Providing rehabilitation services to major traumatic injury survivors in rural Australia: perspectives of rehabilitation practitioners and compensation claims managers

Abstract Purpose The delivery of healthcare services in rural locations can be challenging. From the perspectives of rural rehabilitation practitioners and compensation claims managers, this study explored the experience of providing and coordinating rehabilitation services for rural major traumatic injury survivors. Materials and Methods Semi-structured interviews with 14 rural rehabilitation practitioners and 10 compensation claims managers were transcribed, and reflexive thematic analysis was conducted. Results Six themes were identified (1) Challenges finding and connecting with rural services, (2) Factors relating to insurance claims management, (3) Managing the demand for services, (4) Good working relationships, (5) Limited training and support, and (6) Client resilience and community. System-related barriers included a lack of available search resources to find rural rehabilitation services, limited service/clinician availability and funding policies lacking the flexibility to meet rehabilitation needs in a rural context. Strong peer and interdisciplinary relationships were viewed as crucial facilitators, which rural practitioners were particularly adept at developing. Conclusions Greater consideration of unique needs within rural contexts is required when developing service delivery models. Specifically, flexible and equitable funding policies; facilitating interdisciplinary connections, support and training for rehabilitation practitioners and compensation claims managers; and harnessing clients’ resilience may improve the delivery of rural services. IMPLICATIONS FOR REHABILITATION Rural survivors of major traumatic injury often have ongoing health and rehabilitation needs and struggle to access required treatment services. Rehabilitation providers and compensation claims managers highlighted areas for improvement in rural areas, including resources for locating available services, funding the additional costs of rural service delivery, and greater service choice for clients. Building rural workforce capacity for treatment of major traumatic injury is needed, including improved clinician access to specialist training and support. Developing good working relationships between clients and clinicians, including interdisciplinary collaborations, and supporting client resilience and self-management should be promoted in future service delivery models.


Introduction
Major traumatic injury is a significant contributor to global permanent disability [1].It is defined by the presence of critical and often multiple injuries, including brain, spinal cord, orthopaedic, and internal injury, where there is a high probability of death or disability [2].Transport-related injuries comprise a significant proportion of major trauma, and such injuries occur disproportionately in rural locations [3].Many individuals who survive major traumatic injuries have a prolonged rehabilitation journey, requiring multidisciplinary interventions from primary care physicians and nurses, allied health professionals (e.g., physiotherapists, psychologists and/or occupational therapists), and ancillary practitioners (e.g., exercise physiologists and/or vocational counsellors) with specialist medical input from surgeons and rehabilitation physicians [4].Rehabilitation often begins in the hospital setting and continues in the community [5].Continuity of rehabilitation service provision is imperative to achieve optimal recovery [6].However, this can be difficult to achieve in rural locations where there are limitations in service access and availability [7,8].
Individuals living in rural locations worldwide face many welldocumented barriers to receiving healthcare [9].These can include limited service access, reduced service coordination and continuity of care, and the need for patients or healthcare providers to travel to access rehabilitation, intensifying as remoteness increases [10].The abovementioned reports, predominantly from survivors of major traumatic injury, have aided the understanding of rural healthcare access issues.However, the perspectives of rural rehabilitation clinicians could provide further useful information on the barriers and facilitators to service provision.A specific focus on rehabilitation practitioners working with major traumatic injury survivors in rural locations is needed to better understand their experiences, identify gaps and improve service delivery.Furthermore, claims managers from insurance schemes play a critical role in approving and facilitating access to rehabilitation services in line with organisational and legislative policies for individuals eligible for compensation after injury [11].However, few studies have explored the perspectives of compensation claims managers regarding barriers and facilitators to coordinating care for rural trauma survivors, which is an important perspective within the broader rehabilitation system.This qualitative study aimed to understand the perspectives of a range of rehabilitation practitioners and compensation claims managers in the context of rural service provision for survivors of major traumatic injury.Specifically, it aimed to explore their experience in delivering and coordinating services, including the challenges faced and the barriers and facilitators to service provision.A greater understanding of these factors could inform more context-relevant rehabilitation services in rural locations.

Method
The study was approved by Monash University's Human Research Ethics Committee (ID: 18016).All participants provided informed consent.

Setting
This research took place in Victoria, Australia.Rehabilitation practitioners were identified from a larger study (manuscript submitted) where they were recruited through both the National Health Services Directory (NHSD) [12], a publicly available search listing, and service provision data from the Transport Accident Commission (TAC) [13].The TAC is a government-funded organisation that promotes road safety, and provides support and compensation to individuals who sustain an injury caused by transport-related crashes in Victoria, Australia.Compensation covers all injury-related medical, hospital, paramedical and long-term care costs.For people with lifelong severe injuries, the TAC provides a claims manager to support clients in their recovery, referred to as compensation claims managers for the remainder of this paper.A parallel insurance scheme for Victorians injured at work is called Worksafe Victoria [14].Throughout Australia, the National Disability Insurance Scheme (NDIS) [15] provides funding for services to meet the long-term support needs of individuals with permanent disability resulting in substantially reduced functional capacity.Where government compensation is not available, post-injury rehabilitation needs are primarily met through the public healthcare system (Medicare, Pharmaceutical Benefits Scheme, etc.), private health insurance or personal funds.Rehabilitation practitioners can deliver services under any of these funding schemes.Some of the findings discussed below are unique to individual schemes (i.e., due to their processes or restrictions).In these cases, the scheme is specified to provide context to the results.

