Djing.gii Gudjaagalali (Children Stars) School Clinic; a novel primary care led Rural School Based Integrated model of care

Djing.gii Gudjaagalali (Children Stars) School Clinic; a novel primary care led Rural School Based Integrated model of care | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Djing.gii Gudjaagalali (Children Stars) School Clinic; a novel primary care led Rural School Based Integrated model of care Corin Miller, Santuri Rungan, David Schmidt, Hayley Smithers-Sheedy, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6963481/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background There are more than 1.36 million children living in remote, rural and regional Australia. These children and young people have significantly worse health outcomes than their urban peers and experience inequities in healthcare access. This study explored key components of the integrated care model, including access, coverage, availability, affordability, improved health and equity. Methods General Practitioner (GP) clinical records for 105 students aged 4–18 years were analysed to demonstrate their care journey through the clinic between May 10th, 2022, and June 30th, 2024. Descriptive statistics were used to demonstrate student demographics, referral reasons, unmet need, previous, current and newly diagnosed concerns, and clinic recommendations. Results Students attending clinic were a high-risk group, with 41.9% indicating previous child protection concerns and 13.3% currently in out-of-home care. Aboriginal and/or Torres Strait Islander students made up 45% of clinic attendees in the first year of the study, and 32.4% in total. Half (49.5%) of the sample did not have access to a regular GP outside the school clinic, and only three students (2.9%) had current access to a paediatrician. The most common school referral reasons were learning difficulties (79%), behavioural concerns (77%), and emotional concerns (73%). The underlying reasons for these concerns were often related to psychological trauma (31%), medical conditions (30%), parental separation (30%), mental health concerns (25%), Attention Deficit Hyperactivity Disorder (ADHD) (22%), domestic violence (20%), and sleep difficulties (19%). Prior to clinic review, the proportion of students per condition with unmet needs included autism spectrum disorder (85.72%), social concerns (79.31%), ADHD (71.19%), medical diagnoses (68.63%), and sleep concerns (62%). The average number of clinic recommendations per student was six, with 45% of these recommendations managed within the clinic or school, and 55% requiring external referral. The most common clinic recommendations were mental health practitioner support/referral (81.9%), medication (67.62%) and paediatrician review (60.95%). Conclusions Rural School Based Integrated Care, a GP-led paediatric primary care model for school students in rural Australia, improves access to healthcare for a rural paediatric population with high unmet health, mental health and social needs. Sustainable funding models are needed to deliver this model at scale. Integrated Care Primary Care Pediatric School-based Rural Health Mental Health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background Children and young people (CYP) living in rural and remote areas in Australia have a higher disease burden than their urban peers, but lower health service utilisation due to significant barriers to accessing healthcare ( 1 , 2 ). Australia’s sparse population density outside metropolitan centres, coupled with vast distances and challenging geography, health workforce and infrastructure limitations, all combine to worsen health outcomes for CYP in rural areas ( 3 ). Rural health service funding inequities also exist, with Australian governmental health spending almost $ 850 AUD less per capita per year for those in rural areas compared to urban counterparts ( 4 ). Australia’s Indigenous People, the Aboriginal and/or Torres Strait Islander peoples, are disproportionately affected by the inequities in the rural Australian health system. Children in this group represent 6% of all Australia’s children, but 47% of all children in remote and very remote areas in 2016 ( 5 ). The significant disparities that exist amongst the Australian population are influenced by social determinants of health such as geographical remoteness and Indigenous status. Taking infant death rates as an example, in Major Cities 2.9 deaths per thousand were reported, but this increased to 5.9 per thousand in remote and very remote areas. Aboriginal and/or Torres Strait Islander babies have a higher infant death rate than non-Indigenous babies, at 6.2 versus 3.1 per 1000 live births. In the lowest socioeconomic communities the death rate was close to double that of the most affluent areas at 4.2 versus 2.3 per thousand respectively ( 5 ). These trends continue in childhood, where child deaths in Major Cities have been reported at a rate of 9.4 per 100,000, whereas this rose to 25 per 100,000 in remote and very remote areas. In all locations the rate of Aboriginal and/or Torres Strait Islander child death was 2.4 times that of non-Indigenous children, and those in the lowest socioeconomic areas had 2.3 times the rate of those in the highest socioeconomic demographic ( 1 , 2 , 5 ). For CYP requiring specialist paediatric care, some paediatricians limit the number of referrals they accept for behavioural or neurodevelopmental concerns, and some areas have no access to paediatricians who accept referrals for these conditions ( 6 ). This inequity sees some CYP wait up to six years to access public outpatient paediatric care, or requires families to travel vast distances and pay private fees, resulting in many CYP missing out on the benefits of early intervention completely ( 1 , 6 , 7 ). For CYP with neurodevelopmental, behavioural, mental health or learning concerns, missing out on timely care can lead to life-long negative impacts such as increased risks for chronic health issues, learning and mental health problems, increasing risk of future hospitalisation, homelessness, unemployment, contact with the criminal justice system and the likelihood of interpersonal relationship difficulties ( 1 ). Australians living in remote and very remote areas are over eight times more likely to be unable to access a General Practitioner (GP) when needed ( 4 ). This is reflected in the reduced use of GP care in non-urban areas. In the most remote areas (MMM7) patients accessed 4.3 services with their GP per annum, versus 8.1 services for those in urban centres (MMM1) ( 8 ). GPs are relatively better distributed across rural Australia than other specialist doctors, many allied health providers, nurse practitioners and pharmacists, demonstrating evidence of chronic, ongoing access issues for all health care providers in rural areas ( 8 ). The difficulty accessing federally funded primary care in rural areas results in higher use of state and territory funded emergency departments (EDs) for non-urgent issues in these areas ( 4 , 9 , 10 ). In the state of New South Wales (NSW) in 2019–2020 there were more attendances at regional EDs than all metropolitan EDs, at 1.5 versus 1.4 million, respectively. As two thirds of the population in NSW lives in metropolitan settings, this indicates a much higher proportion of ED visits per person in those living outside the urban centres ( 9 ). Children from impoverished areas with low access to GPs were found to be six times more likely than those from other areas to present to EDs for non-urgent medical care ( 11 ). The use of EDs for primary care contributes to the higher cost of delivering hospital services in rural areas, and in poorer health outcomes, with this issue increasing with remoteness ( 4 , 12 ). The impact of the social determinants of health again disproportionately affects Aboriginal and Torres Strait Islander people, and those living remotely ( 12 , 13 ). Due to chronic and worsening GP workforce shortages in the geographical region where this research was conducted, usual care wait times for GP visits for any reason can be over four months, and at times no GP appointments are available. This is consistent with published data from across non-urban Australia ( 4 , 8 ). The nearest Aboriginal Medical Service is located 100km round-trip away, and similar to many non-urban areas in Australia, the usual care wait time for public paediatric outpatient clinic care for learning, behavioural or emotional concerns is often over two years ( 1 , 6 , 7 ). Innovative healthcare models are urgently required to meet the needs of CYP living outside urban centres. Digital and hybrid digital/face-to-face models are an evolving area of research within this population, however there is limited evidence currently available in the literature around its use and efficacy in the Australian setting ( 3 ). Fully digital models are not always the preferred mode of care due to factors such as cultural or infrastructure barriers, some conditions such as psychological or behavioural concerns, and the requirement for physical examination for some presentations ( 3 ). The need for culturally appropriate care for Aboriginal and/or Torres Strait Islander populations is acknowledged and is essential for any Australian health service to consider ( 14 ). School-based models for CYP are well established internationally, and school-based models of care are increasing in popularity in Australia ( 15 ). Urban models in Australia, including School Based Integrated Care, have proven efficacy and acceptability ( 16 , 17 ). However, evidence for school-based integrated care models in rural Australia is currently lacking. The limited resources in non-urban areas necessitate collaboration and innovation for the provision of services, and school-based models that can meet the requirements of the rural Australian context are a promising area of research. School-based integrated care models that have been co-designed with schools, the social care sector and communities, have the potential to provide a holistic and culturally safe way to improve access and engagement with health services ( 16 , 17 ). These programs can improve healthcare access for priority populations by aligning with community values and leveraging multisector partnerships ( 18 , 19 ). Rural school-based integrated care (RSBIC), a model designed and implemented in a rural Australian context, aims to provide timely, patient-centred, culturally appropriate care closer to home for school students. This research was undertaken in a small coastal town in southern New South Wales, Australia, in a region chronically impacted by lack of available health services, that did not have any local paediatricians until 2019. Over 80% of the region’s population are either moderately or severely socioeconomically disadvantaged ( 24 ), rated amongst the lowest quintile of socioeconomic disadvantage ( 15 ). By road, the nearest tertiary hospital is Canberra, an 8-hour round-trip, and the closest children’s hospital is Sydney, a 13-hour round-trip. More than 20% of local school students identify as Aboriginal and/or Torres Strait Islander ( 14 ). The school clinic, Djing.gii Gudjaagalali (Children Stars) School Clinic, located at Eden Marine High School (EMHS), opened in 2022, informed by existing school-based integrated care models ( 16 , 20 – 25 ) and was co-designed with the community, schools and the health sector. To help establish cultural safety for the clinic, the local Aboriginal Language Group gifted the clinic name and local Aboriginal and/or Torres Strait Islander students and school staff designed the clinic logo. In completing this study, we have drawn on the World Health Organisation Health System Framework ( 26 ), the Domains of Access to healthcare ( 27 ), and the Quintuple aim ( 28 ). Using elements from these frameworks, we chose to focus on evaluating access, coverage, availability, affordability, improved health, and equity to describe and evaluate a novel model of GP-led paediatric primary care, Rural School Based Integrated Care, for school students aged 4–18 years in rural NSW. Rural School Based Integrated Care- Model of Care: Rural School-Based Integrated Care (RSBIC) integrates available services, streamlining the care journey for students with concerns impacting their ability to engage with schooling ( 3 ). The pilot site of the model, Djing.gii Gudjaagalali (Children Stars) School Clinic Eden opened in 2022 and delivers GP-led, horizontally and vertically integrated multidisciplinary care ( 29 ) to students within the grounds of Eden Marine High School’s Wellbeing Hub. The model facilitates horizontal integration with close collaboration between education, health, and social care providers, with case coordination by the Wellbeing Health In-reach Nurse Coordinator (WHIN-C) if required. Vertical integration occurs with the local specialist paediatric outpatient clinic providing outreach services within the school clinic. A “soft launch” approach was taken when establishing the clinic in 2022, due to limited available resources, and the need to establish funding, systems and processes, referral pathways, and governance structures. This meant that for 2022 most referrals came from one primary school only. By 2023 the clinic was established, and the catchment was expanded to cover a community of six schools (one high school, and five primary schools) in a hub and spoke model. Additional referrals from public schools out of clinic catchment were considered on a case-by-case basis. The frequency of clinics reduced from weekly to fortnightly from 2023, but the number of students seen per clinic increased over time, with the mean per clinic rising