Innovative Housing and Support Models: The Australian Experience

1. Innovative Housing and Support Models: The Australian Experience Don Ferguson & James Lim

2. Workshop Outline • A guided tour from start to exit of ISP – using the service pathways • Specific questions • Working in groups on two case studies and overview of selected case studies • Bringing it all together • Q & A

3. How were the support models developed? How do they operate? and What is the role of staff from different professions? Development towards a support model - Intake, Assessment and Case management phase. • File review of information at time of entry. • Identify key elements of support and risk management practices required • Initial formulation of behaviours and support. • Other elements of acquiring information. - interviews, with participants and others, additional information sought prior to engagement to elicit better understanding on nature of support and risk associated with participants. • Seeking prior consent to the release of information. • Interim model of support is developed, trialled and refined over time. Focus is on an inclusive ‘participant centred’ planning approach.

4. Roles of ISP Staff– The 3 Sections of ISP1. Project Management 2. Support Services 3.Supported Living 1. Project Management –Project liaison with inter agencies, nominations of participants, clinical reference group, project management committee and public relations. 2. Support Services –Responsible for the intensive case management and clinical services – assessment, interventions and support to Supported Living. Members of the team: • Manager Support Services – leadership and accountability to case management and clinical practices. • Senior Clinical Consultant - tertiary qualified persons with psychology, behaviour or clinical background, • Specialist Psychologist - assessment, therapy interventions, • Senior Psychologist – Supervision and clinical support, • Case Support Workers – intensive case management support • Transition Support Officers – manage transitioning elements of participant • Vocational Placement Officer – assess, search for work experience and employment opportunities and supporting participants at workplace.

5. Roles of ISP Staff– The 3 Sections of ISP1. Project Management 2. Support Services 3.Supported Living 3. Supported Living – Responsible for establishing of new accommodation unit, in consultation with Support Service. The provision of accommodation placements and supports to participants Members of the team: • Manager Supported Living – provides leadership and accountability to operations of accommodation services. • Network Manager – oversees one or two accommodation units and provide supervision and support to staff as well as on call management support • Residential Support Workers – direct staff working with participants • Key workers – individual RSW identified to be primary staff for a particular individual.

6. How accommodation was acquired ? • Initial capital $3M was made available within the first 12 months of the project. • Funds used to acquire 4 properties and assisted in refitting rental properties • Pending on the profile and geographic catchment of participants, key properties in targeted areas were sourced. • Properties acquired ranged from places with high density dwelling, to semi rural locations or places where there is a good community tolerance and acceptance for social inclusion.

7. How was the accommodation and support model funded and administered ? • ISP funding came directly from NSW Treasury and was placed within financial systems of Ageing, Disability and Home Care. (lead agency of ISP) • Financial management and accountability were easily monitored and appropriate allocations and expenditure tracked. • The majority of services are delivered and administered “in house” with some purchasing of supported accommodation through local community providers. • A greater proportion of services would be contracted through community providers if the ISP expanded to operate in more remote areas.

8. Summary of Service Pathway 0 month 3 12 Timeline 15 18 months

9. How did participants’ circumstances improve with the implementation of their accommodation and support model? andHow were these gains maintained? Case study exercises:

10. Activity:Detailed Case Studies with handouts • Divide group into six groups • Three groups will be working on Case Study : Sue • Three groups “ “ “ “ Case Study: Peter • Time allocated : 30mins • Nominate a presenter to present group findings – 10 mins. • Generate discussion

11. Critical Questions ………? • What do you consider to be some of the important immediate needs for this participant (eg. health, housing, safety, advocacy)? • What do you consider to be some of the important longer term needs for this participant (eg. further assessment, case coordination, ongoing support with behaviour, health and mental health, sustainable housing and support, etc)? • Are there any systemic, social or service inclusion issues highlighted by this case? What challenges might such a person face in having these short and long term needs met from your local service system? • Pick one or more of the following components of an ISP-type intensive transitional support model that you consider could play a role in improving the inclusion and outcomes for this participant, describe how and why? • The ISP Supported Living Services (transitional supported housing, drop in support/ service brokerage, training and support for long term support provider) • The ISP Support Services (case work, clinical staff, vocational and transition support staff) • The ISP project interagency liaison officer?