Participants
Rehabilitation practitioners were eligible if they were communitybased medical doctors (e.g., general practitioners, rehabilitation physicians), nurses, allied health professionals, or ancillary health providers (e.g., vocational counsellors, exercise physiologists) with a primary place of practice in rural locations of Victoria, Australia.Practitioners were required to have provided rehabilitation services to adults (aged 18-65 years) with brain, spinal cord, orthopaedic and/or other major traumatic injuries in the preceding 12 months.For geographic representation across rural Victoria, rehabilitation practitioners were categorised by remoteness level using the Modified Monash Model (MMM) [16].Three levels were conceptualised in this study: regional centres (MMM 2), large to medium rural communities (MMM 3-4) and small rural to remote communities (MMM 5-6).Purposive sampling was used to identify and invite individuals from each remoteness level and health profession.
Compensation claims managers were eligible if they were TAC employees coordinating rehabilitation services for adult (aged 18-65 years) major traumatic injury survivors living in rural areas in the preceding 12 months.
The final sample size was guided by information power [17,18].This method considers aspects of the research such as the investigation aim, the number of eligible participants and the type of analysis selected, which influence the richness of the information obtained.This study aimed to collate perspectives on a range of topics related to delivering and coordinating rehabilitation services and therefore was considered neither narrow nor broad.The sample specificity was considered dense; that is, the number of eligible participants was limited to those working with individuals living in rural areas with major traumatic injuries.Finally, the choice of thematic analysis to search for similarities and differences between participants lends itself to a cross-case analysis approach.On this basis, information power was anticipated to be reached at 10 interviews per participant group.An appraisal at 10 interviews revealed that although the responses were highly relevant to the research topic within the practitioner group, some variation, including new information, was apparent.Therefore, interviews continued.After four further interviews, information power was again assessed, and limited variation was seen.The same assessment conducted with claims managers was sufficient at 10 interviews.Consequently, no further interviews invitations were made.

Procedures
A larger study (manuscript submitted) invited rehabilitation practitioners to complete a survey documenting their personal demographics, employment status, the average number of hours spent treating and travelling to rural clients each week, and total months at their current place of practice and treating major traumatic injured survivors at the time of survey completion.They were also asked to express their interest in undertaking an interview.Selected practitioners were then invited to participate in an interview via telephone.
Compensation claims managers were emailed a description of the study a consent form and the email details of the researcher (VS) from a TAC liaison (independent of the research group).Interested claims managers were asked to contact the researcher and express interest.Potential participants were contacted by telephone to organise the interview.Participating compensation claims managers provided their sociodemographic, employment and professional experience using a verbal questionnaire before the interview.
A semi-structured interview guide was adapted from a structure originally developed by the New South Wales Agency for Clinical Innovation [19] for interviewing practitioners delivering brain injury rehabilitation services.Community representatives who were active rehabilitation practitioners provided feedback on the adapted interview guide, which was then further refined by the research team.Open-ended questions and neutral prompts [20] were used to identify barriers and facilitators to service delivery (rehabilitation practitioners) and coordination (compensation claims managers), use of telehealth, and future consideration of telehealth use for rehabilitation services.Topics specific to delivering services to survivors, including what training is currently available in local regions and resources they used specifically for the treatment of managing major traumatic injury, were included only in the rehabilitation practitioner group guides (see Supplement A).Questions specific to the coordination of services were exclusive to the compensation claims manager guides and sought to establish what resources were available to identify and coordinate services (see Supplement B).
Interviews were conducted between December 2019 and November 2020 by a female neuropsychology trainee (VS) with training and previous experience in qualitative interviewing and under the supervision of experienced qualitative researchers (RS and JP).Interviews were completed via telephone (n ¼ 5), videoconference (n ¼ 11) or face-to-face (n ¼ 8) based on participant preference and COVID-19 restrictions at the time of interview.Seven interviews were conducted during COVID-19 restrictions in Victoria, which led to significant reductions in face-to-face clinical service delivery and increased telehealth use.Participants were asked to respond about their service delivery within the 12 months before these restrictions to keep findings consistent across the sample.Interviews were audio-recorded after obtaining verbal consent and took approximately 45-60 min.

