples). The OPMHS sought to integrate services for older people into existing mental health services to establish an integrated and multidisciplinary system of care for older people. This calls for ongoing collabo-ration between older persons’ service providers (Crotty et al., 2013).

Rural areas have long been identified as hav-ing poorer access than metropolitan areas to health services (Allen, Inder, Lewin, Attia, & Kelly, 2012; Polain, Berry, & Hoskin, 2011; Vagenas, McLaughlin, & Dobson, 2009). This has been related to poor geographical access to services (Allen et al., 2012), extended wait-ing periods for GP appointments (Polain et al., 2011; Vagenas et al., 2009) and limited access to specialist services (Vagenas et al., 2009). Rural people seeking mental health care face difficul-ties in accessing psychiatrists and rely upon GPs to provide primary mental health care (Fuller, Edwards, Martinez, Edwards, & Reid, 2004). GPs face excessive workloads (Taylor, Edwards, Kelly, & Fielke, 2008); limited availability of

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Conversely, the social support that rural peo-ple experience can be protective of mental health. Mental health is associated with a perception of being part of a community but also with the degree of social support available, both of which have been found to be protective for rural people (Kelly et al., 2011). Community engagement is associated with reduced demand for hospital and health services through better provision of self-care (Longman, Passey, Singer, & Morgan, 2013). Community engagement is dependent however, on access to transport and the availabil-ity of community services to engage with, both of which may be problematic for older rural peo-ple (Winterton, Warburton, Clune, & Martin, 2013). In addition, lack of aged care facilities and the placement of older rural people in facilities away from their communities may lead to social disconnection and loneliness (Bernoth, Dietsch, & Davies, 2012).

This paper addresses the impact of the estab-lishment of a locally based older persons’ mental health service on service delivery in rural South Australia. Data for this paper were drawn from an evaluation of the OPMHS service conducted by independent researchers between January 2012 and July 2013. The purpose of the evaluation was to explore the roll out of the service and identify strategies for service improvement, particularly in relation to integration between services. This paper draws on one aspect of the data: The extent to which service providers, carers and consumers view OPHMS as meeting the needs of rural older people with mental health problems.

Methods

Data for this study were collected through case studies at three of the rural sites in which OPMHS clinicians were located. Case stud-ies typically occur within a ‘bounded system’ (Munhall, 2001, p. 361) and provide an ‘inten-sive, systematic investigation of a single indi-vidual, group, community, or some other unit’ (Woods & Catanzaro, 1988, p. 553). They are designed to situate a ‘case within its larger ‘con-text’ or setting’ (Creswell, 2003, p. 249). Data are collected through a range of methods and the conclusions of the case study often take the form

non-governmental community support services (Deans & Soar, 2005; Henderson, Willis, Walter, & Toffoli, 2008); and limited access to crisis care (Turpin, Bartlett, Kavanagh, & Gallios, 2007) leading to the management of acute consumers by metropolitan tertiary ser-vices (Taylor et al., 2008).

The prevalence of mental health problems in older people and their related access to men-tal health services is not clear cut. The National Survey of Mental Health and Well-being Australian Bureau of Statistics (2008) found that while 8.6% of people aged 65–74 and 5.9% of people aged 75–84 had experienced mental health problems within the previous 12 months, this is likely to be unrepresentative of real need as people with dementia and in residential aged care facilities were excluded from the sample (Royal Australian and New Zealand College of Psychiatrists, 2011). There is some evidence that rates of mental illness may be lower in rural and remote areas. Allen et al. (2012) found that older people in remote areas are less likely to report high levels of psychological distress. Rural older people have also been found to have less self-reported use of GP and specialist services. Vagenas et al. (2009) in a national survey of older women found that rural participants were half as likely to have had eight or more GP visits (OR = 0.54) and 40% less likely to have consulted a medical specialist (OR = 0.6) within the previous 12 months than urban women; however this may be an issue of access. Rural regions rely on primary care for medical management of mental illness however access to and use of GP services in rural Australia is complicated by differing rates of GPs across different rural and remote regions, differing medical work practices because of health needs, lower numbers of specialists and travel distances for health professionals that reduce available con-sultation times (National Rural Health Alliance, 2013). Additionally, not all GPs have knowledge of mental health ensuring that consumers often travel significant distances to GPs with greater interest and knowledge of mental health (Deans & Soar, 2005; Taylor et al., 2008). Stigma has also been identified as an issue for older people and may inhibit help-seeking (Garrido, Kane, Kaas, & Kane, 2009; Polain et al., 2011).