from three consults per clinic in 2022, up to eight in 2024. This increase was especially apparent with the addition of a second GP to the clinic in March 2024, as clinics were able to again be offered weekly. The proportion of new versus returning students attending the clinic changed over time. In 2022, most students were new (69%), visiting the clinic for the first time. Providing care within the local high school provides students with a familiar environment for those attending the high school, or with siblings attending the high school. As outlined through our co-design process, the clinic’s location aims to offer a soft entry point into the high school environment, establishing positive connections for students likely to attend the school in future. Co-location with Wellbeing Hub staff ensures integrated provision of services, and the ability to leverage existing relationships to strengthen rapport and trust for students. Strong ties with the local Aboriginal community, and the co-location of cultural groups within the Hub space ensures cultural appropriateness remains a priority. Rural School Based Integrated Care- School Clinic Environment: Clinics are provided within a dedicated clinic space in the school grounds but accessible from the street, without families needing to use the main school office entrance. In addition to the Djing.gii Gudjaagalali (Children Stars) School Clinic, the Wellbeing Hub provides programs to enhance student wellbeing, including cultural programs for Aboriginal and/or Torres Strait Islander students. A Student Support Officer, School Psychologist, and WHIN-C all operate within the Hub, and external services such as cultural groups, non-government organisations, mental health and social support services can utilise the space without charge for activities aligned with Hub goals. Rural School Based Integrated Care- Referral and Care Pathway: Students’ health needs are identified by school staff, WHIN-C, or parents/caregivers. All referrals are discussed with parents and families are supported during their care journey, from identification of a concern, referral into the clinic, and interactions with the clinic, until their care journey concludes (Fig. 1 ). The clinic model has evolved over time, with input from a working group of local stakeholders. A clear referral pathway was needed, so referring schools could ensure equity and appropriateness of referrals (Fig. 1 ). Rural School Based Integrated Care- Integration of Care: On-site visiting GPs with paediatric special interest provide medical and mental health care, facilitate the multidisciplinary care of students, and streamline the care of students requiring paediatric review by ensuring additional information and or tests are completed prior to seeing a paediatrician (Fig. 2 ). By being located at school, clinicians work closely with the WHIN-C, school learning support staff, school counsellors and Aboriginal student support staff. Methods We measured access, coverage, availability, affordability, improved health and equity. Our study period was between May 10th, 2022, and June 30th, 2024. Access was measured as travel times for students to the location of the service. Travel time was calculated from referring schools to the clinic using Google Maps ( 30 ), subsequently doubled to derive the round-trip driving time. Students within 80 minutes round-trip drive time (approximately 70km) were located within the clinic’s official catchment area, totalling 1522 eligible students. Coverage was calculated as the proportion (%) of the enrolled students at each school being referred to the service. The number of enrolled students was determined using the ACARA My School website ( 31 ). Availability was demonstrated by waiting times to access the clinic, clinic utilization, and source of clinic referrals. Clinic waiting times were calculated as the length of the period from the referral date to the student’s initial clinic review date. Student school clinic usage details from clinic booking systems was cross-referenced to GP clinical records and Medicare Benefits Scheme (MBS) receipts ( 32 ). Clinic attendance and “did not attend” visits were recorded from the date of initial clinic review for a total of 12 months after this review. The source of each clinic referral was recorded. Affordability was measured using the cost to consumer and cost of running the service. Cost analysis for the school clinic was performed by comparing MBS receipts data from one of the GPs (GP1) from the school clinic, versus the GP1’s comparable MBS receipts data from a mixed-billing practice they also work at located 25 minutes’ drive away. This direct comparison using the data for the same GP in both contexts, helps to reduce confounding variables such as GP billing style, usual length of consultation, and type of care provided. Comparison was also made to the earnings GP1 would have made if performing the same work in a NSW-funded Hospital working as a Visiting Medical Officer (VMO). Improved health was measured by examining student characteristics, referral reasons, previous concerns/diagnoses, new concern/diagnoses, and clinic recommendations to demonstrate how the service meets the needs of students. Referral reasons were collected from referral forms, emails from the referrers and cross-referenced to GP clinical records. Clinic referrals could contain multiple reasons for referral per student, from a tick-box list, or documented in free-text sections of the form. Student medical records of clinical consultations were created within the clinic and documented remotely within GP clinic software, during the study period. Clinical notes were extracted from Medical Director™( 33 ), de-identified, and loaded into REDCap™ ( 34 ), a secure online repository, by the treating clinician. Data extraction of demographics, referral information, health and socioemotional data from consultations was performed by two independent clinician researchers, with at least 10% of the data reviewed by both to ensure consistency. The treating clinician was excluded from this step to reduce reporting bias. De-identified GP clinical records were analysed by the two independent clinician researchers, who recorded the student’s care journey through the clinic. Previous and new concerns/diagnoses as well as clinic recommendations and referrals were recorded. Previously diagnosed concerns that were not requiring management in clinic were excluded from the “New concern/diagnosis” section as the condition was deemed to be stable and no new management was required. Any previously diagnosed condition that required management in clinic (i.e., previous diagnosis - not stable) or a diagnosis made for the first time in clinic was included as a new condition. Further analysis of the most common conditions was performed to determine the proportion of each condition either previously diagnosed or newly diagnosed. Equity was measured as the proportion of students without access to a GP and/or Paediatrician now accessing care in the clinic, and the proportion of students with unmet need prior to clinic review. Unmet need was calculated as the proportion (%) of students with conditions requiring management in clinic, including previous diagnosis- not stable, and new diagnoses established after clinic review. Analysis: We used descriptive statistics (including mean, standard deviation, median, and interquartile range or IQR) to report the distribution of student demographic characteristics including age at initial clinic review in years, Aboriginal and/or Torres Strait Islander heritage, established clinical relationship with an external GP or paediatrician, and any previous or current child protection concerns. We also calculated the proportions described above for measures including access, coverage, availability, affordability, improved health, and equity. Analyses based on potentially identifying characteristics were not performed to protect the trust of the clinic within the community and individual confidentiality. Additionally, we ensured our local schools Aboriginal Cultural Advisor reviewed this manuscript prior to submission to ensure cultural safety was maintained. We used R Studio for statistical analyses ( 35 ), and the STROBE guidelines for observational research to report our findings ( 36 ). Results Access: In a hub and spoke model, the community of schools within the catchment (within 80 mins round-trip drive time) were eligible to refer their students to the clinic located at the local high school. Three students accessed the clinic from as far away as 130 minutes round-trip drive time (approximately 150km). Coverage: From the five schools within the clinic catchment, the proportion of students referred among those enrolled ranged from 3.41% (9/264) to 17.78% (8/45) with a mean proportion per school of 9.06%. Examining the clinic catchment as a whole, 6.77% (103/1522) of all enrolled students were referred to the clinic. Excluding 2022, where 80% (16/20) of referrals were from Eden Public School, the five schools within catchment referred between 3.41% (9/264) to 13.33% (6/45), with a mean proportion per school of 6.89%. When examining the entire clinic catchment in 2023–2024, a total proportion of 5.39% (82/1522) of enrolled students were referred to the clinic. The clinic is located within the grounds of Eden Marine High School, accounting for the older students in the sample (12–18 years). The remainder of schools within the catchment were primary schools (ages 4–12). Proportionally, the number of students referred to clinic, compared to those enrolled per school, showed a bimodal pattern. The school located 5 minutes round-trip drive away (13.43%, 36/268), and those between 61–80 minutes round-trip drive (17.78%, 8/45), had the highest proportion of enrolled students referred between May 2022 and end June 2024. Availability Clinic Waiting Time: The median wait time from referral date to initial clinic review was 45 days, interquartile range (IQR) 57 days. Clinic Utilisation: From 2022-24 a total of 105 students accessed the service, with a total 335 consultations occurring. The mean number of visits per patient within 12 months inclusive of their initial consultation was 3.2 (S.D 1.72). Only 1 student did not attend their scheduled initial appointment. The number of “failure to attend” appointments within the first year of a student utilising the service ranged from zero to three (mean 0.17, SD 0.54). Source of Clinic Referrals: Over the study period, referrals were most commonly received from the WHIN-C (32.38%), Teachers (27.62%), School Leadership such as Principals, Deputy Principals or Head Teachers (23.81%), or School Psychologists / School Counsellors (19.05%). Other sources of referral included Student Support Officer, external clinician, or self/parent/caregiver (1.9%). Affordability: The clinic is by necessity a no cost to consumer model, relying on MBS rebates to fund GP clinical services (referred to as “bulkbilling”). When compared to GP1’s average gross (pre-tax) private/mixed billing GP clinic income from 2022–2024 (with 55–78% of patients bulk billed, and 21–42% privately billed), the average loss of income per clinic ranged between $ 540 and $ 1005 AUD. When compared to GP1’s earnings when working in the state-funded hospital system, the average loss of income per clinic ranged between $ 1288 to $ 1752 AUD. For the study period this resulted in a mean total loss of almost $ 43,000 for GP1 when compared to private/mixed billing GP clinic work, and just over $ 81,300 when compared to hospital work. These calculations do not include the unpaid work undertaken by GP1 in establishing community and stakeholder engagement, co-designing the model of care, governance, and research activities. Improved health: Student Characteristics: Over the study period the demographics of students accessing the clinic showed an age range of 4.78 to 17.19 years. Overall, 32.4% of students (34/105) identified as Aboriginal and/or Torres Strait Islander, with this proportion higher in the first year (45%, 9/20). A majority of students were male (55%, 58/105), half identified having access to a regular GP (50%, 53/105), previous child protection concerns were recorded for 41.9% (44/105), 11.4% (12/105) had an open case with child protective services and 13.3% (14/105) were living in out-of-home care within the child protection system (Table 1 ). Only 3% (3/105) had access to a paediatrician. Table 1 Student Demographics Demographics 2022 May-Dec 2023 (Jan-Dec) 2024 (Jan-June) Total No. (Col%) No. (Col%) No. (Col%) No. (Col%) Total new patients 20 (100%) 50 (100%) 35 (100%) 105 (100%) Age range (years) 5.43–12.51 4.78–17.19 5.24–16.08 4.78–17.19 Age (years) 4–6 6 (30%) 11 (22%) 11 (31.4%) 28 (26.7%) 7–9 10 (50%) 24 (48%) 11 (31.4%) 45 (42.9%) 10–12 4 (20%) 7 (14%) 5 (14.3%) 16 (15.2%) 13–15 0 (0%) 7 (14%) 5 (14.3%) 12 (11.4%) 16–18 0 (0%) 1 (2%) 3 (8.6%) 4 (3.8%) Gender Male 14 (70%) 27 (54%) 17 (48.6%) 58 (55.24%) Female 6 (30%) 22 (44%) 17 (48.6%) 45 (42.86%) Gender Diverse 0 (0%) 1 (2%) 1 (2.9%) 2 (1.90%) Indigenous Status Aboriginal and/or Torres Strait Islander 9 (45%) 15 (30%) 10 (28.6%) 34 (32.4%) Not Aboriginal or Torres Strait Islander 11 (55%) 35 (70%) 25 (71.4%) 71 (67.6%) Regular GP Yes 14 (70%) 23 (46%) 16 (45.7%) 53 (50.5%) No 6 (30%) 27 (54%) 19 (54.3%) 52 (49.5%) Previous Child Protection Concerns Yes 10 (50%) 25 (50%) 9 (25.7%) 44 (41.9%) No 10 (50%) 25 (50%) 26 (74.3%) 61 (58.1%) Current Open Case Child Protection Service Yes 2 (10%) 6 (12%) 4 (11.4%) 12 (11.4%) * No 18 (90%) 44 (88%) 31 (88.6%) 93 (88.6%) Out of Home Care Yes 3 (15%) 8 (16%) 3 (8.6%) 14 (13.3%) No 17 (85%) 42 (84%) 32 (91%) 91 (86.7%) * All