Data analysis
Audio recordings were professionally transcribed and uploaded into NVivo software (Version 12 Plus) for analysis.Six recursive phases using a reflexive and inductive approach were applied to the transcribed data [17].Phase one involved familiarisation with each interview by VS reading and re-reading the transcriptions and making notes about the data.In the second phase, participant-generated phrases that retained the participant's original language and concepts were selected (by VS) following the complete semantic coding method.Each participant group (practitioners and compensation claim managers) was coded separately at this stage.To ensure the coding process was thorough and rigorous, code labels were refined after each interview, and earlier transcripts underwent an additional coding run in a different order.A coding reliability approach was then used, whereby a coding structure [21] outlining the code labels was established.To enhance the communicability and transparency of the coding process, the coding structure was used to independently code seven rehabilitation practitioner and three compensation claims manager interviews by AL, a psychology honours graduate with previous qualitative research experience.Discrepancies identified during this process were resolved by narrowing or broadening code labels in collaborative research team discussion.In the third phase, the independent codes of the two groups were evaluated by the same research team members.It was determined that there were substantial similarities in the experience of the groups and greater explanatory power and a clearer narrative could be achieved by combining, rather than keeping the codes separate.As part of this process, codes across the groups were combined and similar, or related codes were consolidated to capture central organising concepts, which resulted in the generation of themes.The candidate themes were then checked for representation of the coded participant extract.That is, some themes were merged, others added, and some discarded to ensure they adequately reflected the full dataset.A web-based collaborative whiteboarding tool, Ideaflip [22], was used during this process.Phase four involved naming and refining the themes while a summary of each theme was developed.In phase five, participant phrases representing the themes were extracted for inclusion in phase six, including writing up the results.Selected quotes were edited to assist readability and preserve anonymity, where necessary.Parentheses at the end of quotes provide participant group and pseudonym.In addition, rehabilitation practitioner parentheses include remoteness level and practitioner type.

Results
Forty-eight practitioners volunteered for interviews, of whom 17 were ineligible due to being metropolitan-based or not providing a service within the preceding 12 months to major trauma survivors.Twenty volunteer practitioners were invited, and of these, six did not respond.Fourteen practitioners completed an interview.Eleven compensation claims managers volunteered for interviews and were invited, one of whom subsequently declined.Ten compensation claims managers took part.
Sample characteristics are presented in Table 1.The rehabilitation practitioner group had representation across all levels of remoteness and practitioner types being investigated.An equal proportion (42.9%) of rehabilitation practitioners were working full-time and part-time, travelling on average 15 h per week to provide treatment to clients with major trauma injuries (SD ¼ 10.1, Range: 0-30) and treated fewer than five clients with traumatic injuries per month (64.3%).The majority had worked in a mix of rural and metropolitan settings over their working history (64.3%), treated clients with major trauma for an average of 14.5 years (SD ¼ 8.5, Range: 3-30) and all treated clients eligible under the various compensation schemes available.The compensation claims manager group all worked in a metropolitan region of Victoria, an equal proportion (50.0%) were working full-time or part-time, and the majority had a professional health background (90.0%).
Six main themes were identified via the thematic analysis: (1) Challenges finding and connecting with rural services, (2) Factors relating to insurance claims management, (3) Managing the demand for services, (4) Good working relationships, (5) Limited training and support, and (6) Client resilience and community.Five themes were identified as having shared experiences by both participant groups.One theme was perceived uniquely by the compensation claims manager group, as shown in Figure 1.Each theme with supporting participant quotes are described below.

Challenges finding and connecting with rural services
Half of all participants reported that when additional needs outside their scope or profession arose and required referral, there was a lack of appropriate resources to identify available rehabilitation services within rural locations.This often led to the referral of clients to known services or the provision of service options in the nearest regional centres or cities that could be difficult for injured individuals to travel to or had long waitlists.Practitioners noted that these issues led to some clients perceiving that no services were available and that they had to live with their continuing difficulties:

Because they never heard of services or found some resource, they have to deal with what they think is available, that they're just stuck with it, or they have to adapt themselves, and it just really narrows people's options and limits people. (Rehabilitation practitioner -Occupational therapist, ZJ, Large -Medium Rural)
To overcome the lack of resources to find local services, rehabilitation practitioners relied on their broader professional networks: We have an active professional network.We put the word out we're looking for a practitioner for this particular presentation.Usually one or two colleagues will go, "Oh, such and such."(Rehabilitation practitioner -Psychologist, DS, Large -Medium Rural)  Colleagues within the same organisation were also used by both rehabilitation practitioners and compensation claims managers as sources of service information: While the majority of participants in both groups reported searching the internet if informal resources were unsuccessful, few also noted using or referring clients to relevant professional association 'find a practitioner' websites: I encourage people to go to the occupational therapist (OT) Australia website who have a list of OTs.They're searchable by geographical region and expertise.(Rehabilitation practitioner -Occupational therapist, JE, Large -Medium Rural) However, some limitations to find a practitioner searches were noted.In particular, the geographical location searchable is restricted to the physical location of a practitioner's office.The geographical extent or catchment area that a rural practitioner could service is not available.This was seen as crucial information in rural areas as many practitioners could travel to, or work with clients at some distance from their listed physical location.The ability to narrow down specialties, geographical location serviced, and availability/waitlist information was seen as a good starting point.However, compensation claims managers reported that they spent a considerable amount of time following up these services to determine their catchment area, reducing the time they could be providing clinical services: Both groups highlighted the need for more formal information sources for available services in rural areas.They emphasised the importance of a centralised database of service providers to capture the geographical catchment area and clinical expertise of rehabilitation practitioners.