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experience of the OPMHS service, the strength and weakness of the service, identification of any groups who may not be receiving services and recommendations for improvement of the services. In addition, participants were asked to identify what an ideal service for rural older people with mental illness might look like. All interviews were audio recorded and transcribed verbatim. Analysis was conducted using both an inductive and deductive approach to cod-ing. Initial coding was guided by the inter-view questions with additional codes identified through close reading of the transcripts (Fereday & Muir-Cochrane, 2006). Data were managed using NVivo10. Ethics approval for the projects was gained from the Flinders University Social and Behavioural Ethics Committee and from Human Research Ethics Committee of the South Australian Department of Health.

Results

As this paper addresses the extent to which the OPHMS meets the needs of older rural people with mental health problems data for this paper were drawn from discussion of the strength and weaknesses of the OPMHS. Analysis of the data resulted in the identification of three major themes relating to barriers to access to services and unmet consumer needs, the extent to which

of recommendations for action (Munhall, 2001). The case sites were chosen to represent different communities, models of care and experience with managing older clients. Features of the three sites are summarised in Table 1.

Data for the evaluation were collected through mixed methods consisting of surveys distributed to all members of the rural mental health teams and to aged care service providers who work with the mental health teams; mapping of the client journey of five clients at each of the three case study sites; and interviews with service providers, carers and consumers. Survey results are reported elsewhere (Crotty et al., 2013). This paper draws on the interview data. Interviews were conducted with 22 key informants working within either the mental health team or external aged care agencies along with interviews with 5 carers and 4 con-sumers (see Table 2). The interviews took place within participants’ work places, via telephone or at the carers and consumers’ home. Participants were sent information sheets pertaining to the research and informed consent was obtained prior to the interviews taking place. For tele-phone interviews, consent forms were returned via mail with verbal consent sought before com-mencement of the interview.

The interviews addressed topics including the impact of rural context on care delivery,

ED1

table 1: suMMary of Case study sites

Site 1 Site 2 Site 3

Service community Sees rural and remote clients

Sees rural clients Sees rural and remote clients

Aboriginal and Torres Strait Islander clients

CALD and Aboriginal and Torres Strait Islander clients

Availability of other services

Limited access to NGOs Access to NGOs and metropolitan services

Some access to NGOs

Model of care Older people case managed by all members of the team with OPMHS clinician case managing more complex cases

OPMHS clinician assesses clients who are case managed by OPMHS clinician and one other members of the team

OPMHS clinician assesses clients who are case managed by OPMHS clinician and one other members of the team

Role of OPMHS clinician Consultation liaison Consultation liaison Consultation liaisonCase management Case management Case management

Establishment of services

Older clients managed prior to establishment of OPMHS role

Recently established Established for 18 months

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the OPMHS can meet these needs and the needs the service is unable to meet. The key findings are outlined in Table 3.

Barriers to access and unmet consumer needsA major barrier for both rural service providers and consumers was the availability of services, particularly when compared to the services offered to metropolitan older people. A service provider from the non government sector (NGO) stated:

I know that certainly the country communities don’t get that sort of service like the people in the city may be able to get because there are more resources and more players who can get involved in the service. In the country … resources are limited and at times it really depends on what is around, I don’t think the people in country get equitable services (NGO).

Of particular importance to participants was access to general practitioners and specialist men-tal health services. A carer of an older husband who has mental health problems stated that ‘It was more the GPs that I had a bit more trouble get-ting.’ Lack of choice in relation to GP services was noted by service providers. In one region this

resulted from the concentration of ownership and management of medical practices. A participant working in an NGO in this region argues that this may restrict treatment options:

Another real bee I have in my bonnet up here is that both of the doctor’s clinics are run by all of the same doctors. So they don’t really have a variety of medical services here. So if I’ve come to you and cracked up at you, there’s every chance that you’re not going to want to see me either (NGO).

