Ageing and Pre-Hospital Care: Opportunities for Rural Communities

There is a stark contrast between the health outcomes of older rural-dwelling people in comparison to their urban counterparts. The disparity is not only driven by the inherent challenges that come with geographic isolation (including limitations to public transport, reduced availability of health services, and challenges to technology such as mobile phone reception and the internet) but also by the significant impact of health risk factors on an already vulnerable population. Older age brings additional challenges to health and capacity, and rural-dwelling older people may be inadvertently marginalised by lack of health service provision in their rural communities, affecting their ability to age in place. A deliberate and targeted approach to multidisciplinary health service provision in rural areas is crucial, requiring focused attention from government, policy makers and practitioners alike. Given the challenges that accompany the provision of health services in rural and remote areas, innovative models of health service delivery and new strategic approaches are essential. 

Consequently, it is important to understand health consumers fully: in this case, exploring the reasons older people call for an emergency ambulance [1], often the first point-of-contact with the healthcare system. Mapping demand patterns of two distinct cohorts of rural-dwelling older people, those that live in Residential Aged Care (RAC) and those that live independently in the community, may inform health resource planning for ambulance and other health services in rural areas. Additionally, an understanding of the conditions that prompt rural-dwelling older people to call ambulances (respiratory, cardiovascular and neurological reasons predominate) prompts a reminder of the burden of chronic disease carried by this cohort. Concerningly, the number of older people seeking emergency assistance for pain complaints is very high, at 17.5% of the rural ambulance caseload [1]. While many of these call-outs are to manage pain from an acute condition (such as acute coronary syndrome or falls-related fractures), a significant number are for musculoskeletal or orthopaedic pain, including pain in the hips, back, joints and chronic pre-existing pain. This may reflect the lack of primary care services within regional areas able to manage pain conditions, fewer pain specialists and geriatricians, or potentially highlight access barriers to pain management solutions further from home. That an older person’s only option in a rural area to manage pain is to call an emergency ambulance and be transported to hospital reflects the impact health service provision (or lack thereof) has on this cohort. Addressing the impact of pain, and improving access to pain management services, is a vital component of improving the overall health and wellbeing of older people, and must not be understated. 

As well as enabling an understanding of the epidemiology of the ambulance utilisation of older rural-dwelling people, this study provides a foundation for clinical and learning opportunities for ambulance services. As rural communities continue to age, paramedics are highly likely to assess and care for an increasing number of older people. This highlights the importance of gerontological training, and in particular in the assessment and management of pain in older people. The potential utilisation of rural paramedics in extended care and community roles is an innovative concept in some rural and remote ambulance locations, with the capacity to be developed further. Paramedics with additional training in primary and preventive healthcare may be well placed to fill gaps in primary community care, taking part in preventive care and public health amidst their emergency responder roles. Pilot programs worldwide indicate a reduction in potentially preventable hospital admissions and also in emergency callouts [2]. Challenges here include funding models and financial sustainability of community paramedic programs. 

So, where to from here? The healthcare inequity faced by older rural-dwelling people is alarming, and despite extensive discourse on the subject in recent years [3-7] is yet to achieve profound change. High levels of ambulance demand, most concerningly for pain management, may indicate significant ongoing challenges to older people when attempting to access health care. Change will require concerted effort, appropriate funding, alongside targeted innovative approaches to improving health service provision in rural areas. Without it we risk further marginalising one of our most precious populations.

Thank you to Dr Judy A. Lowthian who reviewed this article prior to submission.