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Multiple and Complex Needs Initiative Victoria, Australia

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Presentation on theme: "Multiple and Complex Needs Initiative Victoria, Australia"— Presentation transcript:

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

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