12. Case Studies Overview of Peter and Sue

13. Peter Case Study 1 - Background Male 51 yo,born in Ireland, arrived in Australia at 9. Both parents consumed alcohol heavily • ABI from attempted suicide at 16 plus a series of head traumas from his 20’s on • Heavy alcohol consumption from a young age leading to cirrhosis of the liver • Hepatitis B & C from Injecting drugs use exacerbating cirrhosis Peter sites the reason for his downward spiral into alcoholism and street living on 2 major occurrences in his younger days: • Firstly his sister was killed by a train when she followed Peter away from the house one day. • Peter’s guilt lead him to a failed suicide attempt (he shot himself in the head) The second was catching his de-facto in bed with another man. Peter came into the care of the ISP project following a 6 month stay in hospital. • He had incurred serious injuries after being bashed while living on the street. • Before this Peter had been living on the street for a reasonably long time due and was existing in a repetitious cycle of getting drunk, getting into fights leading to hospital stays, then going back to the streets (Central station) and getting drunk again. • Throughout his life Peter had come into contact with the following services: Department of Housing, Hospital and Psychiatric Units, Boarding houses, Department of Corrective Services without any long term success.

14. Peter Case Study 1 – Early Interventions • Complete abstinence from alcohol, non-prescription drugs and paracetamol • Referral to Liver Specialist and appropriate treatment for hepatitis and cirrhosis • Chronic Jaw Pain lead to referral to clinic to develop pain coping strategies and reduce reliance on medication • Dental specialist to operate and correct jaw alignment • Re-establish patterns of everyday living after living on the streets: • Sleep routine, • Shower hygiene routine • Budgeting and saving (Access to money was restricted to prevent alcohol consumption) • Clothes washing and wearing clean clothing daily • Food preparation and cooking • Family reunion – reacceptance into the family unit was an extremely motivating factor for Peter

15. Peter Case Study 1 – Mid interventions Meaningful Activities - Once Peter had regular sleeping pattern he was able to use staff support to plan meaningful activities into his daily routine. This began by re-establishing participation in activities of personal interest from his youth and included: • Body building • Drawing and painting initially in the unit and later attending art class in the local area • Snorkelling and fishing Work -to purchase equipment and supplies to sustain his personal interest activities, Peter required a little extra money. He began work in a local supported employment factory; • Initial 3 months 2 days a week • Increased to 3 days then 4 days within 6 months • The extra money allowed Peter to save up enough funds to maintain his hobbies, and purchase desired snorkelling and electronic equipment of substantial value ($3000). Unsuccessful interventions: • Travel training – Peter’s ABI made remembering locations/directions difficult • Attending AA – Peter refused to participate after attending two times, he did not like the negative nature of the group

16. Peter Case Study 1 – Transition and Post ISP Success Transition Accommodation • No evidence of ID prior to age 18 therefore Peter was ineligible to receive group home funding. • Eventually an Aged Care Assessment and aged care facility was identified as suitable placement as it provided: • 24 hour access to staff, • weekly access to medical services on-site • opportunity to engage with a similar peer group Transition Support: • Initial 3 months: ISP staff supported Peter at new Facility, 4 hrs x 4 days per week • Final month: ISP provided extra funds so Facility staff could provide 1:1 support for Peter, 6 hours x 3 days per week The Client post transition: • The less restrictive accommodation setting saw Peter return to drinking alcohol on a regular basis culminating in his banning from one local establishment (drunken behaviour) and a number of public places (for begging and public urination). • However within 6 months Peter regained his motivation to abstain from alcohol and is now stable, consuming little alcohol only on occasion. • Due to the reduced staff available of the setting, Peter has not returned to work or taken part in snorkelling independently, however he is engaging well in the activities provided within the facility and he is now conducting a weekly art class for the residents and supporting other residents in their efforts to abstain from substance abuse.

17. SueCase Study 2 - Background Female 27 , born into a family of Lebanese descent; she is the 6th child of 11 siblings • Diagnosis of Borderline Personality Disorder, characterised by poor impulse control and an inability to effectively regulate her own distress. • IQ in the Borderline range (71 – 75), which is seen to contribute significantly to her behavioural problems. Accommodation –Until entering ISP, Sue was residing alone in independent accommodation through a community housing organisation. The lease with The Department of Housing had expired and was not being offered for renewal as she had lit several fires, damaging two properties and causing risk to others. She was therefore at risk of becoming homeless Support Model - Daily direct ‘drop-in’ support from a psychiatric rehabilitation service ‘Rosewood’, linked to the Local Residential Mental Health Team. Sue also received telephone support from ‘Rosewood’ and she called them at least every few hours. Accessed a number of recreational activities with her support service, which she wanted to continue with upon entering ISP. ‘Rosewood’ were keen to continue providing support and were seen as a valuable community link for her. Hospital Presentation - • Significant self-harm behaviour (cutting and burning self – daily basis). • Daily presentations to hospital reporting distress and an inability to cope.