students with an open case with child protection had previous child protection concerns documented. Each student could be referred for multiple reasons. Of all referral reasons, the majority of students were referred to the clinic for learning concerns (79.05%, 83/105), behavioural concerns (77.14%, 81/105), and emotional concerns (73.33%, 77/105). Of students with previously known concerns/diagnoses, the most common was psychological trauma (31.43%, 33/105), followed by medical diagnoses (29.52%, 31/105) and family characteristics- parents separated (29.52%, 31/105). The two most common new concern/diagnoses were medical diagnoses 40% (42/105) and Attention Deficit Hyperactivity Disorder (ADHD) 40% (42/105). Students’ unmet needs denoted by the proportion of “previous diagnosis – not stable” and “new diagnosis” per condition were shown in Fig. 3 , with the highest proportion of unmet needs seen for those with autism spectrum disorder (ASD) 85.72% (18/21), social concerns 79.31% (23/33), ADHD 71% (42/59), medical diagnoses 68.63% (35/51), sleep concerns 62% (49/50), deliberate self-harm/suicidal ideation (DSH/SI) 57.14% (8/14), and mental health diagnoses 56.52% (26/46). Figure 4 demonstrates that for students referred with the three most common reasons of behavioural, emotional or learning concerns, (left of figure), the underlying concerns uncovered in clinic were broad, including unmet medical, psychological, and social concerns (right of figure). Clinic recommendations: The average number of clinic recommendations per student was six (627/105), with 45% (282/627) of these recommendations managed within the clinic or schools, and 55% (345/627) requiring external referral. The two most common clinic recommendations, medication and paediatrician review, were given to 67.62% (71/105) and 60.95% (64/105) of students, respectively. However, the aggregated recommendation “mental health practitioner support/referral”, consisting of counselling (provided by the school) (46/105), referral to a mental health service (26/105), and continue with current mental health services (14/105), became the most frequent recommendation to the students (81.9%, 86/105). Allied health referrals including occupational therapy (25/105), speech therapy (29/105), referral to a mental health service (26/105), art/music/play therapy (1/105) and cognitive/developmental assessment (43/105) made up 20% (124/627) of all clinic recommendations (Fig. 5 ). Of students recommended to have a paediatric review (n = 64), the majority were for ADHD management (58%, 37/64). At the same time, of students with ADHD requiring diagnosis or management in clinic (40%, 42/105), 88% (37/42) were recommended to be reviewed by a paediatrician. Discussion This paper is among the first to demonstrate the unmet health and wellbeing needs of a sample of school-aged children in rural Australia, and to explore the utility of a GP-led school-based clinic accepting referrals directly from schools in this context. School-based healthcare services have existed internationally for decades, and urban models have been in operation in Australia since at least 2018 ( 16 , 17 , 22 ). In the urban Australian setting, school-based models have been shown to improve equity of access, healthcare provision and student outcomes 6,7). Some Australian states have government-funded school based healthcare services ( 20 ), but NSW, the location of this study, does not. Despite school based healthcare models growing in popularity in rural Australia ( 15 ), the utility of a GP-led clinic in the rural Australian context, that prioritises referrals directly from schools, is not yet well-established ( 15 ). The World Health Organisation (WHO) recognises access to health care as a fundamental human right ( 37 ). Global policies such as the Millenium Development Goals, and Sustainable Development Goals, recognise that investment in children’s health contributes to economic growth and social security ( 38 ). Internationally, the WHO Health Promoting Schools Framework ( 19 ) has influenced the expansion of school-based models of care. This framework aligns with the WHO Health System Framework ( 26 ), the Domains of Access to healthcare ( 27 ), and the Quintuple Aim ( 28 ). Within Australia, this model aligns with Commonwealth Government policy including the Primary Health Care 10 year plan ( 39 ), National Health Reform Agreement ( 40 ), and Closing the Gap ( 41 ). Within NSW, this model aligns with the findings of the NSW Government Special Commission of Inquiry into Healthcare Spending ( 42 ), the Inquiry into Health Outcomes and Access to Health and Hospital Services in Rural, Regional and Remote NSW ( 43 ), NSW Health Regional Health Strategic Plan ( 44 ), First 2000 Days Framework ( 45 ), and the Henry Review into Health Services for Children, Young People and Families ( 46 ). The findings of this paper indicate that the Rural School Based Integrated Care model is providing healthcare access to students not otherwise accessing care and demonstrates that outreach clinics into schools can help meet the care needs for this population. In addition, the uptake of Rural School Based Integrated Care within the clinic’s catchment area was high, demonstrating the high levels of unmet need in the community, and the acceptability and fidelity of the model for schools and families ( 47 ). Access to a GP has been shown to reduce morbidity and mortality, limit potentially preventable hospitalisations, and costs far less per consultation than accessing care in the hospital system ( 48 ). However, children from the lowest socioeconomic quintile in Australia were least likely to access appropriate outpatient management for chronic health conditions due to cost barriers accessing a GP, or private specialist ( 49 ). Almost 90% of Australians visit a GP annually, but access to a GP declines with geographical remoteness ( 48 ). Aboriginal and/or Torres Strait Islander children are disproportionally affected by the lack of accessible rural health services in Australia, negatively impacting health outcomes for this population ( 5 , 41 ). Due to a lack of alternate services and very long usual care waiting times, students in this locality travelled up to 150km round-trip from their referring school to access the clinic. For children in rural Australia requiring paediatric specialty or allied health care for developmental, behavioural, mental health or learning concerns, the current wait time can be up to 6 years ( 1 , 7 ). Some areas of Australia have no access to a paediatrician, and for those that do, many paediatricians limit the number of children they will see for these conditions ( 6 ). The increasing prevalence of mental health and neurodevelopmental disorders in Australian children further adds to the pressures on the health system ( 8 , 50 ). Compared to usual care pathways, school clinic wait times were comparable with accessing standard GP care in the region. When compared to usual wait times for paediatric outpatient care, school clinic wait times were significantly less, from years to just days or weeks. Demonstrating embedding of the school clinic within the community, students utilized the service and returned for care when needed. Referrals were received from all of the public schools within the clinic catchment area, and from a variety of sources. However, a major factor impacting sustainability of the model is the inadequacy of Australian Government (Federal) MBS rebates to cover the cost of providing the GP service, particularly for longer and more complex consultations, which is the norm in this clinic. An economic evaluation of school-based healthcare services in the USA demonstrated a positive benefit–cost ratio ranging from 1.38:1 to 3.05:1( 9 ). However, the structure of funding for Australian health and education sectors, with arbitrary divisions between Federal and State/Territory sources provides a complex environment in which to deliver care for priority populations resulting in barriers to care for those most requiring it ( 51 ). In an example of the inverse care law ( 52 ), MBS patient rebates for GPs do not cover the cost of providing the service, and the charging of private gap-fees would form a financial barrier for those requiring care. The clinic was financed by a combination of sources, but funding needs remain for care coordinators, allied health care providers and child and adolescent psychiatry, which may negatively impact the provision of multidisciplinary care for students. Pay parity for GPs or Rural Generalists when compared to GP clinics charging gap-fees, and for rural areas, hospital work, will be necessary to attract and retain medical staff to work in school clinics. Urgent investment in Aboriginal and/or Torres Strait Islander-led initiatives, prioritising the positive impacts of self-determination, is required, especially in rural and remote Australia ( 14 , 53 ). The findings of this study are consistent with the literature regarding rural Australians and the health system. A 2023 investigation into healthcare spending in Australia demonstrated a government healthcare spend shortfall of $ 6.5 billion AUD annually for rural Australians, when compared to their urban counterparts ( 4 ). Children living in rural Australia face inequities in healthcare access ( 5 ), often missing out on early intervention ( 1 ). Late intervention is estimated to cost Australian Governments $ 15.2 billion AUD/year through high-intensity and crisis services ( 45 ). Children living in out of home care are known to experience higher rates of psychological trauma, and the impact of adverse childhood experiences is known to contribute to increased morbidity and mortality in adulthood ( 54 ). A paucity of available allied health, psychiatry, and tertiary assessment service input is noted ( 3 ). A plausible solution to this issue could be the provision and integration of telehealth services when local services are unavailable in a hybrid model utilising available local staff, supplemented with virtual supports when needed ( 3 ). Student behaviours experienced by school staff as emotional, behavioural or learning concerns were found in this study to be largely due to unmet health, wellbeing, and social needs. The negative impact of these unmet needs on rural Australian student’s learning outcomes is demonstrated in the lower educational outcomes, lower average income, worse health outcomes and lower life expectancy of rural Australians ( 4 ). Within this clinic, high rates of unmet needs were documented for a broad range of conditions, including medical, mental health, neurodevelopmental disorders, as well as social concerns. High numbers of students required mental health care, medication, referral to a paediatrician, and access to other services such as allied health. The majority of paediatric referrals made in clinic were for ADHD management, directly relating to the legislative requirement at the time for paediatrician review prior to commencing first line medications (stimulants) for ADHD. In part due to these access blocks, ADHD costs Australia $ 20 billion AUD annually in social and economic costs such as loss of productivity and increased rates of engagement with the Justice System ( 55 ). It is anticipated that recent NSW government policy changes that will enable GPs to routinely prescribe stimulants for ADHD will make a drastic change to clinic referral patterns, reducing strain on public paediatric clinics and improving outcomes for CYP with ADHD. Strengths and Limitations of the study: A strength of this study is that all students referred to the clinic were included, reducing selection bias. The direct comparison of the same GP’s earnings between contexts reduced confounding variables such as consulting style, MBS billing habits and time management techniques. Recognised limitations of this study include a relatively small sample size, lack of a control group, the inherent restrictions associated with an audit of medical records, constrained cost analysis, and possible self-report bias, especially for conditions associated with possible social stigma or safety concerns, such as substance use, psychological trauma, domestic violence, child protection concerns, or mental health concerns. Despite documenting clinic recommendations, this study was not able to determine if students were able to follow through on these, or access required services. Additionally, comparative analyses of the data were limited due to the risk of identification within a small community. Conclusion This model shows promise for meeting the unmet care needs for students in rural areas comparable to the Australian context. Further mixed methods implementation evaluation, with qualitative interviews with a purposive sample of school and health staff, parents/caregivers and students aged 14–18 years, and an economic evaluation, are necessary to fully understand the generalisability of this model for rural areas in Australia. Abbreviations ADHD Attention Deficit Hyperactivity Disorder ASD Autism Spectrum Disorder CYP children and young people DSH/SI Deliberate self-harm/suicidal ideation DV Domestic violence GP General Practitioner GP1 General Practitioner one (of two that worked in the clinic) IQR interquartile range MBS Medicare Benefit Schedule NSW New South Wales RG Rural Generalist WHIN-C Wellbeing Health In-Reach Nurse Coordinator Declarations Ethics approval and consent to participate This study complied with the Declaration of Helsinki- Ethical Principles for Medical Research Involving Human Participants (56). Ethical approval and waiver of consent was granted by Sydney Local Health District HREC (protocol number X21-0168 and 2020/ETH00532). Further approval was confirmed by NSW Department of Education (SERAP 2020189) the Aboriginal Health and Medical Research Council. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available due to risk of potential breach of patient confidentiality but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research is supported by an Australian Government Research Training Program Scholarship and Rural Mental Health Small Project Research Grant funding from the Peregrine Centre. Authors' contributions CM: conceptualisation, methodology, software, validation, formal analysis, investigation, resources, writing- original draft, writing- review and editing, visualisation, project administration, funding acquisition. SR: conceptualisation, methodology, resources, writing- review and editing, project administration, funding acquisition. DS: conceptualisation, methodology, validation, resources, writing- review and editing, funding acquisition, supervision. HSS: conceptualisation, methodology, validation, writing- review and editing, supervision WE: methodology, investigation, resources, project administration, funding acquisition. EE: methodology, investigation, resources, project administration, funding acquisition. NH: methodology, software, validation, formal analysis, supervision. JK: methodology, software, validation, formal analysis, supervision. LS: conceptualisation, methodology, validation, writing- review and editing, visualisation, supervision. RL: conceptualisation, methodology, validation, writing- review and editing, visualisation, project administration, funding acquisition, supervision. All authors read and approved the final manuscript. Acknowledgements CM would like to thank her PhD supervisors and the University of New South Wales Population Child Health Research team. Additionally, the project team would like to thank Curalo Medical Centre, Vivienne Chelin and Eden Marine High School staff, members of the Eden Working Group, Alison Simpson and Twofold Aboriginal Corporation, Terra Harrison and Jellybean Family Psychology, the NSW Rural Doctors Network, NSW Health Education Training Institute Rural Research Capacity Building Program, Southern NSW Local Health District, Sydney Local Health District, Mumbulla Community Foundation, NSW Office of Regional Youth, The Aboriginal Education Consultative Group, Dr Jessica Weber, A/Prof Hueiming Liu, Keith Duran, and the Australasian School Based Health Alliance. Authors' Information CM is a GP/Rural Generalist Paediatrics, working in rural Australia in private general practice, in the Djing.gii Gudjaagalali School Clinic, and as a Visiting Medical Officer for NSW Health. CM is a current appointed Board member for the Australasian ADHD Professionals Association, Vice President of the Australasian School Based Health Alliance, Deputy Chair of the Royal Australian College of General Practitioners (RACGP) Neurodiversity Special Interest Group, member of the RACGP NSW/ACT Faculty and member of the NSW Health Agency for Clinical Innovation Paediatric Network Executive Committee. References Arefadib N. Reporting the Health and Development of Children in Rural and Remote Australia. Victoria.: The Centre for Community Child Health at the Royal Children’s Hospital and the Murdoch Children’s Research Institute;: Parkville; 2017. Australian Institute of Health and Welfare. Australia’s Health 2022: in brief, catalogue number AUS 241. Australian Government, Australian Institute of Health and Welfare; 2022. Miller C, Smithers-Sheedy H, Hu N, Schmidt D, Christie A, Morris T, et al. Reducing Health Inequity for Children and Young People in Rural Australia: Are Digital Interventions a Panacea? A Rural Generalist's Commentary. Aust J Rural Health. 2025;33:e70015. Nous Group. Evidence base for additional investment in rural health in Australia. National Rural Health Alliance; 2023. Australian Institute of Health and Welfare. Australia’s children. Canberra: Australian Institute of Health and Welfare; 2020. Hiscock H, Gulenc A, Efron D, Freed G. Inequity in Access to Paediatric Care for Developmental and Behavioural Versus Medical Problems in Australia: A National Survey. J Paediatr Child Health. 2018;54(6):705–6. Mascarenhas C. No respite: Government refuses to commit to funding paediatric clinics. The North West Star. 2024 26th April 2024. Royal Australian College of General Practitioners. 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J Paediatrics Child Health 2023;Nov 14;jpc.16515. Rungan SS-MJ, Liu HM, Drinkwater A, Eastwood J. School-Based Integrated Care Within Sydney Local Health District: A Qualitative Study About Partnerships Between the Education and Health Sectors. Int J Integr care. 2024;24(2):13. Jones DBJ, Dyson R, Macbeth P, Lyle D, Sunny P, Thomas A, Sharma I. A community engaged primary healthcare strategy to address rural school student inequities: a descriptive paper. Prim Health Care Res Dev. 2019;20(e26):1–6. Jones DLD, Brunero C, McAllister L, Webb T, Riley SI. Health and Education Outcomes for Children in Remote Communities- A Cross Sector and Developmental Approach. Int J Community Res Engagem. 2015;8(1):1–22. WHO. Everybody business: strengthening health systems to improve health outcomes : WHO’s framework for action. Geneva, Switzerland: World Health Organisation; 2007. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. 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J Biomed Inf. 2009;42(2):377–81. Posit team. RStudio: Integrated Development Environment for R, Boston MA. Posit Software, PBC, ; 2025 [Available from: http://www.posit.co/ Elm Ev, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007;335(7624):806–8. WHO. Human rights: World Health Organisation. 2022 [Available from: https://www.who.int/news-room/fact-sheets/detail/human-rights-and-health Hanifiha MGA, Keykhaei M, Saeedi Moghaddam S, Rezaei N, Pasha Zanous M, et al. Global, regional, and national burden and quality of care index in children and adolescents: A systematic analysis for the global burden of disease study 1990–2017. PLoS ONE. 2022;17(4):e0267596. Australian Government. Future focused primary health care: Australia’s Primary Health Care 10 Year Plan 2022–2032. Canberra: Commonwealth of Australia Department of Health; 2022. Australian Government. 2020-25 National Health Reform Agreement: Commonwealth of Australia; 2024 [Available from: https://www.health.gov.au/our-work/2020-25-national-health-reform-agreement-nhra Australian Government. Closing the gap on Indigenous disadvantage: the challenge for Australia. Canberra: The Australian Government; 2009. Beasley THJR. Special Commission of Inquiry into Healthcare Funding: New South Wales Government, New South Wales Health.; 2025 [Available from: https://www.health.nsw.gov.au/Reports/Pages/special-commission-inquiry-funding.aspx New South Wales Parliament. Health outcomes and access to health and hospital services in rural, regional and remote New South Wales. In: Health LCPCN, editor. Report no 57, 2022. NSW Government. NSW Regional Health Strategic Plan 2022–2032 Priority Framework. Sydney: NSW Ministry of Health; 2023. NSW Health. The First 2000 Days Framework Summary- strategic policy document.; 2019. NSW Ministry of Health. The Henry Review Implementation Plan. St Leonards, NSW: NSW Ministry of Health; 2022. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65–76. Royal Australian College of General Practitioners. General Practice: Health of the Nation 2023. East Melbourne: RACGP; 2023. Callander EJ, Bull C, Lain S, Wakefield CE, Lingam R, Marshall GM, et al. Inequality in early childhood chronic health conditions requiring hospitalisation: A data linkage study of health service utilisation and costs. Paediatr Perinat Epidemiol. 2022;36(1):156–66. Hiscock H, Roberts G, Efron D, Sewell JR, Bryson HE, Price AMH, et al. Children Attending Paediatricians Study: a national prospective audit of outpatient practice from the Australian Paediatric Research Network. Med J Aust. 2011;194(8):392–7. Calder RDRRCNT. Australian health services: too complex to navigate. A review of the national reviews of Australia’s health service arrangements. Australian Health Policy Collab; 2019. Contract No.: Policy Issues Paper 1 2019. JT H. The Inverse Care Law. Lancet. 1971;297(7696):405–12. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework - Summary report 2023. Canberra: Australian Institute of Health and Welfare. 2023 viewed 17th June 2023. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14(4):245–58. Deloitte Access Economics. The social and economic costs of ADHD in Australia Report prepared for the Australian ADHD Professionals Association. 2019. World Medical Association. WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Participants: World Medical Association. 2025 [Available from: https://www.wma.net/policies-post/wma-declaration-of-helsinki/ Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6963481","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501251992,"identity":"d6143b19-4a0a-421f-aec1-0ef6ee951a3b","order_by":0,"name":"Corin 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2","display":"","copyAsset":false,"role":"figure","size":61381,"visible":true,"origin":"","legend":"\u003cp\u003eDetail, Rural School Based Integrated Care- Model of Care\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6963481/v1/3594a8263d4c0c418e86c105.png"},{"id":89273755,"identity":"8d0e2d55-1426-44ad-81ad-6e4a812e9b01","added_by":"auto","created_at":"2025-08-18 09:11:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":22645,"visible":true,"origin":"","legend":"\u003cp\u003eProportion of Students per Condition (%) requiring management in clinic for previous but not stable diagnosis or new diagnosis\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6963481/v1/967064af1bc13183c2b29bd2.png"},{"id":89274317,"identity":"7723eb62-b92d-4b4a-821d-c776475e0102","added_by":"auto","created_at":"2025-08-18 09:19:08","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":129769,"visible":true,"origin":"","legend":"\u003cp\u003eMost Common Referral Reasons and New Concerns/Diagnoses Identified in Clinic\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6963481/v1/b8c52756727f95735d3959ee.png"},{"id":89275951,"identity":"d86bcf6f-8f72-4673-ba9a-fe79e0006121","added_by":"auto","created_at":"2025-08-18 09:27:08","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":55210,"visible":true,"origin":"","legend":"\u003cp\u003eClinic Recommendations\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6963481/v1/c1d48af9e1f493200eb9158c.png"},{"id":89276491,"identity":"7fbb6390-0287-4879-9211-d24250ea64c1","added_by":"auto","created_at":"2025-08-18 09:35:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1463700,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6963481/v1/f45e3b2b-435a-4ab8-add4-62eeffc2104d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Djing.gii Gudjaagalali (Children Stars) School Clinic; a novel primary care led Rural School Based Integrated model of care","fulltext":[{"header":"Background","content":"\u003cp\u003eChildren and young people (CYP) living in rural and remote areas in Australia have a higher disease burden than their urban peers, but lower health service utilisation due to significant barriers to accessing healthcare (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Australia\u0026rsquo;s sparse population density outside metropolitan centres, coupled with vast distances and challenging geography, health workforce and infrastructure limitations, all combine to worsen health outcomes for CYP in rural areas (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Rural health service funding inequities also exist, with Australian governmental health spending almost \u003cspan\u003e$\u003c/span\u003e850 AUD less per capita per year for those in rural areas compared to urban counterparts (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAustralia\u0026rsquo;s Indigenous People, the Aboriginal and/or Torres Strait Islander peoples, are disproportionately affected by the inequities in the rural Australian health system. Children in this group represent 6% of all Australia\u0026rsquo;s children, but 47% of all children in remote and very remote areas in 2016 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe significant disparities that exist amongst the Australian population are influenced by social determinants of health such as geographical remoteness and Indigenous status. Taking infant death rates as an example, in Major Cities 2.9 deaths per thousand were reported, but this increased to 5.9 per thousand in remote and very remote areas. Aboriginal and/or Torres Strait Islander babies have a higher infant death rate than non-Indigenous babies, at 6.2 versus 3.1 per 1000 live births. In the lowest socioeconomic communities the death rate was close to double that of the most affluent areas at 4.2 versus 2.3 per thousand respectively (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). These trends continue in childhood, where child deaths in Major Cities have been reported at a rate of 9.4 per 100,000, whereas this rose to 25 per 100,000 in remote and very remote areas. In all locations the rate of Aboriginal and/or Torres Strait Islander child death was 2.4 times that of non-Indigenous children, and those in the lowest socioeconomic areas had 2.3 times the rate of those in the highest socioeconomic demographic (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). For CYP requiring specialist paediatric care, some paediatricians limit the number of referrals they accept for behavioural or neurodevelopmental concerns, and some areas have no access to paediatricians who accept referrals for these