Factors relating to insurance claims management
Insurer factors included issues relevant to rehabilitation practitioners and compensation claims managers that impacted service provision.However, how these matters presented for each participant group differed somewhat.For instance, rehabilitation practitioners noted reluctance to provide services for clients funded by specific compensation schemes they perceived provided inadequate fee remittance or number of approved treatment sessions.This was even more pertinent for practitioners who had begun working with emerging compensation schemes, whose reimbursements were substantially higher than existing ones:

I think maybe one barrier to clinicians registering for the [state schemes] is the wage. People don't want to do their work because it's less than what you would charge privately. It's half the cost of what [some of the national schemes] are paying. I'm the only speech therapist in this region
doing the work because it's not worth their time.(Rehabilitation practitioner -Speech pathologist, NU, Regional) Another funding issue raised by several rehabilitation practitioners was the funding caps and limited allowance for reimbursement when health practitioners were required to travel long distances to treat rural major traumatic injury clients in their homes.This resulted in practitioners declining referrals or only accepting new clients located in similar regions to their existing clients: Compensation funds don't pay to travel unless it's within two hours from where you as a provider is located.That is why, and I know this sounds quite shallow, I don't do it because I don't get paid.I try to fill up my days when I do travel so it's worthwhile.(Rehabilitation practitioner -Nurse, KS, Small Rural -Remote) When travel costs were paid, some insurance schemes extracted this from the pool of funds allocated to services, impacting the number of hours a practitioner was funded to provide therapy: Your travel time eats into your intervention time.We have approved a certain number of hours for improving quality of life, which goes very quickly with extensive travel.You can add to the plan, but that can take a year to go through the bureaucracy.By then, the person has lost their services.(Rehabilitation practitioner -Neuropsychologist, XP, Regional) Some rehabilitation practitioners and compensation claims managers felt that compensation funds would limit what rehabilitation services survivors of major traumatic injury could access based on an arbitrary number of years post-injury.This experience varied based on the scheme which services were being delivered under (e.g., TAC, WorkCover etc.): I think there's an assumption that if people are a certain number of years post-injury, they're not going to benefit from input.But there's so many rehabilitation techniques I implement at different parts of their journey.(Rehabilitation practitioner -Speech pathologist, NU, Regional) The majority of rehabilitation practitioners also noted that when they identified additional service needs for their clients, they would send them back to their compensation claims manager and would "leave it up to them" to choose a service.In contrast, compensation claims managers reported that such requests from clients could only be met by providing service options: I'm not allowed to pick providers.I could give them options, but it's meant to come from the primary care physician or the client.I am limited in how much I could do because that would be seen as us preferentially selecting treaters.(Compensation claims manager, BC) Compensation claims managers emphasised the focus on developing eventual independence through self-management in their clients: We can pay for services for a certain amount of time.Once you're at a point of maintenance and no more gains can be achieved, I may be helping them be more independent, self-managing and reducing services rather than introducing new ones.(Compensation claims manager, OL) Connecting with compensation funds by telephone and email was reported by many rehabilitation practitioners to be difficult, which impacted on receipt of timely approvals for their service resulting in adverse impacts on clients.However, some described good access and responsiveness when needed: We can go a month without being able to get a hold of a claims manager, and you cannot make decisions without their approval.It holds up everything for the clients.It not only affects the client, but it affects our service.(Rehabilitation practitioner -Social worker, FD, Large -Medium Rural) I always find it easy to access the claims manager, and get quick answers.It makes things a lot easier.(Rehabilitation practitioner -Nurse, KS, Small Rural -Remote)

Managing the demand for services
This theme refers to how rehabilitation practitioners and compensation claims managers managed the reality of having few rehabilitation services available to people in rural locations and the impact this had on service delivery.Compensation claims managers highlighted that lack of choice in available rehabilitation services often meant suggesting alternative services, less qualified services, or services in other rural towns: If there's only one physio in town and you can't get an appointment, maybe there's an osteo or a chiropractor, or can they drive a little bit.Is there one [physio] two towns away that has something?(Compensation claims manager, UK) Most providers are limited in rural areas.If the client's in maintenance, it may be more suitable for a less specific or [less] qualified therapist to take over.(Compensation claims manager, HX) However, travelling to appointments was not always an option for clients as a result of physical and psychological injury-related conditions or the lack of transport options in rural regions:

