1. Multiple and Complex Needs Initiative Victoria, Australia
Outside In Conference, St John’s, NL, Canada October 2009

2. STRUCTURE of presentation: four sections; 1 – intro/context; 2 history/rationale/model 1 and 2; 3 the model in action (Mel), and 4 review and reflections. So: 4 opportunities to ask questions.
Intro/Context…
Aust population: approx 22 million
Vic population: approx 5.2 million
In Aust and NZ – some similar approaches – NSW, SA, Tas, two in NZ
6 states, 2 territories
Canada – approx 32 million
Ontario – 12 mill, Toronto, 5 mill
NL – 505,000, St John’s 182,000

3. 3. The Victorian Department of Human Services - Regions
8 DHS regions
3 metro
5 rural
Regional Coordinators and regional panels in each region
Metro 1: FTE
Metros 2 & 3: 1.2 FTE
Rurals: .8FTE
Combined with SfHRT staffing
8 regions. Regional coordinators advising and supporting local panels. Care Plan coordination – aim for 50% provided by Indigo – auspiced by WRHC. Statewide. Other 50% - provided by local agencies..

4. 4. Questions

5. 5. 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
Service responses lacking, inadequate and clients refused services or excluded due to service eligibility requirements
POSITIVE and NEGATIVE drivers for change; goodwill to do better, criticism of govt response
Criticism and lack of trust in government

6. 6. Early scoping work
Two years of consultation and data collection
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. 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
90% - at least one incidence of harm to self, staff and community, 47% harm for all three
91% socially isolated, little family contact
55% chronic health problems

8. 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
Time limited
Emphasis on planning (not dollars)
Intention to engage/re-engage with service system
Note – not to cure, massively reduce need for service OR funds OR to ‘take over”..
In the context of brokerage: think planned spending, rather than chaotic spending.

9. 9. What we wanted from the system (1)
Greater collaboration, partnership, flexibility (“seamless”, “joined up”)
Better use of service resources – “capacity building”
Better use of financial resources – cost effectiveness
To get agencies to “stretch” and to provide care planning for cross-program clients.
CPC aim of MACNI – both models:
50%: Indigo – who can go state-wide
50%: local agencies – “stepping up”

10. 10. What we wanted from the system (2)
Capacity building means:
Stepping up..crossing boundaries..
Care plan coordination:
50% provided by Indigo
- State-wide, auspiced by Western Region Health Centre
50% provided by local agencies

11. 11. What are the most important things?
Commitment
Resource

12. 12. Elements of MACNI
Regional coordination mechanisms (within government)
A legislative framework
Assessment, planning, and intensive case management function (in the funded sector)
Time-limited
NOT a crisis response – planned intervention
Some client attached dollars
Became operational in late 2004
Human Services (Complex Needs) Act 2003 – sunset clause May 2007, extended to May 2009

13. 13. 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
The leg always generates a lot of interest….
Interesting regulatory issue….
Seen as highly authorising?
“Holds” some of the negotiation burden?

14. 14. 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.
Elegant and carefully crafted to address gaps in program service delivery…
…..”derive benefit”…..
Should MACNI be the response of last resort?

15. 15. 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
Intensive case management function – delivered by Indigo Intensive Case Management Service
MACN Panel – an independent statutory body
Legislation: a matter of trust, authority

16. 16. The MACNI service model V1
Existing Service System 1
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

17. 17. 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 by regions
This work was achieved with MACNI worker resource, but without proceeding down path of eligibility..capacity building…

18. 18. 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

19. 19. 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

20. 20. 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

21. 21. 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
Very slow throughput
Rigid timeframes
Long delays
A linear, “clunky” model
All had to learn:
Not a crisis response
2. it’s a parallel, partnership process – aim to keep engaged/ re-engage the broader service system

22. 22. Questions

23. 23. The model in action (1) Some practice benefits
Care plan coordination
State-wide focus
Information sharing provisions
Care plan coordination – was the one element that everyone agreed was of benefit. goal: 50% by specifically funded service; 50% by other agencies
Information sharing provisions – not actually necessary, but levelled the playing field
State wide focus allowed workers to cross regional and rural physical and service boundaries- crucial for a transient client group