18. SueCase Study 2 – Issues Present at referral • Significant self-harm behaviour (cutting and burning self – daily basis). • Daily hospital presentations reporting distress and an inability to cope. • Arson(Fire setting at place of residence). • Department of Housing placement breakdowns due to fire-setting behaviour. • Aggression - verbal and physical • Lack of appropriate support in community • Lack of appropriate intervention for mental health. • Exhausts services due to constant contact (phone on an hourly basis seeking support)

19. SueCase Study 2 – Impact & outcome of intervention Accommodation • Provided with 24 hour staff supported accommodation in a cluster model of units. • Assisted to develop and engage in a comprehensive weekly schedule of activities to keep her busy and occupied. Therapeutic Intervention: Teaching of replacement skills for self-harm within a DBT framework and infusing these strategies within her service model by training residential staff. These skills include: • Emotion regulation and Distress tolerance • Problem solving • Anticipating risk (Identifying triggers)

20. SueCase Study 2 – Impact & Outcome of Interventions Development and Implementation of Behaviour Support Strategies • Comprehensive communication strategies developed for Behaviour Intervention Support Plan. This is especially important when working with BPD Clients to minimise staff splitting and ensure a consistent implementation of rules and coping strategies. • Residential staff provided with training and mentoring in BISP implementation during fortnightly and monthly team meetings. Feedback also gathered in these meetings and changes to BISP made accordingly. • Restrictions and protocols in place at residence to manage risk of fire setting and access to sharp items to self-harm with. Hospital Strategy • Co-ordination with hospitals to gain consistent response i.e. hospital staff refused Sue admission as they were aware that she had appropriate support at home and encouraged her to return to her residence. Management plan in place. Client’s Hospital admissions were reduced to less than monthly. • Management plan and reward system surrounding appropriate phone use.

21. SueCase Study 2 – Transition and Post ISP Transition • Successfully re-negotiated access to public housing for Sue after previously being blacklisted. The following was implemented to support Sue’s to move toward more independent living: • Over a 7 month period there was a gradual reduction of staff support hours, eventually returning to her previous level of 5 hrs per day. • There was also a gradual re-introduction of access to fire setting equipment and sharp implements as Sue proved she could keep herself safe. • Successful liaison with Department of Health to acquire a residential property. • Transition from the ISP to being supported by a community health provider within the limits of her funding i.e. 5 hours per day Monday to Friday with weekend telephone support.

22. SueCase Study 2 – Post ISP Post ISP • Sue’s house was a 2 bedroom stand alone house in which she lived alone. Unfortunately soon after her move her sister, with whom she has an antagonistic relationship, became homeless and moved in with her. It took two months of intervention to remove her. • Sue continued to engage with her new service provider and some new activities. However after a number of months, attention by staff and her support network dropped away, particularly after hours. Sue eventually returned to her previous behaviours and this culminated in another fire setting event. • Sue spent a short period of time custody and was then transferred to a mental health service while awaiting a new community placement.

23. SueCase Study 2 – Post ISP Some Lessons learnt • Clearer indicators of foreseeable risks when Sue is not coping and appropriate interventions need to be in placed when these risks emerge. • More assertive monitoring and follow up is required for participants after leaving ISP to ensure continual implementation support. Current Situation • Notwithstanding the breakdown of this placement, some gains have been made by Sue in managing her relationships and emotions and there is a far greater commitment by key stakeholders to assisting Sue to re-establish her supports and finding a suitable place to live.