They're anxious to get into a car, they're fearful they might get hurt again. Some of them just simply physically can't get into a car because they have a fractured arm or ankle and have a cast on, or they aren't cleared to drive yet. (Compensation claims manager, FJ)
In metropolitan areas, you could use Cab Care.That doesn't exist in the country.If it's over a hundred kilometres you might be able to use a transport system, or if you're lucky, there might be a volunteer system.(Compensation claims manager, QN) From a rehabilitation practitioner perspective, they reported being in high demand due to no other practitioners in the region, leading to increased wait times: Due to the lack of services within rural regions, many rehabilitation practitioners reported feeling pressured into being "a jack of all trades, but a master of none".In addition, many practitioners felt obligated to extend their services across extensive geographical catchment areas due to deficiencies in service availability for clients within their region, which often meant committing additional time to their work: I over-commit to my job role in rural areas.I see more clients in a day, so there is difficulty in managing a caseload in a rural area.It's the fact that there's such a demand.(Rehabilitation practitioner -Psychologist, GN, Large -Medium Rural) Other clinicians discussed reducing the scope of their geographical catchment area and service offerings as a way to manage the demand and allow for maintenance of clinical competence: I was previously seeing people within an hour's travel from here.I just couldn't sustain that.Now that I've restricted my practice reach, it's easier.I can spend more time seeing clients rather than travelling.(Rehabilitation practitioner -Occupational therapist, RO, Regional)

I've reduced the range of services I offer because I can't have expertise across all those fields as a sole practitioner. I've confined my practice to fairly tight boundaries that I can maintain my competencies in.
(Rehabilitation practitioner -Occupational therapist, JE, Large -Medium Rural) Using different types of technology was supported by both participant groups as a potential solution to improving service access.Opinions relating to telehealth varied with some hesitancy expressed about use with some client groups and for some types of therapies:

Some clients don't have a smartphone or the internet at home. Others have it but have no idea how to set it up. It's extremely challenging over the phone to set something up without being able to show them. Some clients are savvy with technology, and they love it. (Rehabilitation practitioner -Social worker, FD, Large -Medium Rural)
A physiotherapy treatment could be quite hands-on, which would require them to be there in person.If they set up an exercise program that they're doing at home, that could be done over the phone.It is just a review similar to maybe a primary care physician, psychology, anything that doesn't require hands-on type treatment.(Compensation claims manager, VY) Notably, telehealth was also reported to be of limited benefit in some rural regions due to inadequate infrastructure:

Good working relationships
The importance of good relationships to effectively treat major trauma clients was the focus of this theme.Establishing good relationships with primary care physicians was noted as particularly important by both rehabilitation practitioner and compensation claims manager groups.Compensation claims managers reported relying on primary care physicians as the central point of contact for care coordination of rural clients.Therefore, the quality and consistency of the primary care physicians were seen to be of essential importance in facilitating a multidisciplinary approach to care, which they also acknowledged was otherwise fragmented in rural locations: If there is a good primary care physician proactively involved and linking in the client.They know the local people.That makes a huge difference.

(Compensation claims manager, BC)
Corroborating this finding, rehabilitation practitioners found it harder to establish strong multidisciplinary teams in rural areas.However, they reported that having a good relationship with local primary care physicians helped clients get access or referral to services they needed: It's a lot easier if there's a good primary care physicians [sic]on board.They could be the one that steers everything.That's where you're going for referrals.(Rehabilitation practitioner -Nurse, KS, Small Rural -Remote) Similarly, good case management by compensation claims managers, where the claims manager was working toward the same goal (i.e., client outcomes), was seen by rehabilitation practitioners as essential for ensuring a holistic approach to care, including facilitating a multidisciplinary team: It is pivotal having a good claims manager who is in contact with clinicians.Who organises team meetings.This is where I see the best interdisciplinary work and the best outcomes for clients.(Rehabilitation practitioner -Speech pathologist, NU, Regional) Further, rehabilitation practitioners felt that the compensation claims manager's relationship with the client also played a vital role in facilitating good outcomes: When the client has a good relationship with the claims manager, it makes things easier.Often there's a breakdown in the relationship between the client and claims manager.That makes it quite difficult because then the client doesn't have any motivation in their recovery.(Rehabilitation practitioner -Nurse, KS, Small Rural -Remote)

PERSPECTIVES ON PROVIDING REHABILITATION SERVICES IN RURAL AUSTRALIA
In addition, compensation claims managers noted a need to have good working relationships with rehabilitation practitioners:

We have a lot of interaction and involvement with service providers. It is essential they work collaboratively. They can be imperative in helping to support and navigate the journey for clients. (Compensation claims manager, DA)
Compensation managers highlighted that maintaining relationships with known 'good' rehabilitation practitioners from previous clients was important.Additionally, formal and informal peer relationships were relied upon by rehabilitation practitioners when treating major traumatic injury clients: I have an OT network that's a bit of a brain's trust.We have a Google group.That's an avenue we all use to see if anyone has come across this before.(Rehabilitation practitioner -Occupational therapist, RO, Regional)

