Enhancing Systems for Mental Health: Under 1 Roof Project Overview

1. North Brisbane Partners in Recovery Forum

2. Overview • About Under 1 Roof • Reflections on “systemic change” • Our framework for this project • How we went about it • What we have learned • So what and what next?

3. About Under 1 Roof Our members • 139 Club Inc • Bric Housing Company • Brisbane Housing Company • Brisbane Youth Service • Footprints in Brisbane • New Farm Neighbourhood Centre • Rotary Club of Fortitude Valley • Queensland Intravenous Health Network (QuIHN) • Communify Queensland • Mission Australia • Youth Emergency Services • Care Housing • Red Cross

4. About Under 1 Roof Our structures • Board (governance, accountability, strategy) • Quality forum (managers, focussed on implementing quality improvements) • Case coordination meetings/practice – meetings every two weeks, clients with complex needs • Learning and development: training, resources, Synthesis Series

5. Systemic change:Scoping of the project • To develop and trial a triage system including relevant/helpful tools which will address systemic issues and barriers to people who have a mental illness • To include a learning and development component to support change • PIR Innovation Fund: mental illness, innovation and systems focus

6. Systemic change:Focussing our work Not one part of something but how all of the parts add up and function together. So we had to consider: • the way the various parts of the service system relate to each other and the quality of these relationships • service delivery models and funding patterns and programs • how resources are accessed (guidelines, eligibility etc) • housing products • Information transmission, resources and infrastructure

7. Systemic change:Interconnections Factors impacting on outcomes Spheres of influence and change Systems are about how multiple components relate to each other and operate. Under 1 Roof, 2013

8. Systemic change:Tools are only part of the story • A triage system is made up of related elements • One element will be the tools that support assessment, prioritisation, case planning and plan implementation • Important that we understand a Triage System is not only a Triage Tool.

9. Systemic change:

10. Systemic change:Requires insight • The Triage Project trial focus is on systems elements • Systems change will take thorough account of client characteristics such as mental illness. • It will have implications for practice and resources (existing and new).

11. Our framework:Our inputs to triage model

12. Our framework: Reflecting best practice • A triage system informed by recovery principles and practices • A triage system informed by best practice in ending homelessness: • Housing first • Assertive and persistent practice • System integration • Wrap around support.

13. Our framework;Acknowledging complexity • Specialist homelessness services • Multi-agency involvement (beyond SHS) • Decentralised with various gateways • Social and private housing systems • People need broader resources and assistance than just a specialised homelessness response

14. Our framework:Understanding homelessness • Degrees of homelessness and various levels • Diverse drivers which can co-exist making the causes more complex and solutions more challenging • Diverse population groups with different needs

15. Our framework:Insights into mental illness • U1R: 52.2% of clients with a mental illness (2013-2014) and more with mental health issues; 70.8% presented with 2 or more complex issues; 39% with 3 or more complex issues • Homelessness is also a cause of mental ill-health – one study showed that 16% of a sample of homeless people developed mental health symptoms • SANE sample identified 90% had experienced homelessness or insecurity about their accommodation at some point • A higher proportion of Under 1 Roof clients who disengage from services live with a mental illness and/or substance use issue (61% compared to 51% for 2012-2013)

16. Our framework:Design for implications of mental illness… • Difficulty with medication side effects, screening out environmental stimuli: • Noise and crowds can be challenging • Sustaining concentration: restlessness, shortened attention span, distraction, and difficulty understanding or remembering verbal directions. • Maintaining stamina and difficulty sustaining an activity • Handling time pressures and multiple tasks: difficulty prioritizing tasks, and meeting deadlines. Challenges in multi-task work.

17. Our framework:Getting and keeping housing • Hearing and understanding information • Consideration of options and alternatives • The capacity to make plans • Receiving, interpreting and following instructions • Sequencing events and actions in the required order as part of a plan • Remembering actions that need to be taken and time frames/deadlines • Making appointments, recording times, turning up on time • Completing and submitting essential paperwork • Recounting information and progress between different services • Engaging with several important relationships (support worker, specialist help, health professionals, housing provider, private housing etc) • Travelling between appointments/inspections • Weighing up alternatives and making decisions • Arranging to move, managing belongings • Developing new, important relationships with housing option/provider, neighbours

18. Our framework:Access points for the homeless • Specialist homelessness services as a critical point of contact for people • Housing providers including the Housing Service Centres which are part of the Queensland Government Department of Housing and Public Works • Mental health services may also be the first point of contact for people with mental health issues and mental illness • Other specialist services in areas such as substance use • Mainstream services in the broader service system such as community centres, hospitals, police etc. • Access points span government and non-government services.