conditions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This inequity sees some CYP wait up to six years to access public outpatient paediatric care, or requires families to travel vast distances and pay private fees, resulting in many CYP missing out on the benefits of early intervention completely (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). For CYP with neurodevelopmental, behavioural, mental health or learning concerns, missing out on timely care can lead to life-long negative impacts such as increased risks for chronic health issues, learning and mental health problems, increasing risk of future hospitalisation, homelessness, unemployment, contact with the criminal justice system and the likelihood of interpersonal relationship difficulties (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAustralians living in remote and very remote areas are over eight times more likely to be unable to access a General Practitioner (GP) when needed (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This is reflected in the reduced use of GP care in non-urban areas. In the most remote areas (MMM7) patients accessed 4.3 services with their GP per annum, versus 8.1 services for those in urban centres (MMM1) (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). GPs are relatively better distributed across rural Australia than other specialist doctors, many allied health providers, nurse practitioners and pharmacists, demonstrating evidence of chronic, ongoing access issues for all health care providers in rural areas (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe difficulty accessing federally funded primary care in rural areas results in higher use of state and territory funded emergency departments (EDs) for non-urgent issues in these areas (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In the state of New South Wales (NSW) in 2019\u0026ndash;2020 there were more attendances at regional EDs than all metropolitan EDs, at 1.5 versus 1.4\u0026nbsp;million, respectively. As two thirds of the population in NSW lives in metropolitan settings, this indicates a much higher proportion of ED visits per person in those living outside the urban centres (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Children from impoverished areas with low access to GPs were found to be six times more likely than those from other areas to present to EDs for non-urgent medical care (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The use of EDs for primary care contributes to the higher cost of delivering hospital services in rural areas, and in poorer health outcomes, with this issue increasing with remoteness (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The impact of the social determinants of health again disproportionately affects Aboriginal and Torres Strait Islander people, and those living remotely (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDue to chronic and worsening GP workforce shortages in the geographical region where this research was conducted, usual care wait times for GP visits for any reason can be over four months, and at times no GP appointments are available. This is consistent with published data from across non-urban Australia (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The nearest Aboriginal Medical Service is located 100km round-trip away, and similar to many non-urban areas in Australia, the usual care wait time for public paediatric outpatient clinic care for learning, behavioural or emotional concerns is often over two years (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInnovative healthcare models are urgently required to meet the needs of CYP living outside urban centres. Digital and hybrid digital/face-to-face models are an evolving area of research within this population, however there is limited evidence currently available in the literature around its use and efficacy in the Australian setting (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Fully digital models are not always the preferred mode of care due to factors such as cultural or infrastructure barriers, some conditions such as psychological or behavioural concerns, and the requirement for physical examination for some presentations (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The need for culturally appropriate care for Aboriginal and/or Torres Strait Islander populations is acknowledged and is essential for any Australian health service to consider (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSchool-based models for CYP are well established internationally, and school-based models of care are increasing in popularity in Australia (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Urban models in Australia, including School Based Integrated Care, have proven efficacy and acceptability (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, evidence for school-based integrated care models in rural Australia is currently lacking. The limited resources in non-urban areas necessitate collaboration and innovation for the provision of services, and school-based models that can meet the requirements of the rural Australian context are a promising area of research.\u003c/p\u003e\u003cp\u003eSchool-based integrated care models that have been co-designed with schools, the social care sector and communities, have the potential to provide a holistic and culturally safe way to improve access and engagement with health services (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These programs can improve healthcare access for priority populations by aligning with community values and leveraging multisector partnerships (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRural school-based integrated care (RSBIC), a model designed and implemented in a rural Australian context, aims to provide timely, patient-centred, culturally appropriate care closer to home for school students. This research was undertaken in a small coastal town in southern New South Wales, Australia, in a region chronically impacted by lack of available health services, that did not have any local paediatricians until 2019. Over 80% of the region\u0026rsquo;s population are either moderately or severely socioeconomically disadvantaged (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), rated amongst the lowest quintile of socioeconomic disadvantage (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). By road, the nearest tertiary hospital is Canberra, an 8-hour round-trip, and the closest children\u0026rsquo;s hospital is Sydney, a 13-hour round-trip. More than 20% of local school students identify as Aboriginal and/or Torres Strait Islander (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The school clinic, Djing.gii Gudjaagalali (Children Stars) School Clinic, located at Eden Marine High School (EMHS), opened in 2022, informed by existing school-based integrated care models (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and was co-designed with the community, schools and the health sector. To help establish cultural safety for the clinic, the local Aboriginal Language Group gifted the clinic name and local Aboriginal and/or Torres Strait Islander students and school staff designed the clinic logo.\u003c/p\u003e\u003cp\u003eIn completing this study, we have drawn on the World Health Organisation Health System Framework (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), the Domains of Access to healthcare (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), and the Quintuple aim (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Using elements from these frameworks, we chose to focus on evaluating \u003cb\u003eaccess, coverage, availability, affordability, improved health, and equity\u003c/b\u003e to describe and evaluate a novel model of GP-led paediatric primary care, Rural School Based Integrated Care, for school students aged 4\u0026ndash;18 years in rural NSW.\u003c/p\u003e\n\u003ch3\u003eRural School Based Integrated Care- Model of Care:\u003c/h3\u003e\n\u003cp\u003eRural School-Based Integrated Care (RSBIC) integrates available services, streamlining the care journey for students with concerns impacting their ability to engage with schooling (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The pilot site of the model, Djing.gii Gudjaagalali (Children Stars) School Clinic Eden opened in 2022 and delivers GP-led, horizontally and vertically integrated multidisciplinary care (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) to students within the grounds of Eden Marine High School\u0026rsquo;s Wellbeing Hub. The model facilitates horizontal integration with close collaboration between education, health, and social care providers, with case coordination by the Wellbeing Health In-reach Nurse Coordinator (WHIN-C) if required. Vertical integration occurs with the local specialist paediatric outpatient clinic providing outreach services within the school clinic.\u003c/p\u003e\u003cp\u003eA \u0026ldquo;soft launch\u0026rdquo; approach was taken when establishing the clinic in 2022, due to limited available resources, and the need to establish funding, systems and processes, referral pathways, and governance structures. This meant that for 2022 most referrals came from one primary school only. By 2023 the clinic was established, and the catchment was expanded to cover a community of six schools (one high school, and five primary schools) in a hub and spoke model. Additional referrals from public schools out of clinic catchment were considered on a case-by-case basis. The frequency of clinics reduced from weekly to fortnightly from 2023, but the number of students seen per clinic increased over time, with the mean per clinic rising from three consults per clinic in 2022, up to eight in 2024. This increase was especially apparent with the addition of a second GP to the clinic in March 2024, as clinics were able to again be offered weekly. The proportion of new versus returning students attending the clinic changed over time. In 2022, most students were new (69%), visiting the clinic for the first time.\u003c/p\u003e\u003cp\u003eProviding care within the local high school provides students with a familiar environment for those attending the high school, or with siblings attending the high school. As outlined through our co-design process, the clinic\u0026rsquo;s location aims to offer a soft entry point into the high school environment, establishing positive connections for students likely to attend the school in future. Co-location with Wellbeing Hub staff ensures integrated provision of services, and the ability to leverage existing relationships to strengthen rapport and trust for students. Strong ties with the local Aboriginal community, and the co-location of cultural groups within the Hub space ensures cultural appropriateness remains a priority.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eRural School Based Integrated Care- School Clinic Environment:\u003c/h2\u003e\u003cp\u003eClinics are provided within a dedicated clinic space in the school grounds but accessible from the street, without families needing to use the main school office entrance. In addition to the Djing.gii Gudjaagalali (Children Stars) School Clinic, the Wellbeing Hub provides programs to enhance student wellbeing, including cultural programs for Aboriginal and/or Torres Strait Islander students. A Student Support Officer, School Psychologist, and WHIN-C all operate within the Hub, and external services such as cultural groups, non-government organisations, mental health and social support services can utilise the space without charge for activities aligned with Hub goals.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRural School Based Integrated Care- Referral and Care Pathway:\u003c/h3\u003e\n\u003cp\u003eStudents\u0026rsquo; health needs are identified by school staff, WHIN-C, or parents/caregivers. All referrals are discussed with parents and families are supported during their care journey, from identification of a concern, referral into the clinic, and interactions with the clinic, until their care journey concludes (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The clinic model has evolved over time, with input from a working group of local stakeholders. A clear referral pathway was needed, so referring schools could ensure equity and appropriateness of referrals (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eRural School Based Integrated Care- Integration of Care:\u003c/h3\u003e\n\u003cp\u003eOn-site visiting GPs with paediatric special interest provide medical and mental health care, facilitate the multidisciplinary care of students, and streamline the care of students requiring paediatric review by ensuring additional information and or tests are completed prior to seeing a paediatrician (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). By being located at school, clinicians work closely with the WHIN-C, school learning support staff, school counsellors and Aboriginal student support staff.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe measured access, coverage, availability, affordability, improved health and equity. Our study period was between May 10th, 2022, and June 30th, 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAccess\u003c/b\u003e was measured as travel times for students to the location of the service. Travel time was calculated from referring schools to the clinic using Google Maps (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), subsequently doubled to derive the round-trip driving time. Students within 80 minutes round-trip drive time (approximately 70km) were located within the clinic\u0026rsquo;s official catchment area, totalling 1522 eligible students.