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Multiple and Complex Needs Initiative Victoria, Australia

Multiple and Complex Needs Initiative Victoria, Australia. Outside In Conference, St John’s, NL, Canada 20-21 October 2009. The Victorian Department of Human Services -Regions. Questions. The beginning.

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Multiple and Complex Needs Initiative Victoria, Australia

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  1. Multiple and Complex Needs InitiativeVictoria, Australia Outside In Conference, St John’s, NL, Canada 20-21 October 2009

  2. The Victorian Department of Human Services-Regions

  3. Questions

  4. The beginning • History of concerns raised by service providers, clinicians, carers, advocacy groups, Police, Courts and others • Poor service outcomes for a small but significant group with complex needs that challenge existing policy and legislative frameworks • Strong stakeholder support for change

  5. MACNI funding • Department of Human Services • Disability • Child Protection • Youth Justice • Housing and Community Building • Department of Health • Mental Health • Alcohol and Drugs • Department of Justice

  6. Early scoping work • Two years of consultation and data collection 2002-2004 • Identified a group of 247 individuals with “multiple and complex” needs • Client costs: On average - $248,000 pa Highest cost package in 02/03 was $643,000

  7. Early profiling – client characteristics • Characteristics of Client Group • Young – 44% 18 to 35 years • 2:1 ratio of men to women • Major presenting problems – combinations of mental disorders, intellectual impairment, acquired brain injury, substance abuse • High risk behaviours – to community, staff and self • 71% - current or past contact with criminal justice system • High volume users of emergency services • Significant accommodation issues – 35% homeless, short term or crisis accommodation • 91% socially isolated, little family contact • 55% chronic health problems

  8. What we wanted for individuals • Achieve stability in: housing, health and well-being, safety, social connectedness • Provide a platform for long-term engagement in the service system • Pursue planned and consistent therapeutic goals for each person

  9. What we wanted from the system • Greater collaboration, partnership, flexibility (“seamless”, “joined up”) • Better use of service resources – “capacity building” • Better use of financial resources – cost effectiveness

  10. Elements of MACNI • Regional coordination mechanisms (within government) • A legislative framework • Assessment, planning, and intensive case management function (in the funded sector) • Time-limited • Client attached dollars

  11. The legislation • Unique feature.. • Elements of the HS(CN) Act 2003 • Eligibility criteria • Supports voluntary nature of initiative, and right of refusal at any time • Key decisions made by an independent statutory body • Detailed programmatic prescription at the “black law” level

  12. The eligibility criteria • A person who has attained 16 years of age; and • Appears to have 2 or more of the following: • A mental disorder • An intellectual impairment • An acquired brain injury • Is an alcoholic or drug–dependent person; and • has exhibited violent or dangerous behaviour that caused serious harm to himself or herself or some other person, or • is exhibiting behaviour which is reasonably likely to place himself or herself or some other person at risk of serious harm; and • is in need of intensive supervision and support and would derive benefit from receiving coordinated services.

  13. The first model 2004-2009 • Legislation – time limited • MACN Panel • Regional coordinators and regional panels • Specifically funded Community Service Organisations – state-wide roles • Brokerage – client attached dollars

  14. The MACNI service model V1 1 Existing Service System DHS Region Regional Gateway contact Regional Co-ordinator (consultation/problem solving, referral, local panel consideration, RD sign off) 2 3 Multiple and Complex Needs Panel (Eligibility,Care Plan, Care Plan Coordinator, Care Plan Review) 5 4 Care Plan assessment & care planning service (Indigo Assessment Service) Collaborative service provision with identified lead case manager from either the existing system or specific state-wide service Indigo

  15. Activity 1 June 04 to 31 May 09 – regional level • 688 consultations at the regional level Most of these consultations led to improved problem solving and local solutions; recognised as significant boost to capacity • 167 considered for referral, leading to..

  16. Resolved at the regional level-Case study • Highly vulnerable young woman • Chaotic, abusive, multi-generational, dysfunctional family background • substance abuse since age of 11 (petrol/chroming) • ABI, schizophrenia • Brain tumour • Criminal justice system involvement • Constant moves between Melbourne/rural Vic/NSW

  17. Case study-What the region did • Response has taken approx. 3 years to develop • Mental Health service: provides co-ordination - Disability service: provides funds - across regional/state boundaries • Formal communication strategy between critical providers- police, mental health, Hospital Koori Unit • Involved providers persistent eg. Guardian/region • Flexible accommodation support

  18. Activity 1 June 04 to 31 May 09 – MACN Panel • 84 referrals (from regions) • 79 determined eligible • 56 care plans determined • 39 care plans extended into second year • 39 care plans concluded