19. How we went about it:Participants • Advisory group: funding body, U1R agencies, government and non-government stakeholders • 24 agencies participated • Acknowledged concurrent processes and tools: QHIP, CHART and VI-SPDAT • Sector reported that various assessment and data recording processes placed a burden on time • Specialist system uses CHART – no access to CHART for others • Project developed a pre-assessment form (PAF) to link the non-specialist system

20. How we went about it:The client contact • 116 PAFs were received • 74 were from non-SHS agencies (completing and submitting the whole form) and 42 from SHS agencies (submitting only page three when receiving referrals). • As was expected, more forms were received from Non-SHS agencies because the trial acknowledged that SHS agencies were already conducting assessments via the mandated CHART process and it was decided not to add to work-loads or duplicate effort. • This equated to a total of 74 clients assessed using the PAF. • For the period of the trial - specialist homelessness services participating in the trial recorded 497 entries on chart • Estimates from the non-SHS of homeless people presenting: 403 • 74 is therefore only a sample

21. Profile of clients

22. How we went about it:Presenting issues: • 25%: Access to accommodation • 24%: Other support relating to homelessness (primarily relating to sustaining tenancies, seeking alternative housing and navigating public and private rental housing) • 18%: financial support (to assist with sustaining tenancy, rent arrears, bill payment, relocation costs, household purchases of emergency relief) • 11%: Access to legal and / or tenancy services Other less frequent primary presenting needs were: • 7%: People in crisis seeking access to immediate supported housing or domestic violence support (4%) • Personal and / or family support - 7% and 4% respectively • Transitional supported accommodation (1%).

23. What we have learned:Systems design • This project has affirmed the importance of working to develop a Triage System that builds on existing infrastructure and results in recognition for the important and complementary roles of specialist and non-specialist services. • This project occurred at a point in time where other initiatives were maturing such as QHIP and CHART while important innovations like the VI-SPDAT improved capacity to understand and prioritise the needs of highly vulnerable people • The current structure of QHIP and CHART only allows access by the specialist system and this project has identified that a key systems’ change would be to allow integrated access so that the non-specialist system in contact with homeless people can assess people they are in contact with or at least more effectively link to specialist services.

24. What we have learned:Elements of a triage system • Governance arrangements which harness leadership, and work towards a vision of improved access and outcomes for homeless people • A core role for the specialist homelessness system in both: • Supporting decentralised access points where homeless people naturally present • Directly doing intake and assessment • Directly providing support and accommodation options. • This includes a role for designated specialist services with capacity for ‘hub’ activities including supporting the broader sector, information provision, assessment, referrals and initiating case plans. • Decentralised access points will be valued and recognised as a key way for homeless people to access assistance without taxing their own personal resources.

25. What we have learned:Overall structure • CHART is proposed as a tool to support and enable triage and that a new or additional tool would add a burden to a system already experiencing high volume • If access to CHART involves delays, then a tool such as the PAF should reflect the content of CHART and be available to the non-specialist system to assess a person and commence a case plan. • A web-based platform for assessments, case planning and ongoing case management and where other key assessments have been done such as a housing application and/or VI-SPDAT, include visibility of these assessments to reduce the burden on clients re-telling their story. • Initial intake and assessment will prioritise people for resources (housing and support) and prioritise a person’s highest, most critical presenting needs as a basis for areas to focus on first. • A case plan commences at the point of triage and moves with the client.

26. What we have learned:Contextual requirements • A learning and development framework will accompany the triage system with a focus on themes such as assessment, warm referrals, case planning, case coordination and understanding/working with vulnerability across various domains including a focus on mental illness. • A triage system will define various roles including: • Governance • Leadership • Specialist homelessness system hub support • Specialist homelessness system – wider services • Decentralised access points (government and non-government).

27. Model • Both specialist and non-specialist agencies are important access points for people who are homeless or at risk of homelessness • The non-specialist system can play a role in diverting people from the specialist system and directly to the assistance that a person needs. This system also provides a range of support options that contribute to quality of life. • The specialist system is needed to play a direct role assessing and assisting people, as well as providing specialist support to the wider service system. In that sense it is a direct service provider as well as a systems’ enabler.

28. So what and what next:The model: • Centralised • Decentralised • Hub and Spoke (centralised support, decentralised access).

29. jj Source: Under 1 Roof