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 millionVic population: approx 5.2 millionIn Aust and NZ – some similar approaches – NSW, SA, Tas, two in NZ6 states, 2 territoriesCanada – approx 32 millionOntario – 12 mill, Toronto, 5 millNL – 505,000, St John’s 182,000
3 3. The Victorian Department of Human Services - Regions 8 DHS regions3 metro5 ruralRegional Coordinators and regional panels in each regionMetro 1: FTEMetros 2 & 3: 1.2 FTERurals: .8FTECombined with SfHRT staffing8 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..
5 5. The beginningHistory of concerns raised by service providers, clinicians, carers, advocacy groups, Police, Courts and othersPoor service outcomes for a small but significant group with complex needs that challenge existing policy and legislative frameworksStrong stakeholder support for changeService responses lacking, inadequate and clients refused services or excluded due to service eligibility requirementsPOSITIVE and NEGATIVE drivers for change; goodwill to do better, criticism of govt responseCriticism and lack of trust in government
6 6. Early scoping workTwo years of consultation and data collectionIdentified a group of 247 individuals with “multiple and complex” needsClient costs:On average - $248,000 paHighest cost package in 02/03 was $643,000
7 7. Early profiling – client characteristics Characteristics of Client GroupYoung – 44% 18 to 35 years2:1 ratio of men to womenMajor presenting problems – combinations of mental disorders, intellectual impairment, acquired brain injury, substance abuseHigh risk behaviours – to community, staff and self71% - current or past contact with criminal justice systemHigh volume users of emergency servicesSignificant accommodation issues – 35% homeless, short term or crisis accommodation90% - at least one incidence of harm to self, staff and community, 47% harm for all three91% socially isolated, little family contact55% chronic health problems
8 8. What we wanted for individuals Achieve stability in: housing, health and well-being, safety, social connectednessProvide a platform for long-term engagement in the service systemPursue planned and consistent therapeutic goals for each personTime limitedEmphasis on planning (not dollars)Intention to engage/re-engage with service systemNote – 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 effectivenessTo 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-wide50%: 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 Centre50% provided by local agencies
11 11. What are the most important things? CommitmentResource
12 12. Elements of MACNIRegional coordination mechanisms (within government)A legislative frameworkAssessment, planning, and intensive case management function (in the funded sector)Time-limitedNOT a crisis response – planned interventionSome client attached dollarsBecame operational in late 2004Human 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 criteriaSupports voluntary nature of initiative, and right of refusal at any timeKey decisions made by an independent statutory bodyDetailed programmatic prescription at the “black law” levelThe 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; andAppears to have 2 or more of the following:A mental disorderAn intellectual impairmentAn acquired brain injuryIs an alcoholic or drug–dependent person; andhas exhibited violent or dangerous behaviour that caused serious harm to himself or herself or some other person, oris exhibiting behaviour which is reasonably likely to place himself or herself or some other person at risk of serious harm; andis 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 panelsSpecifically funded Community Service Organisations – state-wide rolesBrokerage – client attached dollarsIntensive case management function – delivered by Indigo Intensive Case Management ServiceMACN Panel – an independent statutory bodyLegislation: a matter of trust, authority
16 16. The MACNI service model V1 Existing Service System1DHS Region Regional Gatewaycontact Regional Co-ordinator(consultation/problem solving, referral, local panel consideration, RD sign off)23Multiple and Complex Needs Panel(Eligibility, Care Plan, Care Plan Coordinator, Care Plan Review)54Care Planassessment & 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 levelMost of these consultations led to improved problem solving and local solutions; recognised as significant boost to capacity167 considered for referral by regionsThis 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 womanChaotic, abusive, multi-generational, dysfunctional family backgroundsubstance abuse since age of 11 (petrol/chroming)ABI, schizophreniaBrain tumourCriminal justice system involvementConstant moves between Melbourne/rural Vic/NSW
19 19. Case study -What the region did Response has taken approx. 3 years to developMental Health service: provides co-ordination - Disability service: provides funds - across regional/state boundariesFormal communication strategy between critical providers- police, mental health, Hospital Koori UnitInvolved providers persistent eg. Guardian/regionFlexible accommodation support
20 20. Activity: 1 June 04 to 31 May 09 – MACN Panel 84 referrals (from regions)79 determined eligible56 care plans determined39 care plans extended into second year39 care plans concluded
21 21. The first model – issues Very slow start up; steep learning curveDeveloping shared understanding of roles and responsibilities:PanelAssessment/care plan development/care plan coordinationRegional coordination and local capacityVery slow throughputRigid timeframesLong delaysA linear, “clunky” modelAll had to learn:Not a crisis response2. it’s a parallel, partnership process – aim to keep engaged/ re-engage the broader service system