Limited training and support
Training and support specifically for major traumatic injury were considered important, but also limited by rehabilitation practitioners and compensation claims managers.For rehabilitation practitioners, accessing ongoing training was difficult due to the heavy clinical demands on their time, and the need to travel to training locations, often in larger regional or metropolitan centres.Consequently, they regularly received their training and support through webinars as they considered travel to other locations too time-consuming and costly: Webinars are great because often conferences are in Melbourne.They're not always that easy to get to, and sometimes they're interstate.Webinars are always good, and more and more, they're offering that as an option.(Rehabilitation practitioner -Speech pathologist, NU, Regional) Within this context, several rehabilitation practitioners reduced their scope of practice to ensure that they could keep up to date with best practices.
Many compensation claims managers felt further training about specific major traumatic injuries (e.g., brain, spinal) would be beneficial to their case management.Moreover, they reported the current system, which uses a clinical panel including a range of experienced health professionals to support their decision making regarding client treatment, was typically reactive rather than proactive: We do have our clinical panel.That's a more reactive approach to something.If something is not going right or a request for something doesn't seem justifiable, we send it to the clinical panel to call the practitioner.They give them the tools to appropriately diagnose and set treatment times, etc.We could try and flip that.(Compensation claims manager, VY)

Client resilience and community
This theme represented factors relevant to rural major traumatic injury survivors that impacted their care coordination, which was identified only in the compensation claims manager group.They felt that clients in rural locations were very resilient, optimistic and often took ownership of their rehabilitation.While positive, this was also identified as a factor that reduced the client's use of available services: People from rural areas are more stoic.They just get on with things.They put up with higher levels of pain or more levels of unwellness.People in the city areas can access services a lot more readily.It's at their fingertips.In rural, it's not.They have to go out of their way to access it.They'll get on with their lives, not access it and push through it.(Compensation claims manager, IM) Some viewed rural clients as time-poor due to work and/or family commitments, which influenced their uptake of rehabilitation services:

They may run working farms. Depending on what their location and commute are, it can require a bit of travel. The rehabilitation provider and compensation claims manager access to the client is limited. (Compensation claims manager, HX)
With the lack of transport options for clients and the difficulty of having rehabilitation practitioners travel to clients, compensation claims managers encouraged clients to use informal support, such as family and friends, more often.Other factors impacting rural clients were the smaller, close-knit communities.While this had its benefits, the lack of privacy in rural communities was seen as a potential downside: Someone who is connected to their community that makes a difference, there's more support for them.But there is less privacy.Sometimes information gets shared with the broader community, which then makes them less willing to accept support.(Compensation claims manager, DA)