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCoverage\u003c/b\u003e was calculated as the proportion (%) of the enrolled students at each school being referred to the service. The number of enrolled students was determined using the ACARA My School website (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eAvailability\u003c/b\u003e was demonstrated by waiting times to access the clinic, clinic utilization, and source of clinic referrals. Clinic waiting times were calculated as the length of the period from the referral date to the student\u0026rsquo;s initial clinic review date. Student school clinic usage details from clinic booking systems was cross-referenced to GP clinical records and Medicare Benefits Scheme (MBS) receipts (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Clinic attendance and \u0026ldquo;did not attend\u0026rdquo; visits were recorded from the date of initial clinic review for a total of 12 months after this review. The source of each clinic referral was recorded.\u003c/p\u003e\u003cp\u003e\u003cb\u003eAffordability\u003c/b\u003e was measured using the cost to consumer and cost of running the service. Cost analysis for the school clinic was performed by comparing MBS receipts data from one of the GPs (GP1) from the school clinic, versus the GP1\u0026rsquo;s comparable MBS receipts data from a mixed-billing practice they also work at located 25 minutes\u0026rsquo; drive away. This direct comparison using the data for the same GP in both contexts, helps to reduce confounding variables such as GP billing style, usual length of consultation, and type of care provided. Comparison was also made to the earnings GP1 would have made if performing the same work in a NSW-funded Hospital working as a Visiting Medical Officer (VMO).\u003c/p\u003e\u003cp\u003e\u003cb\u003eImproved health\u003c/b\u003e was measured by examining student characteristics, referral reasons, previous concerns/diagnoses, new concern/diagnoses, and clinic recommendations to demonstrate how the service meets the needs of students.\u003c/p\u003e\u003cp\u003eReferral reasons were collected from referral forms, emails from the referrers and cross-referenced to GP clinical records. Clinic referrals could contain multiple reasons for referral per student, from a tick-box list, or documented in free-text sections of the form.\u003c/p\u003e\u003cp\u003eStudent medical records of clinical consultations were created within the clinic and documented remotely within GP clinic software, during the study period. Clinical notes were extracted from Medical Director\u0026trade;(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), de-identified, and loaded into REDCap\u0026trade; (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e), a secure online repository, by the treating clinician. Data extraction of demographics, referral information, health and socioemotional data from consultations was performed by two independent clinician researchers, with at least 10% of the data reviewed by both to ensure consistency. The treating clinician was excluded from this step to reduce reporting bias.\u003c/p\u003e\u003cp\u003eDe-identified GP clinical records were analysed by the two independent clinician researchers, who recorded the student\u0026rsquo;s care journey through the clinic. Previous and new concerns/diagnoses as well as clinic recommendations and referrals were recorded. Previously diagnosed concerns that were not requiring management in clinic were excluded from the \u0026ldquo;New concern/diagnosis\u0026rdquo; section as the condition was deemed to be stable and no new management was required. Any previously diagnosed condition that required management in clinic (i.e., previous diagnosis - not stable) or a diagnosis made for the first time in clinic was included as a new condition. Further analysis of the most common conditions was performed to determine the proportion of each condition either previously diagnosed or newly diagnosed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEquity\u003c/b\u003e was measured as the proportion of students without access to a GP and/or Paediatrician now accessing care in the clinic, and the proportion of students with unmet need prior to clinic review. Unmet need was calculated as the proportion (%) of students with conditions requiring management in clinic, including previous diagnosis- not stable, and new diagnoses established after clinic review.\u003c/p\u003e\n\u003ch3\u003eAnalysis:\u003c/h3\u003e\n\u003cp\u003e We used descriptive statistics (including mean, standard deviation, median, and interquartile range or IQR) to report the distribution of student demographic characteristics including age at initial clinic review in years, Aboriginal and/or Torres Strait Islander heritage, established clinical relationship with an external GP or paediatrician, and any previous or current child protection concerns. We also calculated the proportions described above for measures including access, coverage, availability, affordability, improved health, and equity.\u003c/p\u003e\u003cp\u003eAnalyses based on potentially identifying characteristics were not performed to protect the trust of the clinic within the community and individual confidentiality. Additionally, we ensured our local schools Aboriginal Cultural Advisor reviewed this manuscript prior to submission to ensure cultural safety was maintained. We used R Studio for statistical analyses (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), and the STROBE guidelines for observational research to report our findings (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eAccess:\u003c/h2\u003e\u003cp\u003eIn a hub and spoke model, the community of schools within the catchment (within 80 mins round-trip drive time) were eligible to refer their students to the clinic located at the local high school. Three students accessed the clinic from as far away as 130 minutes round-trip drive time (approximately 150km).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCoverage:\u003c/h3\u003e\n\u003cp\u003eFrom the five schools within the clinic catchment, the proportion of students referred among those enrolled ranged from 3.41% (9/264) to 17.78% (8/45) with a mean proportion per school of 9.06%. Examining the clinic catchment as a whole, 6.77% (103/1522) of all enrolled students were referred to the clinic. Excluding 2022, where 80% (16/20) of referrals were from Eden Public School, the five schools within catchment referred between 3.41% (9/264) to 13.33% (6/45), with a mean proportion per school of 6.89%. When examining the entire clinic catchment in 2023\u0026ndash;2024, a total proportion of 5.39% (82/1522) of enrolled students were referred to the clinic.\u003c/p\u003e\u003cp\u003eThe clinic is located within the grounds of Eden Marine High School, accounting for the older students in the sample (12\u0026ndash;18 years). The remainder of schools within the catchment were primary schools (ages 4\u0026ndash;12). Proportionally, the number of students referred to clinic, compared to those enrolled per school, showed a bimodal pattern. The school located 5 minutes round-trip drive away (13.43%, 36/268), and those between 61\u0026ndash;80 minutes round-trip drive (17.78%, 8/45), had the highest proportion of enrolled students referred between May 2022 and end June 2024.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eAvailability\u003c/h2\u003e\u003cp\u003eClinic Waiting Time: The median wait time from referral date to initial clinic review was 45 days, interquartile range (IQR) 57 days.\u003c/p\u003e\u003cp\u003eClinic Utilisation: From 2022-24 a total of 105 students accessed the service, with a total 335 consultations occurring. The mean number of visits per patient within 12 months inclusive of their initial consultation was 3.2 (S.D 1.72). Only 1 student did not attend their scheduled initial appointment. The number of \u0026ldquo;failure to attend\u0026rdquo; appointments within the first year of a student utilising the service ranged from zero to three (mean 0.17, SD 0.54).\u003c/p\u003e\u003cp\u003eSource of Clinic Referrals: Over the study period, referrals were most commonly received from the WHIN-C (32.38%), Teachers (27.62%), School Leadership such as Principals, Deputy Principals or Head Teachers (23.81%), or School Psychologists / School Counsellors (19.05%). Other sources of referral included Student Support Officer, external clinician, or self/parent/caregiver (1.9%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAffordability:\u003c/h2\u003e\u003cp\u003eThe clinic is by necessity a no cost to consumer model, relying on MBS rebates to fund GP clinical services (referred to as \u0026ldquo;bulkbilling\u0026rdquo;). When compared to GP1\u0026rsquo;s average gross (pre-tax) private/mixed billing GP clinic income from 2022\u0026ndash;2024 (with 55\u0026ndash;78% of patients bulk billed, and 21\u0026ndash;42% privately billed), the average loss of income per clinic ranged between \u003cspan\u003e$\u003c/span\u003e540 and \u003cspan\u003e$\u003c/span\u003e1005 AUD. When compared to GP1\u0026rsquo;s earnings when working in the state-funded hospital system, the average loss of income per clinic ranged between \u003cspan\u003e$\u003c/span\u003e1288 to \u003cspan\u003e$\u003c/span\u003e1752 AUD. For the study period this resulted in a mean total loss of almost \u003cspan\u003e$\u003c/span\u003e43,000 for GP1 when compared to private/mixed billing GP clinic work, and just over \u003cspan\u003e$\u003c/span\u003e81,300 when compared to hospital work. These calculations do not include the unpaid work undertaken by GP1 in establishing community and stakeholder engagement, co-designing the model of care, governance, and research activities.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eImproved health:\u003c/h2\u003e\u003cp\u003eStudent Characteristics: Over the study period the demographics of students accessing the clinic showed an age range of 4.78 to 17.19 years. Overall, 32.4% of students (34/105) identified as Aboriginal and/or Torres Strait Islander, with this proportion higher in the first year (45%, 9/20). A majority of students were male (55%, 58/105), half identified having access to a regular GP (50%, 53/105), previous child protection concerns were recorded for 41.9% (44/105), 11.4% (12/105) had an open case with child protective services and 13.3% (14/105) were living in out-of-home care within the child protection system (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Only 3% (3/105) had access to a paediatrician.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStudent Demographics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2022 May-Dec\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2023 (Jan-Dec)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2024 (Jan-June)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo. (Col%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. (Col%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo. (Col%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo. (Col%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal new patients\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (100%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (100%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (100%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e105 (100%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge range (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.43\u0026ndash;12.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.78\u0026ndash;17.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.24\u0026ndash;16.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e4.78\u0026ndash;17.19\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u0026ndash;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (22%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (31.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e28 (26.7%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u0026ndash;9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (48%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (31.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e45 (42.9%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u0026ndash;12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (14.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e16 (15.2%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (14%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (14.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e12 (11.4%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u0026ndash;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e4 (3.8%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (48.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e58 (55.24%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (44%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (48.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e45 (42.86%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGender Diverse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (2.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e2 (1.90%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIndigenous Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAboriginal and/or Torres Strait Islander\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (28.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e34 (32.4%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot Aboriginal or Torres Strait Islander\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (55%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (71.