24. More Case Studies if time permits Sculptures by the Sea, Bondi NSW

25. JoeCase Study 3 Client Summary • 28 year old man of Aboriginal descent. • Diagnosis: • Treatment Resistant Schizophrenia • Mild intellectual disability • Poly-substance abuse and Intravenous drug user • use strongly associated with the aboriginal section of the central Sydney suburb of Redfern known as ‘The Block’, which has a high concentration of drug users and dealers. • HIV Positive • Frontal lobe lesion (consistent with Aids related Dementia) • Hepatitis A,B &C positive

26. JoeCase Study 3 - Background Issues at Referral • Unsafe Injecting practices (using dirty needles, injecting the trace substances left in used needles, potential spread of disease to others) • High levels of infections due to injecting practices. Hospitalisation for treatment. • Theft (to acquire illicit substances). • Frequent contact with Police (3-4 times per week). • Non-compliance with treatment for mental health and HIV. • Non-compliance with Methadone program. • Impulsive, erratic and unpredictable behaviour. • Low frustration tolerance (esp. to waiting) • Agitation and verbal aggression / threats • Homeless

27. Joe Case Study 3 - Ongoing Interventions Impact and Outcome of Intervention • Provided with 24 hour supported accommodation in Mount Druitt, a western Sydney suburb where Joe’s mother and siblings live. It has developed strong Aboriginal community programs • Schedule of daily activities tailored to meet his need for stimulation and access to the community (‘walkabout’). • Staff facilitate compliance with medication regime, methadone program and attendance at specialist appointments. • Encouraged integration into local Aboriginal community. • Aboriginal men’s group (“The Shed”) • Engaged in Aboriginal art.

28. Joe Case Study 3 - Ongoing Interventions Impact and Outcome of Intervention • Establish links with Aboriginal Elders. • Staff consult Elders when issues arise. • Elders speak to client. • Re-established positive family links. • Frequency of contact increased. • Support staff developed good working relationship with family. • Significant reduction in offending behaviour and contact with Police (1 incident in the last 3 years). • Reduction in substance use and substance seeking behaviour. • Improved medical health.

29. Joe Case Study 3 - Outcomes Current Situation • The Client’s mental illness has proven to be treatment resistant. • The greatest gains have been made in stabilising Joe’s external environment (housing stability, consistent implementation of routine and house rules) and anchoring his routine activities in the local Aboriginal Community and meeting with family.

30. Joe Case Study 3 - Transition Transition • The Client was accepted into the Community Justice Program (CJP), Department of Aged, Disability and Home Care Services (DADHC). The CJP is targeted to providing support to people with an intellectual disability who are exiting custody, placing themselves or others at serious risk of harm and who present a level of complexity that requires services beyond that of DADHC may normally provide. The primary aim of the program is to minimise recidivism rates for this group and enable appropriate community integration. • Joe was accepted to received a CJP On-Site Supported Living (OSSL) model. This model promotes independent living with flexible support and supervision hours (access to 24 hours), behaviour support and skill building. • CJP is current identifying a suitable OSSL placement for Joe. Once a placement has been identified, ISP and CJP will work closely together to develop a detailed transition plan.

31. David - Case Study 4 Client Summary • 18 year old Male. Family is of Italian origin. • Diagnosis: • Schizophrenia • Conduct Disorder • Inhalant Induced Mood Disorder (with mixed features of manic and depressive episodes) • Suspected ABI due to inhalant abuse. • Cognitive functioning in ‘Mildly Intellectually Delayed’ range. • Poly-substance abuse from age 14yrs. • Involvement with Juvenile Justice. Incarcerated in Juvenile Detention Centres for violent offences and breach of AVO’s

32. David - Case Study 4 Issues present at Referral • History of violence and aggression. • Turbulent violent relationship with family. AVO’s in place. • Turbulent violent relationship with his girlfriend. They have a 6 month old daughter together. • High level substance abuse – mainly inhalants (paint) • Considered ineligible for Drug & Alcohol Rehabilitation Programs due to his violence, diminished cognitive capacity and mental health issues. • Not eligible for disability funded services. • Untreated mental health issues. • Lack of appropriate support in the community. • Unwillingness to engage with services.

33. David - Case Study 4 Impact and Outcome of Intervention • 4 weeks after acceptance into ISP – offended and was placed on remand in custody. First adult incarceration. • Number of accommodation placements trialled unsuccessfully – continued high level substance use, aggression, absconding and re-offending. • Placed into highly structured setting with high level supervision and some external containment. • Restricted access to substances • Consistent medication administration for mental health • Implemented therapeutic programmes to gradually facilitate more independence and less supervision, based on presentation and behaviour. • Engagement with Drug & Alcohol group therapy.