Attendance at an emergency department was also viewed as a poor choice for this population. A community health worker stated that older people did not like to use the local hospital emer-gency departments even though they have a duty doctor as ‘It’s not uncommon to go and see the duty doctor and have them say, ‘What you doing here? This could have waited’ and for an older person with an illness they don’t get ‘this can wait.’ It’s scary now’ (Community Health).

Access to specialist mental health services is also identified as a problem by service providers and carers. A local General Practitioner when asked about availability of mental health services for older people within his region highlighted dif-ficulties arising from the previous centralisation of services for older people in Adelaide:

For many years they [the mental health team] were restricted to seeing people aged eighteen to sixty five only, so when I had an eighty-year-old patient with schizophrenia turn up who had become unstable because of another illness they said ‘well we can’t help you, we’re not allowed to.’ Mental health services for older people was running out of Adelaide. They had a visiting [psychiatrist] service once a month which then disappeared for about five or six years (GP).

Limited access to specialist services was viewed as leading to delays in assessment and diagnosis which had flow on effects in terms of treatment. A carer describes the impact of lack of service conti-nuity in getting her husband assessed when unwell:

He’s [husband] one of the barriers for the simple reason is his good times and his bad times, but if you get him on a good time he’s fine. And then you just about think the doctor thinks, or whoever it is thinking ‘I wonder why he’s here for that,’ because he’s good. But when he’s on a bad time can even hardly talk (Carer).

table 2: suMMary of partiCipants at eaCH site

Site 1 4 Mental health team members (MHT) 3 Governmental community service providers

(community service) 2 Carers 1 ConsumerSite 2 1 Mental health team member 3 Governmental community service providers 1 Aboriginal health service provider 1 Non-governmental service provider 1 Representative of a small rural hospital with aged

care beds (rural hospital) 1 Residential aged care service providers (aged care) 3 ConsumersSite 3 3 Mental health team members 2 Residential aged care service providers (Aged care) 1 GP 1 Non-governmental service provider

3 Carers

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Delays in assessment and diagnosis also lead to restrictions in putting other services in place. A community health manager described difficulties in accessing some resources without a diagnosis:

I have like a merry-go-round with that in some cases when people are waiting to see a specialist to get a diag-nosis as such, you can’t access things like RIBS [fund-ing] without a diagnosis from mental health … quite often I’m going around in circles because what they need is something underneath the mental health ban-ner, but without that mental health diagnosis, I can’t get it (Community Health Manager).

Access to specialist services is hindered by cost of those services but also by availability of trans-port to Adelaide. A Community Health Nurse stated in relation to cost that: ‘I’m not sure what gaps they’ve got to pay with different specialist that can be off-putting for some.’ Transport is problem-atic when people are hospitalised. A consumer noted:

… The sort of response you get from Adelaide hospi-tals is completely negative. The just don’t understand that there’s not a bus waiting for you to take you to the hospital. And one time I had to go to the hospital down there and they said ‘Couldn’t I stay with friends?’ Well I’ve got friends but none of them are in Adelaide (Consumer).

As a consequence local mental health services have to be creative in getting transport needs met. A respondent from an NGO noted that:

… On a number of occasions the mental health team has called us and said can you get so and so down to the Royal Adelaide or Glenside [psychiatric hospital]

if it’s voluntary. We’ve actually taken a detained patient down to Glenside which was good fun but he knew we were safe so he didn’t give us any problems (NGO).

Capacity of OPMHS to meet unmet needsThe second theme identifies the strengths of the service. Responses fall under three major sub-themes: Service access, service integration and the knowledge of the OPMHS clinician.

The establishment of the OPMHS clinicians’ role was viewed as increasing access to trained staff, as typified by an Aged Care employee who stated, ‘I’ve found the service to be really good, like she’s able to come fairly promptly. We have a very good rapport with her; she’s really good with deal-ing with care staff as well as dealing with residents’ (Aged Care). The OPMHS role is particularly important for aged care facilities as they may have difficulties in accessing other services for mental health:

The biggest strength that we have at the moment with her [OPMHS clinician] is that our GP here is very reluctant to have anything to do with the men-tal health aspect [and] … doesn’t really have much to do with the residents or their mental health state, so we certainly rely on her very much so to work on our behalf … it’s somebody else that we can refer to for information or assistance (Aged Care).