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e71 (67.6%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRegular GP\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (70%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (46%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16 (45.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e53 (50.5%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (54%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e19 (54.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e52 (49.5%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrevious Child Protection Concerns\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (25.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e44 (41.9%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (74.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e61 (58.1%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCurrent Open Case Child Protection Service\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (12%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (11.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e12 (11.4%) *\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (90%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (88%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31 (88.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e93 (88.6%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOut of Home Care\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (15%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e14 (13.3%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (85%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e32 (91%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e91 (86.7%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e* All students with an open case with child protection had previous child protection concerns documented.\u003c/p\u003e\u003cp\u003eEach student could be referred for multiple reasons. Of all referral reasons, the majority of students were referred to the clinic for learning concerns (79.05%, 83/105), behavioural concerns (77.14%, 81/105), and emotional concerns (73.33%, 77/105). Of students with previously known concerns/diagnoses, the most common was psychological trauma (31.43%, 33/105), followed by medical diagnoses (29.52%, 31/105) and family characteristics- parents separated (29.52%, 31/105). The two most common new concern/diagnoses were medical diagnoses 40% (42/105) and Attention Deficit Hyperactivity Disorder (ADHD) 40% (42/105). Students\u0026rsquo; unmet needs denoted by the proportion of \u0026ldquo;previous diagnosis \u0026ndash; not stable\u0026rdquo; and \u0026ldquo;new diagnosis\u0026rdquo; per condition were shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, with the highest proportion of unmet needs seen for those with autism spectrum disorder (ASD) 85.72% (18/21), social concerns 79.31% (23/33), ADHD 71% (42/59), medical diagnoses 68.63% (35/51), sleep concerns 62% (49/50), deliberate self-harm/suicidal ideation (DSH/SI) 57.14% (8/14), and mental health diagnoses 56.52% (26/46).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e demonstrates that for students referred with the three most common reasons of behavioural, emotional or learning concerns, (left of figure), the underlying concerns uncovered in clinic were broad, including unmet medical, psychological, and social concerns (right of figure).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eClinic recommendations:\u003c/h2\u003e\u003cp\u003eThe average number of clinic recommendations per student was six (627/105), with 45% (282/627) of these recommendations managed within the clinic or schools, and 55% (345/627) requiring external referral. The two most common clinic recommendations, medication and paediatrician review, were given to 67.62% (71/105) and 60.95% (64/105) of students, respectively. However, the aggregated recommendation \u0026ldquo;mental health practitioner support/referral\u0026rdquo;, consisting of counselling (provided by the school) (46/105), referral to a mental health service (26/105), and continue with current mental health services (14/105), became the most frequent recommendation to the students (81.9%, 86/105). Allied health referrals including occupational therapy (25/105), speech therapy (29/105), referral to a mental health service (26/105), art/music/play therapy (1/105) and cognitive/developmental assessment (43/105) made up 20% (124/627) of all clinic recommendations (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Of students recommended to have a paediatric review (n\u0026thinsp;=\u0026thinsp;64), the majority were for ADHD management (58%, 37/64). At the same time, of students with ADHD requiring diagnosis or management in clinic (40%, 42/105), 88% (37/42) were recommended to be reviewed by a paediatrician.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper is among the first to demonstrate the unmet health and wellbeing needs of a sample of school-aged children in rural Australia, and to explore the utility of a GP-led school-based clinic accepting referrals directly from schools in this context. School-based healthcare services have existed internationally for decades, and urban models have been in operation in Australia since at least 2018 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In the urban Australian setting, school-based models have been shown to improve equity of access, healthcare provision and student outcomes 6,7). Some Australian states have government-funded school based healthcare services (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), but NSW, the location of this study, does not. Despite school based healthcare models growing in popularity in rural Australia (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), the utility of a GP-led clinic in the rural Australian context, that prioritises referrals directly from schools, is not yet well-established (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe World Health Organisation (WHO) recognises access to health care as a fundamental human right (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Global policies such as the Millenium Development Goals, and Sustainable Development Goals, recognise that investment in children\u0026rsquo;s health contributes to economic growth and social security (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Internationally, the WHO Health Promoting Schools Framework (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) has influenced the expansion of school-based models of care. This framework aligns with the WHO Health System Framework (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), the Domains of Access to healthcare (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), and the Quintuple Aim (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Within Australia, this model aligns with Commonwealth Government policy including the Primary Health Care 10 year plan (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), National Health Reform Agreement (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), and Closing the Gap (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Within NSW, this model aligns with the findings of the NSW Government Special Commission of Inquiry into Healthcare Spending (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), the Inquiry into Health Outcomes and Access to Health and Hospital Services in Rural, Regional and Remote NSW (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), NSW Health Regional Health Strategic Plan (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), First 2000 Days Framework (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), and the Henry Review into Health Services for Children, Young People and Families (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe findings of this paper indicate that the Rural School Based Integrated Care model is providing healthcare access to students not otherwise accessing care and demonstrates that outreach clinics into schools can help meet the care needs for this population. In addition, the uptake of Rural School Based Integrated Care within the clinic\u0026rsquo;s catchment area was high, demonstrating the high levels of unmet need in the community, and the acceptability and fidelity of the model for schools and families (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccess to a GP has been shown to reduce morbidity and mortality, limit potentially preventable hospitalisations, and costs far less per consultation than accessing care in the hospital system (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). However, children from the lowest socioeconomic quintile in Australia were least likely to access appropriate outpatient management for chronic health conditions due to cost barriers accessing a GP, or private specialist (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Almost 90% of Australians visit a GP annually, but access to a GP declines with geographical remoteness (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Aboriginal and/or Torres Strait Islander children are disproportionally affected by the lack of accessible rural health services in Australia, negatively impacting health outcomes for this population (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Due to a lack of alternate services and very long usual care waiting times, students in this locality travelled up to 150km round-trip from their referring school to access the clinic.\u003c/p\u003e\u003cp\u003eFor children in rural Australia requiring paediatric specialty or allied health care for developmental, behavioural, mental health or learning concerns, the current wait time can be up to 6 years (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Some areas of Australia have no access to a paediatrician, and for those that do, many paediatricians limit the number of children they will see for these conditions (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The increasing prevalence of mental health and neurodevelopmental disorders in Australian children further adds to the pressures on the health system (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Compared to usual care pathways, school clinic wait times were comparable with accessing standard GP care in the region. When compared to usual wait times for paediatric outpatient care, school clinic wait times were significantly less, from years to just days or weeks. Demonstrating embedding of the school clinic within the community, students utilized the service and returned for care when needed. Referrals were received from all of the public schools within the clinic catchment area, and from a variety of sources. However, a major factor impacting sustainability of the model is the inadequacy of Australian Government (Federal) MBS rebates to cover the cost of providing the GP service, particularly for longer and more complex consultations, which is the norm in this clinic.\u003c/p\u003e\u003cp\u003eAn economic evaluation of school-based healthcare services in the USA demonstrated a positive benefit\u0026ndash;cost ratio ranging from 1.38:1 to 3.05:1(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, the structure of funding for Australian health and education sectors, with arbitrary divisions between Federal and State/Territory sources provides a complex environment in which to deliver care for priority populations resulting in barriers to care for those most requiring it (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). In an example of the inverse care law (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), MBS patient rebates for GPs do not cover the cost of providing the service, and the charging of private gap-fees would form a financial barrier for those requiring care. The clinic was financed by a combination of sources, but funding needs remain for care coordinators, allied health care providers and child and adolescent psychiatry, which may negatively impact the provision of multidisciplinary care for students. Pay parity for GPs or Rural Generalists when compared to GP clinics charging gap-fees, and for rural areas, hospital work, will be necessary to attract and retain medical staff to work in school clinics. Urgent investment in Aboriginal and/or Torres Strait Islander-led initiatives, prioritising the positive impacts of self-determination, is required, especially in rural and remote Australia (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe findings of this study are consistent with the literature regarding rural Australians and the health system. A 2023 investigation into healthcare spending in Australia demonstrated a government healthcare spend shortfall of \u003cspan\u003e$\u003c/span\u003e6.5\u0026nbsp;billion AUD annually for rural Australians, when compared to their urban counterparts (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Children living in rural Australia face inequities in healthcare access (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), often missing out on early intervention (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Late intervention is estimated to cost Australian Governments \u003cspan\u003e$\u003c/span\u003e15.2\u0026nbsp;billion AUD/year through high-intensity and crisis services (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Children living in out of home care are known to experience higher rates of psychological trauma, and the impact of adverse childhood experiences is known to contribute to increased morbidity and mortality in adulthood (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). A paucity of available allied health, psychiatry, and tertiary assessment service input is noted (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). A plausible solution to this issue could be the provision and integration of telehealth services when local services are unavailable in a hybrid model utilising available local staff, supplemented with virtual supports when needed (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStudent behaviours experienced by school staff as emotional, behavioural or learning concerns were found in this study to be largely due to unmet health, wellbeing, and social needs. The negative impact of these unmet needs on rural Australian student\u0026rsquo;s learning outcomes is demonstrated in the lower educational outcomes, lower average income, worse health outcomes and lower life expectancy of rural Australians (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Within this clinic, high rates of unmet needs were documented for a broad range of conditions, including medical, mental health, neurodevelopmental disorders, as well as social concerns. High numbers of students required mental health care, medication, referral to a paediatrician, and access to other services such as allied health. The majority of paediatric referrals made in clinic were for ADHD management, directly relating to the legislative requirement at the time for paediatrician review prior to commencing first line medications (stimulants) for ADHD. In part due to these access blocks, ADHD costs Australia \u003cspan\u003e$\u003c/span\u003e20\u0026nbsp;billion AUD annually in social and economic costs such as loss of productivity and increased rates of engagement with the Justice System (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). It is anticipated that recent NSW government policy changes that will enable GPs to routinely prescribe stimulants for ADHD will make a drastic change to clinic referral patterns, reducing strain on public paediatric clinics and improving outcomes for CYP with ADHD.