Discussion
This study investigated the experiences of delivering and coordinating rehabilitation services for major traumatic injury survivors in rural Victoria, Australia, from the perspectives of rural rehabilitation practitioners and compensation claims managers.The current findings present these experiences summarised by six themes: (1) Challenges finding and connecting with rural services, (2) Factors relating to insurance claims management, (3) Managing the demand for services, (4) Good working relationships, (5) Limited training and support, and (6) Client resilience and community.
The importance of infrastructure to locate and connect with healthcare access in rural regions has been raised by practitioners in previous research [23][24][25].In the present investigation, both participant groups discussed difficulties searching for client services in local rural areas.In one previous study, this was a problem when metropolitan or larger regional centres referred clients to services in smaller rural towns closer to their homes [25].Our findings suggest that the issue is not exclusive to practitioners and claims managers in metropolitan areas, as practitioners within small rural locations also reported difficulty searching and identifying services available within their own regions.Some practitioners with resources for identifying services in their regions noted a lack of adequate descriptions of the scope of services, particularly the catchment area, resulting in a need to place additional phone calls to find suitable local services.Similar experiences have previously been reported in rural locations for people requiring treatment for developmental disabilities [24].Accordingly, there is a need to create resources, co-designed with practitioners and clients, that enable the identification of clinicians and services with expertise in major trauma and, importantly, relative to their geographical service catchment area.
Previous investigations have highlighted the important role of compensation claims managers in assisting with access to rehabilitation services [11].In state-led compensation schemes in Victoria, legislation defines eligibility for lifelong support following injury.The challenges compensation claims managers experience navigating complex legislative and organisational policies were highlighted in this present investigation, particularly among clients who were many years post-injury and were no longer making objective gains in their rehabilitation.In complex and longer-term cases, tools and resources that support decision-making and applying best practice evidence within policies of the schemes may help address some of the challenges identified in the present and other similar investigations [26].
An interesting finding was that the theme of 'client resilience and community' was unique to the compensation claim manager group.It is possible that this theme was influenced by the type of interactions rehabilitation practitioners and compensation case managers had with survivors.The role of compensation claim managers in identifying and coordinating rehabilitation needs and services meant they received feedback from survivors about not needing to initiate or not requiring the frequency of services recommended.This was perceived as a display of resilience by compensation claims managers.Conversely, rehabilitation practitioners only engaged with major traumatic injury survivors who had already decided to access services, limiting their exposure to the same client feedback.It is also possible that individuals seeking services may have been more severely injured and in greater need of rehabilitation services and, thereby, less likely to be perceived by practitioners as resilient.Another potential reason that only the compensation claims managers described the resilience of people living in regional areas was that they had client portfolios that included both regional and metropolitan clients, and they could draw general comparisons between groups.In contrast, rural clinicians only provided services to rural clients, resulting in a lack of group comparison for this theme to emerge.Finally, is it also possible that the resilience described reflects more of a coping response by people living in rural areas where they also have reduced access to services.
This study identified many challenges in rural regions, including a general lack of clinicians, high caseloads, and additional travel time and financial pressures that required clinicians to reduce client catchment areas and avoid lower-fee referrals.Clinicians reported these factors were contributing to delays in initiating services to clients or restricting them entirely.Notably, rehabilitation practitioners providing services funded by insurance schemes noted poor remuneration for costs associated with extended travel.Practitioners reported having to decide whether they could service a client at all due to lack of reimbursement for travel time or the limitations such reimbursement might place on funds for therapy.Finding ways to address these challenges in rural settings and meet the United Nations [27] 2030 Agenda for Sustainable Development, including providing access to healthcare services when and where they are needed, is necessary.Telehealth is one way to potentially address some of these challenges, particularly significant travel demands [28].However, participants in this investigation reported some hesitancy due to reduced infrastructure to support its use in more remote areas and limited client engagement.The COVID-19 pandemic challenged many previously encountered infrastructure, policy and remuneration barriers [29].Such a shift has likely paved the way for clinicians to become more accepting of telehealth; however, future research is needed to confirm this.Further exploration of factors that may facilitate successful and sustainable telehealth and funded travel when needed in rural areas is required.Perspectives of the clients identified in this and our previous work with survivors [8] could also be harnessed to help address these broader identified challenges.More specifically, claims managers noted that clients in rural areas often show resilience and commitment to self-direct their own recovery.Self-management of rehabilitation may be one way of helping to reduce the demand for services while also providing clients with the ability to manage their own rehabilitation.The current findings suggest that incorporating telehealth and in-person interactions to achieve a hybrid approach could better meet the needs of rural practitioners and clients.In addition, enursing gains made to incorporate telehealth into practice during the COVID-19 panademic that improved service access remains a permanent feature of the rural health care landscape are needed.
The limited number of clinicians in rural areas has led to an emphasis for rural practitioners to have a wide range of clinical skills to address a more varied caseload, termed 'generalist expertise' [30,31].Some rehabilitation practitioners in the present investigation indicated that this was true for their practice.However, other rehabilitation practitioners stated they had to reduce the scope of services offered to manage not only caseloads but also to maintain high standards and competency in the broad range of presentations.Like therapists in previous studies of this nature [31], rehabilitation practitioners in the present study disclosed concern regarding their ability to maintain professional competencies relating to major traumatic injury presentations.This could suggest that at least some rehabilitation practitioners interviewed did not feel comfortable with the 'generalist expertise' approach to treating complex major trauma cases in rural regions.Participants reported using various strategies, including informal networks within and outside their workplaces, to overcome the abovementioned workforce capacity issues.Previous researchers have highlighted the benefits of good networking between practitioners within rural locations to increase the range of available services and encouraging multidisciplinary communication and learning [32,33].Furthermore, multidisciplinary team approaches effectively improve functional outcomes when used during the rehabilitation of persons with major traumatic injury [4].Given that the participants in this study similarly acknowledged the importance of multidisciplinary relationships and the difficulty in achieving these in rural settings, research into more innovative ways to facilitate multidisciplinary care across rural locations is needed.There already exists examples of such services [34], using virtual technology to connect various disciplines with the aim of providing assessment and therapies to individuals without local access.In addition to client benefits, clinicians report advantages, including increased multidisciplinary engagement, relationships, knowledge and capability.Furthermore, both practitioners and claims managers in this present study highlighted the integral role primary care physicians play in the rehabilitation of rural major traumatic injury survivors, including providing education, support and facilitating access to an array of rehabilitation services.Concurrent incentives are required to address existing primary care physican workforce shortages and ensure appropriate resourcing for primary care physicians to support major traumatic injury survivors.
Difficulties accessing professional development and continuing education opportunities for rehabilitation practitioners in rural areas also need to be addressed [30,31].In more recent times, some participants indicated that access to webinars was increasingly available due to COVID-19.Continued access to online attendance options for rurally located practitioners beyond the pandemic should be considered.A caveat to this consideration is our findings from a survey conducted with similar practitioners (manuscript submitted), who reported that webinars were among their least preferred training delivery methods.Instead, they preferred in-person workshop delivery.The more interactive and case-based approaches typically provided at workshops may be preferred and should be incorporated into future training programs.Other more targeted and recurrent programs to support rural practitioners could also be considered.Project Extension for Community Healthcare Outcomes [35,36] is one such program that delivers case-based learning sessions via videoconferencing for various conditions and clinical groups and could be modelled for other major traumatic injury therapies.
The findings of the present study are subject to certain limitations.First, the results of this study are, to some extent, reflective of the applicable health policies and geographical context of one state within Australia.The state of Victoria has several unique nofault injury compensation schemes that fund medical and rehabilitation care regardless of an individual's role in the injury event.Further, unlike other regions of Australia and globally, Victoria does not have very remote areas (MMM 7).It is also noted that no practitioners or compensation claims managers clearly reported providing their services to Aboriginal and Torres Strait Islander peoples.This somewhat concerning finding could reflect limited engagement with existing services by First Nations peoples or that individuals are not being asked about their cultural background and warrants further investigation.Future research should also include a focus on the experience of working with culturally and linguistically diverse major traumatic injury survivors in rural locations, as well as how rural services are accessed by First Peoples.It must also be acknowledged that several of the themes identified could apply and, in some cases, have been found in metropolitan settings.These include a perceived lack of reimbursement for compensable clients by general practitioners [37] and the benefits of good working relationships between compensation claim managers and health practitioners [11,26].However, rural-specific factors (e.g., fewer health practitioners, pressures of distance) previously discussed are likely to exacerbate these issues for rural practitioners.Lastly, this study provides a comprehensive understanding of a specific group of rehabilitation practitioners and compensation claims managers obtained by conducting interviews until information power was reached.In addition, the compensation claims managers were recruited through one transport-related insurance scheme in Victoria.Accordingly, the transferability of the findings to other geographical remoteness regions and different compensation schemes remains unclear.In particular, transport-related injuries are associated with higher rates of blunt trauma (e.g., injury produced by compression, tearing and acceleration or deceleration) and, therefore, higher proportions of spinal, head and multiple injuries compared to other injury aetiologies.This is likely to impact the types of services and supports required, including requirements for rehabilitation.Further, the types of supports funded and the ways of accessing and paying for services may differ between schemes.It is possible that the experiences within other compensation schemes and injury groups may differ.As such, readers should consider the study context and participant characteristics to establish the applicability of findings to their environment [38].The research provides a helpful template to guide future research exploring consequences and service access patterns in other insurance schemes (e.g., the National Disability Insurance Scheme), which can be used to compare and contrast prospective findings.International research addressing these specific contextual differences is also warranted.
In summary, this study has enhanced our understanding of rural rehabilitation practitioners' and compensation claims managers' experiences of providing and coordinating rehabilitation services for major traumatic injury survivors residing in rural locations.Both rehabilitation practitioners and compensation claims managers identified system-related barriers to delivering rural rehabilitation services, including inadequate resources for locating rehabilitation services and the limitations imposed by the need to travel for service provision, training and support.Rehabilitation practitioners were particularly resourceful in rural areas and actively sought ways to connect with peers from the same and different disciplines.Good relationships between practitioners, clients, compensation claims managers and primary care physicians were considered essential facilitators of quality multidisciplinary care, and an opportunity exists to better champion clients' resilience to self-manage their rehabilitation.The present findings provide guidance in the future design of service delivery models and the training of clinicians to help optimise rehabilitation for survivors of major traumatic injury in rural locations.