24. 24. 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
Incorporates- Care Planning, Care Plan, Care Team and Care plan Coordination/coordinator.
Risk management: statutory, non- statutory..
Other names for care plan coordination: intensive case coordination, complex case management
Key feature: multi-service coordination

25. 25. 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
No it isn’t, planning is the most important thing.
The focus is necessarily on stable accommodation as opposed to housing.
Small targeted amounts of money can be enough to make a critical difference. Sometimes – no extra money needed

26. 26. Questions

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

28. 28. External evaluation (2)
Improvement in individual outcomes? Yes
Improvement in service coordination? Yes
Adequacy of legislation? Yes
Achievement of cost-benefit? Less clear
Strong benefits in local work; gate-keeping valued and effective
Improvements in collaboration in the service system – benefits for a much larger group than just those determined eligible for MACNI – ref “resolved at regional level”..
Legislation – didn’t really adequately address the question. Concern had been whether we needed an involuntary component.
The Panel was considered to be expensive
Evaluation cost approx $500,000

29. 29. External evaluation (3)
76% reduction in presentations to hospital emergency departments
34% reduction in number of hospital admissions
57% reduction in hospital bed days
76% clients – from 310 presentations to 74
34% clients – from 223 admissions to 147
57% inpatient bed days to 611
KPMG consideredit was expensive…and suggested significant devolution…

30. 30. 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
Mental health services the largest referrer
31% under 25
53% 26-45
16% over 45
3 to 1 male to female

31. 31. Snapshot study (2)
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. 32. Outcomes: Comparative data – key findings
Safety is percentage of individuals at low or not risk
ALL CLIENTS
Pre- MACNI
Post- MACNI
Improvement
Stable Housing 21 44
41%
Health & Well-Being 48 78
26.00%
Social Connectedness
114
186
32%
Safety 18 54
31.50%
Overall Change
201
362
31.40%

33. 33. Key Findings (1) Successful client outcomes for 13 of the 19
57% overall improvement
across all 4
platforms
Pre-
MACNI
Post- %
improve
Stable
Accomm 0%
63%
Health/
Wellbeing
10.5%
80%
69.5%
Social
Connect 4%
55%
51%
Safety
28%
74%
46%

34. 34. Key Findings (2) Service system: Individuals:
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
NB – capacity building in sector – benefits to a much larger group of individuals than just those who get a MACNI service
1/6 had Indigo as CPC

35. 35. More about the unsuccessful outcomes
4 out of 6 transitioning from youth to adult services
5 out of 6 – histories of Youth Justice/Child Protection
3 out of 6 - indigenous backgrounds
5 out of 6 had non-Indigo Care Plan Coord.
There was only one other client in the 19 cohort that was transitioning from youth to adult.
There were no other individuals with Koori backgrounds in the cohort
4 - jail, 1 – streets, 1 – hospital – EVEN SO:
ALL showed improvement during MACNI

36. 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
CPC Role - – independent, coordination focus and able to move around state and service boundaries

37. 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. 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
Cost of care plans affected by variables other than client need….New model puts some “caps” and limits..

39. 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
Intensive case management function – delivered by Indigo Intensive Case Management Service
assessment not separate from plannin
Legislation: proved popular
Kept: info sharing, eligibility criteria, framework for care planning
No longer a Panel
Change to role of Indigo: now includes early consultation and advice, mentoring.

40. 40. MACNI service model V2 Care Plan Coordination
Can be provided by local service providers or by the state wide service provider (Indigo)
Collaborative and coordinated service provision for up to 3 years, inclusive of earlier phase
DHS Regions
Regional panels review the progress of the care plans
Care plans can be varied or terminated by the regional panels
CERG
Can be approached for additional funds &/or if review assistance is required

41. 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
Ongoing legislation, no sunset clause
Leads to reduction in admin burden and better targeting of effort
Care plan – max duration increased from 2 to 3 years

42. 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
Greater flexibility, flatter structure
Aim to improve accountability, responsibility, ongoing partnerships
Central group: state government, three departments. Mix of senior program and clinical people

43. 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
Legislation
An independent statutory body
Cross-program collaboration
Assessment and planning
Work at the local/regional level
Client attached dollars
“Authority”
“Expertise”
Trust in the service system..
This work occurs in a CONTESTED SPACE

44. 44. Some things we didn’t do
A good job for people with indigenous backgrounds
A review from the perspective of service users

45. 45. Questions