\u003c/p\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and Limitations of the study:\u003c/h2\u003e\u003cp\u003eA strength of this study is that all students referred to the clinic were included, reducing selection bias. The direct comparison of the same GP\u0026rsquo;s earnings between contexts reduced confounding variables such as consulting style, MBS billing habits and time management techniques. Recognised limitations of this study include a relatively small sample size, lack of a control group, the inherent restrictions associated with an audit of medical records, constrained cost analysis, and possible self-report bias, especially for conditions associated with possible social stigma or safety concerns, such as substance use, psychological trauma, domestic violence, child protection concerns, or mental health concerns. Despite documenting clinic recommendations, this study was not able to determine if students were able to follow through on these, or access required services. Additionally, comparative analyses of the data were limited due to the risk of identification within a small community.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis model shows promise for meeting the unmet care needs for students in rural areas comparable to the Australian context. Further mixed methods implementation evaluation, with qualitative interviews with a purposive sample of school and health staff, parents/caregivers and students aged 14\u0026ndash;18 years, and an economic evaluation, are necessary to fully understand the generalisability of this model for rural areas in Australia.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eADHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAttention Deficit Hyperactivity Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAutism Spectrum Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCYP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003echildren and young people\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDSH/SI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDeliberate self-harm/suicidal ideation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDomestic violence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Practitioner\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGP1\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGeneral Practitioner one (of two that worked in the clinic)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003einterquartile range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMBS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMedicare Benefit Schedule\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNew South Wales\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRG\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eRural Generalist\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHIN-C\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWellbeing Health In-Reach Nurse Coordinator\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study complied with the Declaration of Helsinki- Ethical Principles for Medical Research Involving Human Participants (56). Ethical approval and waiver of consent was granted by Sydney Local Health District HREC (protocol number X21-0168 and 2020/ETH00532). Further approval was confirmed by NSW Department of Education (SERAP 2020189) the Aboriginal Health and Medical Research Council.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to risk of potential breach of patient confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research is supported by an Australian Government Research Training Program Scholarship and Rural Mental Health Small Project Research Grant funding from the Peregrine Centre.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCM: conceptualisation, methodology, software, validation, formal analysis, investigation, resources, writing- original draft, writing- review and editing, visualisation, project administration, funding acquisition.\u003c/p\u003e\n\u003cp\u003eSR: conceptualisation, methodology, resources, writing- review and editing, project administration, funding acquisition.\u003c/p\u003e\n\u003cp\u003eDS: conceptualisation, methodology, validation, resources, writing- review and editing, funding acquisition, supervision.\u003c/p\u003e\n\u003cp\u003eHSS: conceptualisation, methodology, validation, writing- review and editing, supervision\u003c/p\u003e\n\u003cp\u003eWE: methodology, investigation, resources, project administration, funding acquisition.\u003c/p\u003e\n\u003cp\u003eEE: methodology, investigation, resources, project administration, funding acquisition.\u003c/p\u003e\n\u003cp\u003eNH: methodology, software, validation, formal analysis, supervision.\u003c/p\u003e\n\u003cp\u003eJK: methodology, software, validation, formal analysis, supervision.\u003c/p\u003e\n\u003cp\u003eLS: conceptualisation, methodology, validation, writing- review and editing, visualisation, supervision.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRL: conceptualisation, methodology, validation, writing- review and editing, visualisation, project administration, funding acquisition, supervision.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCM would like to thank her PhD supervisors and the University of New South Wales Population Child Health Research team. Additionally, the project team would like to thank Curalo Medical Centre, Vivienne Chelin and Eden Marine High School staff, members of the Eden Working Group, Alison Simpson and Twofold Aboriginal Corporation, Terra Harrison and Jellybean Family Psychology, the NSW Rural Doctors Network, NSW Health Education Training Institute Rural Research Capacity Building Program, Southern NSW Local Health District, Sydney Local Health District, Mumbulla Community Foundation, NSW Office of Regional Youth, The Aboriginal Education Consultative Group, Dr Jessica Weber, A/Prof Hueiming Liu, Keith Duran, and the Australasian School Based Health Alliance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCM is a GP/Rural Generalist Paediatrics, working in rural Australia in private general practice, in the Djing.gii Gudjaagalali School Clinic, and as a Visiting Medical Officer for NSW Health. CM is a current appointed Board member for the Australasian ADHD Professionals Association, Vice President of the Australasian School Based Health Alliance, Deputy Chair of the Royal Australian College of General Practitioners (RACGP) Neurodiversity Special Interest Group, member of the RACGP NSW/ACT Faculty and member of the NSW Health Agency for Clinical Innovation Paediatric Network Executive Committee.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArefadib N. Reporting the Health and Development of Children in Rural and Remote Australia. Victoria.: The Centre for Community Child Health at the Royal Children\u0026rsquo;s Hospital and the Murdoch Children\u0026rsquo;s Research Institute;: Parkville; 2017.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAustralian Institute of Health and Welfare. Australia\u0026rsquo;s Health 2022: in brief, catalogue number AUS 241. 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WMA Declaration of Helsinki \u0026ndash; Ethical Principles for Medical Research Involving Human Participants: World Medical Association. 2025 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki/\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Integrated Care, Primary Care, Pediatric, School-based, Rural, Health, Mental Health","lastPublishedDoi":"10.21203/rs.3.rs-6963481/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6963481/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere are more than 1.36\u0026nbsp;million children living in remote, rural and regional Australia. These children and young people have significantly worse health outcomes than their urban peers and experience inequities in healthcare access. This study explored key components of the integrated care model, including access, coverage, availability, affordability, improved health and equity.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eGeneral Practitioner (GP) clinical records for 105 students aged 4\u0026ndash;18 years were analysed to demonstrate their care journey through the clinic between May 10th, 2022, and June 30th, 2024. Descriptive statistics were used to demonstrate student demographics, referral reasons, unmet need, previous, current and newly diagnosed concerns, and clinic recommendations.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eStudents attending clinic were a high-risk group, with 41.9% indicating previous child protection concerns and 13.3% currently in out-of-home care. Aboriginal and/or Torres Strait Islander students made up 45% of clinic attendees in the first year of the study, and 32.4% in total. Half (49.5%) of the sample did not have access to a regular GP outside the school clinic, and only three students (2.9%) had current access to a paediatrician. The most common school referral reasons were learning difficulties (79%), behavioural concerns (77%), and emotional concerns (73%). The underlying reasons for these concerns were often related to psychological trauma (31%), medical conditions (30%), parental separation (30%), mental health concerns (25%), Attention Deficit Hyperactivity Disorder (ADHD) (22%), domestic violence (20%), and sleep difficulties (19%). Prior to clinic review, the proportion of students per condition with unmet needs included autism spectrum disorder (85.72%), social concerns (79.31%), ADHD (71.19%), medical diagnoses (68.63%), and sleep concerns (62%). The average number of clinic recommendations per student was six, with 45% of these recommendations managed within the clinic or school, and 55% requiring external referral. The most common clinic recommendations were mental health practitioner support/referral (81.9%), medication (67.62%) and paediatrician review (60.95%).\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eRural School Based Integrated Care, a GP-led paediatric primary care model for school students in rural Australia, improves access to healthcare for a rural paediatric population with high unmet health, mental health and social needs. Sustainable funding models are needed to deliver this model at scale.\u003c/p\u003e","manuscriptTitle":"Djing.gii Gudjaagalali (Children Stars) School Clinic; a novel primary care led Rural School Based Integrated model of care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 09:11:04","doi":"10.21203/rs.3.rs-6963481/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-19T14:48:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"185752247574898231756835891449178171378","date":"2026-05-14T03:26:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113535851260567656292584459535161461920","date":"2025-09-15T05:05:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-05T17:49:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-14T10:27:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-27T05:47:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-27T04:07:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-06-27T04:04:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4d254ab-1c16-4b49-8867-561d560641bb","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-19T14:48:11+00:00","index":112,"fulltext":""},{"type":"reviewerAgreed","content":"185752247574898231756835891449178171378","date":"2026-05-14T03:26:22+00:00","index":111,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-05T17:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-18 09:11:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6963481","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6963481","identity":"rs-6963481","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}