Figure 1 .
Figure 1.Clinician and claims manager perspectives of providing traumatic injury rehabilitation services in rural areas.The six themes are depicted by their shared relationship (solid line box) in both the rehabilitation practitioner and compensation claims manager groups or the sole association (dotted line box) to the compensation claims manager group.

I
ring people from all sorts of places to try to find out what their actual catchment is.It might be helpful to understand who would cover where.You're playing chase your tail to try and find someone.(Compensation claims manager, BC)

I
'm generally booked out for 10 weeks in advance.When I take on a new client, I book the first, second and third sessions.You only get that big wait once.(Rehabilitation practitioner -Psychologist, DS, Large -Medium Rural) Further compounding limiting availability, rehabilitation practitioners noted the time spent travelling to client's rural locations: I'm spending that much time on the road and not enough time working directly with the client.It limits the number of clients that you can see.(Rehabilitation practitioner -Social worker, FD, Large -Medium Rural)

Table 1 .
Sociodemographic variables for interviewed rehabilitation practitioner and compensation claims manager participants.
Within our business we catch up fortnightly.Ifwe have come across a new service that's popped up, we're able to share it.(Rehabilitation practitioner -Neuropsychologist, XP, Large -Medium Rural) There's no official way to find providers within those areas.You ask around informally within the business if someone knew of someone in a particular area.Once you know of people, you tend just to get straight to the source and ask them.If they don't have capacity, you ask that person for another recommendation.It's pretty much word of mouth.(Compensation claims manager, HX)