34. David - Case Study 4 Impact and Outcome of Intervention: • Moved to open accommodation model with low supervision (after 14 months in restricted setting). • Begun work at a nursery part time. Increased to 4 ½ days per week. • Abstaining from drugs and alcohol. • Significant reduction in aggressive behaviour (January – October 2009: 2 incidents). • Positive re-engagement with family members. • Begun 1:1 individual therapy to work on life goals and social skills. • Social role valorisation: Working man and father.

35. LouiseCase Study 5 Female, 40 years old, a refugee from south-east Asia who had been homeless for 8 years • Diagnosis: Schizophrenia with secondary Depression • Communication: Non-English speaker: her native language cannot be identified. • Brief history • 8 -19 years - lived in a refugee camp in Vietnam with mother and brother • 19-31 years - sponsored to migrate to Australia alone and had since then lost contact with the family. Lived with extended family. • 31-39 years - the family moved but she was not invited to move with them and was abandoned at the house. She was escorted to reside in a crisis accommodation set up primarily for homeless males and lived there till ISP involvement. • Extremely withdrawn and timid, consistently refused to engage with service provider. • No history of unlawful activities

36. LouiseCase Study 5 Issues present at Referral • Refused to engage with all service providers, rarely spoke to anyone throughout her stay at the crisis accommodation. • Persistently fallen between the service provision cracks due to her did not “act out” or cause problems with the law. She remained an isolated person who only came into contact with services from time to time. • No diagnosis or assessments could be made due to her non-engagement and poor English skills. Without formal diagnosis and assessment, she was not eligible for disability funded services or accommodation options. • Symptoms of deteriorating mental health included eating out of garbage bins, hoarding of food scrap and rubbish in her room and rapidly deteriorating hygiene and personal care skills. • Received no social support and had nil contact with her extended family • Has had a passive-acceptance to novel circumstances which perhaps masked her underlying anxiety and consistently placed her in vulnerable positions in life.

37. LouiseCase Study 5 Impact and Outcome of Intervention • Mental Health - Scheduled in Mental Health Unit for review and with the help of psychotropic medications she slowly became more communicative and was able to inform the staff of the symptoms she experienced. • Therapeutic Intervention - Clinical Consultant at ISP was able to communicate with her using Cantonese. Weekly visits to build rapport and helped with communicating with other service providers. • Accommodation - Placement is an NGO secure crisis accommodation service for females. • Living Skills and Community Support –Cantonese speaking support workers from a Chinese NGO were contracted for regular drop-in support in order to rebuild her daily living, self-care and community-living skills. • Encouraged to access the community daily and utilise community services • Encouraged to take part in different community activities to expand her social network.

38. Louise - Outcomes • Mental Health - She still does not fully comprehend her mental health diagnosis, however, she is very compliant in taking her daily medications. • Living Skills - With assistance, she rapidly regained most of the daily living, self care, and community living skills lost through years of displacement. Since she has access to fresh food and has gained adequate cooking skills, she has ceased eating out of the bin. • Money Skills - She accesses the bank to collect her pension money three times a week, with regular income, her hoarding behaviour diminished. She did not feel the need to stockpile items in the case that she ‘runs out of money’. • Community Support – Language appropriate support within the community has been established e.g., she accesses the bank, Chinese activity group, dentist, General Practitioner and psychiatrist regularly. • Weekly Routine - She currently has a very active weekly schedule, • Works two full days per week; • attends a community English class; • Participates in other community activities run by the Chinese NGO. • Receives drop in support 5 days a week for a few of hours each day. • Transition – She is due to exit ISP shortly and move into a two bedroom secured unit located right next door to the Chinese NGO, in an area with a large Asian population. She will continue to receive daily drop-in support funded jointly by Department of Health and ISP.

39. Success and the challenges that lie ahead ? • Ongoing evaluation by The Social Policy & Research Centre of the University of New South Wales (be to finalised in end of year) , indicates that ISP has a made a significant impact to the quality of lives of participants. • Recent government announcements • Recurrent funding • Project status now becomes a recurrent Program. • A shift in service systems for people with complex needs in NSW. • Continual efforts are needed to reshape service systems. • Refining establishments of permanent positions, policies and procedures. • Ongoing - quality improvement and assurance post evaluation. • Service agreements with nominating agencies pre-ntake to ensure ongoing involvement with participants post transition.