For consumers and carers the person in this role co-ordinates and enables access to services. A carer from a remote region of South Australia highlights the role of the OPMHS clinician in putting services in place:

table 3: suMMary of findings about serviCe needs

Barriers to access and exiting needs

Role of OPHMS in meeting unmet needs

Ongoing unmet needs

Service availability

Access to GPs

Access to specialist mental health services

Delays in assessment, diagnosis and treatment

Transport/access to metropolitan services

Identified person that can be called upon

Not enough employees to meet service demand

Co-ordination and facilitation of access to other services

Limited capacity to meet needs of CALD and Aboriginal communities

Access to telepsychiatry services

Difficulties in meeting the needs of smaller communities

Improved communication between and integration of services

Limited access to after-hours crisis care

Access to specialist knowledge

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Whatever you find is tough, they can un-toughen it and you find it, it’s not so tough after all because you’ve got their support, even though they’re … 3 hours away … you’ve got that support through just talking and they can put in place what needs to be put in place (Carer).

The OPMHS clinician also enables access to psychiatric services through telepsychiatry. While some consumers and service providers had reservations about teleconferencing the ser-vice was viewed by the mental health teams as enhancing assessment and medication manage-ment. The role of telepsychiatry in improving assessment practices is noted in by a member of a mental health team: ‘Telepsychiatry, that’s very supportive to have that, you know, the workers can get assessment like that’ (MHT). For another mental health team member access to telepyschi-atry adds credence to medication and treatment recommendations for local GPs as ‘doctor to doctor just works much better, especially with doc-tors who are a bit funny about taking advice from nurses’ (MHT). The service as a whole enabled maintenance of older people within their own communities:

We do speak on occasion to rural and remote [special-ist service at Glenside Hospital] if we’ve got a really big problem. We have collaborated with Glenside in the past before we had the mental health for older persons and it would have been so much better to have [had] mental health for older persons [then] rather than hav-ing to deal with Glenside … when we [didn’t] have the services or expertise to manage somebody (Aged Care).

Reservations about telepsychiatry largely came from carers and staff working in residential aged care and relate to the suitability of this service for older people. A participant from a rural hospital viewed the services as confusing for her residents:

… It confuses the hell out of the residents … They can barely see the screen, they can hardly concentrate because is not a medium they are used to dealing with (Rural hospital).

Another service provider highlights the dif-ficulties of transporting Aged Care residents to the nearest teleconferencing facilities in another town. Reservations about telepyschiatry services are tempered however, by acceptance that it is

better than not having access to specialist services. A carer states:

I think it’s better to talk in person because you have that one on one feeling, but I was happy enough because I knew I couldn’t get him to Adelaide, but then again if the guy had of come over here which I hardly think he would of, because we don’t have psy-chiatrists and that … (carer).

A second subtheme relates to the role of the OPMHS clinician in providing a focus for com-munication and integration of services. For a carer this is evident in the way the OPMHS clinician has helped her negotiate other services:

… They all work in together and they know a lot but there’s always, each place has got a different outlook, each place has got a different, you know they’re all dif-ferent, they’ve got to treat them all differently. They’re all not the same so they’ve [OPMHS clinician] been quite good actually, for me as well too because I’ve got to cope with it all.

For service providers the OPMHS role has improved integration through information shar-ing and joint assessment of consumers. One com-munity health employee describes working ‘fairly closely with [the OPMHS clinician] … because we perhaps sometimes do a joint visit. So [clinican] would do more of the clinical assessment and I do more of the information’ (Community Health). An NGO employee in the same region notes an improvement in communication about hospitali-sation and discharge of consumers. ‘If the mental health team were involved they generally let us know unless it is a genuine oversight. But as for communi-cation from doctors or hospitals, very little’ (NGO).

The final subtheme relates to the knowledge base of the OPMHS clinician which was valued by consumers and service providers from within and outside of the community mental health team alike. Consumers and carers highlight knowledge of medication management and of other services. One consumer stated: ‘ they’re very good … they know what they’re talking about, they know their tablets. And what they don’t know they will look into as well’ (Consumer). For another consumer the strength of the services is that ‘anything you want you’ve only got to ask, and someone will help you, someone who’s able to’ (Consumer).