  19. Referral characteristics • Appearance of a mental disorder – 88% • Substance abuse issues – 72% • Intellectual impairment – 59% • ABI – 50% • Some form of homelessness – almost 40% • In custody/prison – 20%

  20. The first model – issues • Very slow start up; steep learning curve • Developing shared understanding of roles and responsibilities: • Panel • Assessment/care plan development/care plan coordination • Regional coordination and local capacity

  21. Questions

  22. The model in action (1) • Some practice benefits • Care plan coordination • State-wide focus • Information sharing provisions

  23. The model in action (2) • Care Plan Coordination • Is different from case management or direct service • Is vital when there are multiple services involved • Has “dual beneficiaries”: the clients, and the system • Is a good tool for sharing risk • Needs to be recognised and resourced • 1:5 worker to client ratio

  24. The model in action (3) • Some assumptions that proved not to be true • Housing is the most important thing (ALL the “platforms” need equal consideration and planning) • Lots of extra money needed • Its harder in the rural areas to do a good job

  25. Questions

  26. External evaluation - KPMG • 4 reports over 3 years • Final report February 2008 • 4 “evaluation questions”

  27. External evaluation (2) • Improvement in individual outcomes? Yes • Improvement in service coordination? Yes • Adequacy of legislation? Yes • Achievement of cost-benefit? Not clear..

  28. External evaluation (3) • 76% reduction in presentations to hospital emergency departments • 34% reduction in number of hospital admissions • 57% reduction in hospital bed days

  29. Internal review - snapshot study (1) • “Snapshot” July-Sept 08 • Client status pre and post MACNI was assessed against the four MACNI platforms: • Stable accommodation • Health and well-being • Social connectedness • Safety

  30. Snapshot study (2) - background data • Mental Health Services the largest referrer - 31% • Age: • 31% - under 25 years, • 53% - 26-45 years, • 16% - over 45 years • 3:1 ratio males to females

  31. Snapshot study (3) • 19 out of 22 clients who had exited from MACNI were reviewed • Four data sources • KPMG evaluation case studies • MACNI case files and reports • Interviews with key service providers • Client Outcome Survey

  32. OUTCOMES - Comparative data – key findings

  33. Key Findings (1) • Successful client outcomes for 13 of the 19 • 57% overall improvement across all 4 platforms

  34. Key Findings (2) • Service system: • MACNI leads to capacity building of sector • Biggest achievement was bringing people to the table and getting them to communicate • Individuals: • Most successful - disengaged, isolated, highly transient, significant criminal justice histories & homeless • Least successful - those transiting from youth to adult services, those with indigenous backgrounds

  35. More about the unsuccessful outcomes • 4 males & 2 females • 4 out of 6 transitioning from youth to adult services • 3 out of 6 - indigenous backgrounds • 5 out of 6 - histories of Youth Justice/Child Protection • 5 out of 6 had non-Indigo Care Plan Coord. • 4 - jail, 1 – streets, 1 – hospital – EVEN SO: • ALL showed improvement during MACNI

  36. What were the successes? • Care Plan – an effective tool • Care Plan Coordination - critical role • Coordination through care teams • Access to training and mentoring • Reflective space – insists on focus and attention • Some additional dollars useful

  37. What were the challenges? • Complexity of service system • Complexity of the MACNI model • Transitions difficult to negotiate – can “mirror” broader service system problems • Maintaining momentum and commitment after MACNI

  38. Sustainability • MACNI is a time-limited intervention • Ongoing care planning is critical to sustaining the gains - NB • Good planning may: • Reduce costs – or not • Highlight/confirm the need for ongoing costs – high, or otherwise

  39. The second model June 2009 • Legislation - ongoing • Government gate-keeping and review group • Regional coordinators and regional panels – better resourced, making key decisions • One specifically funded CSO – still state-wide, with broader role • Brokerage – client attached dollars

  40. MACNI service model V2

  41. The Future – the framework • Human Services (Complex Needs) Act 2009 • Maintained: information sharing provisions, eligibility criteria, framework for care plan coordination • Changed: strict separation between assessment and care planning, maximum length of care plan • Removed: independent statutory body

  42. The Future – making the decisions • Central group still “keeps the gate” • Regional services make more of the key decisions • More staffing resource at the regional level • Tighter guidelines around client attached dollars

  43. Some reflections on the elements.. • Legislation • The MACN Panel • Cross-program collaboration • Assessment and planning • State-wide authority and service delivery • Work at the local/regional level • Client attached dollars

  44. Some things we haven’t done yet • A good job for people from indigenous backgrounds • A review from the perspective of service users

  45. Questions

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