23 23. The model in action (1) Some practice benefits Care plan coordinationState-wide focusInformation sharing provisionsCare plan coordination – was the one element that everyone agreed was of benefit. goal: 50% by specifically funded service; 50% by other agenciesInformation sharing provisions – not actually necessary, but levelled the playing fieldState 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 serviceIs vital when there are multiple services involvedHas “dual beneficiaries”: the clients, and the systemIs a good tool for sharing riskNeeds to be recognised and resourced1:5 worker to client ratioIncorporates- 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 managementKey feature: multi-service coordination
25 25. The model in action (3)Some assumptions that proved not to be trueHousing is the most important thing(ALL the “platforms” need equal consideration and planning)Lots of extra money neededIts harder in the rural areas to do a good jobNo 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
27 27. External evaluation - KPMG 4 reports over 3 yearsFinal report February 20084 “evaluation questions”
28 28. External evaluation (2) Improvement in individual outcomes? YesImprovement in service coordination? YesAdequacy of legislation? YesAchievement of cost-benefit? Less clearStrong benefits in local work; gate-keeping valued and effectiveImprovements 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 expensiveEvaluation cost approx $500,000
29 29. External evaluation (3) 76% reduction in presentations to hospital emergency departments34% reduction in number of hospital admissions57% reduction in hospital bed days76% clients – from 310 presentations to 7434% clients – from 223 admissions to 14757% inpatient bed days to 611KPMG consideredit was expensive…and suggested significant devolution…
30 30. Internal review - snapshot study(1) “Snapshot” July-Sept 08Client status pre and post MACNI was assessed against the four MACNI platforms:Stable accommodationHealth and well-beingSocial connectednessSafetyMental health services the largest referrer31% under 2553% 26-4516% over 453 to 1 male to female
31 31. Snapshot study (2)19 out of 22 clients who had exited from MACNI were reviewedFour data sourcesKPMG evaluation case studiesMACNI case files and reportsInterviews with key service providersClient Outcome Survey
32 32. Outcomes: Comparative data – key findings Safety is percentage of individuals at low or not riskALL CLIENTSPre- MACNIPost- MACNIImprovementStable Housing214441%Health & Well-Being487826.00%Social Connectedness11418632%Safety185431.50%Overall Change20136231.40%
33 33. Key Findings (1) Successful client outcomes for 13 of the 19 57% overall improvementacross all 4platformsPre-MACNIPost-%improveStableAccomm0%63%Health/Wellbeing10.5%80%69.5%SocialConnect4%55%51%Safety28%74%46%
34 34. Key Findings (2) Service system: Individuals: MACNI leads to capacity building of sectorBiggest achievement was bringing people to the table and getting them to communicateIndividuals:Most successful - disengaged, isolated, highly transient, significant criminal justice histories & homelessLeast successful - those transiting from youth to adult services, those with indigenous backgroundsNB – capacity building in sector – benefits to a much larger group of individuals than just those who get a MACNI service1/6 had Indigo as CPC
35 35. More about the unsuccessful outcomes 4 out of 6 transitioning from youth to adult services5 out of 6 – histories of Youth Justice/Child Protection3 out of 6 - indigenous backgrounds5 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 cohort4 - jail, 1 – streets, 1 – hospital – EVEN SO:ALL showed improvement during MACNI
36 36. What were the successes? Care Plan – an effective toolCare Plan Coordination - critical roleCoordination through care teamsAccess to training and mentoringReflective space – insists on focus and attentionSome additional dollars usefulCPC Role - – independent, coordination focus and able to move around state and service boundaries
37 37. What were the challenges? Complexity of service systemComplexity of the MACNI modelTransitions difficult to negotiate – can “mirror” broader service system problemsMaintaining momentum and commitment after MACNI
38 38. Sustainability MACNI is a time-limited intervention Ongoing care planning is critical to sustaining the gains - NBGood planning may:Reduce costs – or notHighlight/confirm the need for ongoing costs – high, or otherwiseCost 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 groupRegional coordinators and regional panels – better resourced, making key decisionsOne specifically funded CSO – still state-wide, with broader roleBrokerage – client attached dollarsIntensive case management function – delivered by Indigo Intensive Case Management Serviceassessment not separate from planninLegislation: proved popularKept: info sharing, eligibility criteria, framework for care planningNo longer a PanelChange 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 phaseDHS RegionsRegional panels review the progress of the care plansCare plans can be varied or terminated by the regional panelsCERGCan be approached for additional funds &/or if review assistance is required
41 41. The Future – the framework Human Services (Complex Needs) Act 2009Maintained: information sharing provisions, eligibility criteria, framework for care plan coordinationChanged: strict separation between assessment and care planning, maximum length of care planRemoved: independent statutory bodyOngoing legislation, no sunset clauseLeads to reduction in admin burden and better targeting of effortCare 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 decisionsMore staffing resource at the regional levelTighter guidelines around client attached dollarsGreater flexibility, flatter structureAim to improve accountability, responsibility, ongoing partnershipsCentral group: state government, three departments. Mix of senior program and clinical people
43 43. Some reflections on the elements.. LegislationThe MACN PanelCross-program collaborationAssessment and planningState-wide authority and service deliveryWork at the local/regional levelClient attached dollarsLegislationAn independent statutory bodyCross-program collaborationAssessment and planningWork at the local/regional levelClient 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 backgroundsA review from the perspective of service users