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Service providers outside of the mental health team value the specialist knowledge of the OPMHS clinician. A community health employee at noted that the OPMHS clinician has ‘been very approachable and very helpful. And the rest of the team is too, but I guess I just feel that she’s got that specialist knowledge’ (Community Health). Of note, is knowledge about organic causes of behavioural disturbance, as an Aged Care employee stated:

They’ve been really good and very helpful, saying this could be the mental illness, this could be dementia or this could just be acting out. They take you through things (Aged care).

The OPMHS clinician is viewed as having an important role in sharing this knowledge. An employee at another aged care facility states: ‘we are getting good support and they are helping us with education’ (Aged Care).

Finally, the OPMHS clinician is described as having a role in educating other members of the mental health team. When asked about the capacity of the local mental health team to man-age older people with mental health problems one team member stated:

If you asked me twelve months ago I would have said probably not but I think it’s getting better because of the dedicated role and the people in the role are actu-ally educating the team and making them aware of what’s available (MHT).

Unresolved needsA final theme relates to ongoing needs that have not been met by the OPMHS clinicians. These data were drawn from discussion of the weak-nesses of the service. The primary limitation iden-tified by participants is the amount of resource available to each mental health team. A number of participants called for the employment of addi-tional OPMHS staff:

The weakness I think is that we need more of the posi-tions. We certainly need … even though we try to plan for distribution throughout the team to pick up the referrals, I think we still need to have more designated people in the Older Person’s Mental Health Service. Certainly more designated psychiatrists who would look after that service (MHT).

For many participants the need for mental health services for older persons in rural South Australia is underestimated. A participant from an NGO states that ‘I think we really undersell mental health for older people. I really think there is a mar-ket out there that nobody is tapping into’(NGO). There is also a perception for some mental health teams that the establishment of the role has cre-ated a service expectation that they will struggle to meet. One team leader says:

By creating the service … we created the demand. How do you actually supply the service for the demand? I think that is the problem especially in the [region] where suddenly we’re getting all these referrals and we’ve got one worker and even if the team picks up some of the referrals as well it’s still quite an over-whelming demand (MHT).

As a result of limited resources some groups notably Aboriginal and Torres Strait Islander, culturally and linguistically diverse (CALD) and people in remote locations are viewed as falling through the gaps. An NGO employee noted that ‘here you’re getting more and more nationalities com-ing in as well … so one person is not enough’(NGO). Likewise, a community health employee iden-tified inequity in service access for people from smaller communities:

We’re just privileged and lucky enough to live in a big town, but these [people in smaller communities] to me are your priority people. They don’t get enough of anything as it is now because everything is so thinly placed. Once again they have to physically get up and move to actually be able to get support for a service … Why should they have to move just to actually have some support? (Community Health).

Those who do not fit comfortably within a particular diagnosis group or who cross service boundaries also miss on essential services:

… It’s okay if you fit a certain box. For people outside of that box, I find it’s not streamlined. I find that some peo-ple get left completely out of things if they are borderline to not having the right diagnosis (Community Health).

Another ongoing issue was access to after-hours crisis care. Participants note ringing an emergency number in ‘Adelaide and then the number comes back. So if it comes back on a Friday

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night and everyone’s gone home, it gets picked up on a Monday morning and the police have had to deal with it over the weekend ’ (NGO). This leads to calls for greater flexibility in service delivery to meet consumer needs after hours. A community health worker stated that the weakness is:

… Things don’t happen Monday to Friday, nine to five and that is huge … It would be good for flexibility about the hours, I think (Community Health).

discussion

The findings of an evaluation of the OPMHS in South Australia is reported in this paper, in response to a shift in service delivery from centralised services to local regions through the placement of an Older Person’s Clinicians within rural mental health teams. Evaluation data suggest that these regions had previously experienced difficulties with access to services leading to delays in assessment and put-ting support into place. The placement of specialist older persons’ clinicians undertaking consultation liaison and case management responsibilities within rural mental health teams improved both access and integration of service delivery through providing an identified clinician to co-ordinate services and develop partnerships, most notably with aged care and community health services. Wakerman et al. (2009) argue for the localisation of services within rural communities as it creates local accountability and increased sustainability for those services. In addition, local governance of services is identified as enabling flexibility and responsiveness in service delivery (Wakerman et al., 2009). Localised ser-vice delivery is facilitated by informal relationships between service providers which enable creative use of limited resources (Crotty, Henderson, & Fuller, 2012). Data from this study suggest that the localisation of services enables service delivery through improved integration of existing services, in line with current policy which promotes greater use of primary care for mental health care delivery and development of service partnerships (Henderson & Fuller, 2011). Increased responsiveness to consumer needs and service delivery is evident in the degree of consumer and carer satisfaction with services and with consumers accessing services from a range of service providers.

Service improvement may also be associated with the introduction of local case management for older people. Case management for older peo-ple has been associated with improved medication management, improved access to community sup-port services, improved consumer mental health and well-being, fewer unmet needs and reduced admission to aged care facilities (Low, Yap, & Brodaty, 2011; You, Dunt, Doyle, & Hseuh, 2012). Data suggest that there has been improve-ment in medication management, particularly in aged care facilities and more timely assessment of consumers, as facilitated by telepsychiatry. Telepsychiatry has been identified as being a cost effective way of increasing treatment options in rural and remote locations and also allows older people to been seen within their community (Swinton, Robinson, & Bischoff, 2009). The tele-psychiatry services are well regarded by the mental health teams in this study but are not the favoured option of consumers and carers who would prefer face-to-face services. Despite this, it is acknowl-edged by consumers and carers that use of telepsy-chiatry services is better than not having a service.

Despite improvement in service delivery some continuing limitations are identified. There is a perception among service providers that demand could outstrip supply. Our respondents identify an ‘untapped market’ for mental health services among older rural people. There is also a per-ception that a number of communities, notably remote, CALD and Aboriginal communities are not well serviced. CALD groups have routinely been identified as being at risk in policy documents due to migration experiences while Aboriginal people face challenges arising from social dislo-cation, racism and social inequality (Henderson, 2007). Lack of responsiveness to Aboriginal com-munities is not unique to this service. Isaacs, Pyett, Oakley-Browne, Gruis, and Waples-Crowe (2010) note that Aboriginal people have subop-timal use of all mental health services, often only accessing services when in crisis and when family and community resources have been exhausted. Poor utilisation of mental health services has been associated with lack of trust in mainstream ser-vices, lack of Aboriginal health workers, poverty, stigma, different understanding of mental illness

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(a focus upon social and emotional well-being vs. a biomedical approach), capacity to manage co-morbidity and waiting times. Isaacs, Mayberry, and Gruis (2012) call for increased funding and relationship building with communities and spe-cialist Aboriginal Health Services to build capac-ity to meet the mental health needs of Aboriginal communities. A second issue is availability of after-hours crisis care. The establishment of men-tal health beds in rural hospitals may address this need to some extent, however limited access to specialist staff suggests that this is a problem that is unlikely to be resolved in the short term.

This study has limitations. Firstly, the case study sites were self-selected and may not be representative of all rural mental health teams. They were however, representative of all service models and included teams with varying time since establishment of the service and different social contexts. Secondly, the carers and consum-ers interviewed for this study were identified by the mental health team and there is potential for selection of participants with positive experiences. This approach was viewed as necessary however, to prevent stress upon people who were unwell when the interviews were conducted.

conclusion

This paper has reported data from an evaluation of an OPMHS established in rural South Australia. The distinctive feature of this service is the localisation of service delivery through the placement of older persons’ clinicians undertaking both consultation liaison and case management responsibilities within regional mental health teams. Benefits in increasing accessibility of services and improved assessment times were found including the development of ser-vice partnerships and greater access to mental health care for residents in aged care facilities and increas-ing knowledge of local service providers of older people’s mental health. Ongoing issues include difficulties in meeting service demand, particularly for Aboriginal and Torres Strait Islander, CALD and remote communities and access to after-hours crisis care which is compounded by non-recurrent funding resulting in discontinuation of contracted positions and ongoing insecurity about the stability of these positions.ED2

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Received xx Month 20xx Accepted xx Month 20xx

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Queries

ED1 Please check the inclusion of running title ‘Meeting unmet needs? The role of a rural mental health service’ is fine.

ED2 Please provide ‘acknowledgement’ for this article.ED3 Please provide volume number and page range for ‘Winterton et al., 2013.’ED4 Please provide received and accepted dates.