OUTCOMES, SERVICE MODELS AND INTEGRATED SERVICE DELIVERY Paul Flatau The University of Western Australia Centre for Social Impact 1

THE FUNDING CONTEXT 2

Three Steps to Contract What would success look like for our clients Client Outcomes How will we achieve success for our clients Service Delivery Model Why we should be funded to deliver services The Value Proposition

Three Steps to Contract Step 1: Define Your Intended Client Outcomes Step 2 Develop Your Service Delivery Model Step 3 Establish Your Value Proposition

Step 1: Outcomes InputsActivitiesOutputsOutcomesImpacts The focus of the WA Government’s procurement reform Your Planned Work Your Intended Results

Step 1: Outcomes Inputs, Activities, Engagement Outputs Number of participants reached, number of contacts and intensity of contact Learning Changes in knowledge, skill and attitude Actions Changes in behaviour and practices Impact Long-term effects for the individual, community and systems Change relative to baseline and the counterfactual Understand the needs and histories of clients. Outcomes should be judged relative to needs Outputs Outcomes Impact

DAO Residential Rehab Service Outocmes Improvement in clients wellbeing (physical, mental, emotional, social, standard definition) in the: Short term(3-6 months post treatment) Long term (+6 months post treatment) Greater awareness/understanding of own drug use and factors impacting upon Improvement in the clients capacity to relate to family and function in the community Short term(3-6 months post treatment) Long term (+6 months post treatment) 7

Step 2: The Service Delivery Model Establish HOW and WHY your service will achieve intended outcomes and impacts What links the activities you are undertaking to the intended short-term and medium-term outcomes and final impacts for clients and communities? How will your service model achieve the ends you are after? The THEORY OF CHANGE logic model

Step 3: The Value Proposition Why your service represents value for money ……Because you can demonstrate that your service delivery model produces (or has the capacity to produce) positive benefits for your clients and long-term positive impacts for the community … and you can do this at the right price

THE ROLE OF SERVICE INTEGRATION 10

Focus Findings from ongoing studies IN HOMELESSNESS on comorbidity and homelessness and social exclusion Comorbidity: coexisting substance use and (other) mental health disorders Homelessness: primary homelessness; supported accommodation and temporary accommodation (couch surfing family or friends; hotel/motel as have nowhere else to go; boarding/rooming houses) Social exclusion: Income, wealth, resources, friendships, family 11

MP Baseline: Mental Health Mental Health Around half of all respondents indicated they had been diagnosed with a mental health disorder (excluding substance use disorders) Prevalence of mental health disorders 33% with mood disorders 34% anxiety disorders 17% psychotic disorders 12% personality disorders 51% substance use disorder Others less than 10% 34% Comorbidity (diagnosed substance use disorder and diagnosed other mental health disorder) 36% currently taking medication for a mental health condition 12

MP Baseline: AOD 13 Outreach and Emergency Short and Medium Term Accommodation Ever tried Past month Dependence Ever tried Past month Dependence n%n%n%%n%n% Heroin Opioids other than heroin Alcohol Cannabis Amphetamines Cocaine Tranquillisers Hallucinogens Inhalants Average

MP Baseline: Mental Health 14 Lifetime exposure to different traumatic events

MP Baseline: Mental Health High to very high levels of psychological distress & very high rates of PTSD & psychosis 95% had experienced one or more traumatic events eg witness someone being badly injured/killed; serious physical assault; life threatening accident etc Typically early adolescence when 1st traumatic event occurred with worst exposure in early adulthood  trauma history well established by adulthood 20% of MP clients screened with post-traumatic stress disorder (PTSD) compared with 1% of adult male pop 15

MP Baseline: Quality of Life 16 Figures exclude participants who did not respond to the relevant questions. Findings on the 2000 Victorian Validation Study are reported in Australian WHOQOL Field Study Centre (2000 p.26).

MP Baseline: Deprivation & Social Exclusion 78% couldn’t afford dental treatment if needed; 80% unable to afford prescribed medicines Causes of social isolation (short & medium term accommodation respondents) Lack of money: 81% Lack of own transport: 71% Absence of supportive family: 70% Family related problems: 66% Lack of friends to provide support: 60% Lack of involvement in community/sport: 49% Mental health: 37% Physical health: 31% 17

Intergenerational Homelessness Survey (HIS) 18

Prevalence of Intergenerational Homelessness, by Sex

Parental Experiences of Jail, Stays in Hospital and Problematic Drug and Alcohol Use While Growing Up

Parental Experiences of Jail, Stays in Hospital and Problematic Drug and Alcohol Use While Growing Up, by Indigenous Status

IHS – Respondent Problems 23 Lifetime experiences of problems among respondents (select indicators only). Feeling depressed, anxious or stressed highest rating in terms of seriousness of lifetime problems. Proxy of Comorbidity: 20 per cent of respondents cited a serious alcohol or other drug problem (at some point in their lives) and a serious problem of feeling depressed, anxious or stressed (at some point in their lives)

IHS – Respondent A&OD and Depressed, Anxious or Stressed 24

Comorbidity and Other Associations Those respondents with (proxy of) comorbidity are much more likely (than those without comorbidity) to …have experienced homelessness first prior to the age of 12 …have experienced primary homelessness at some point in their lives …have experienced their parents argue with each other all the time …have seen or heard their parents physically harm each other or threaten each other with a weapon all the time …left home more often because of violence between parents (with a slightly greater chance of being residential and foster care) …have run away from home more and done so more often 25

Comorbidity and Other Associations …consider they have had at some point in their lives a serious problem with Gambling Keeping bad company Being bored Being lonely Repeating the same mistakes Losing their temper Managing their money/debt Getting on with their family Dealing with the authorities 26

What is integration?

Motivation Effectiveness of Service Delivery A fragmented human services system may: Result in gaps in service delivery; Pull clients in different directions; Provide clients with conflicting advice and support and treatment options; Produce ineffective referral pathways; and, Impose unnecessary transaction costs on clients as they navigate the human services system

MotivationCont… Effectiveness of Service Delivery but potential issues … Service integration may be costly (high setup costs and high transaction costs for agencies), unwieldy and time-consuming Possible loss of control/autonomy among agencies Differing values of organisations Difficulties in transmitting specific knowledge among partnership members Free rider problems Requires leadership and good management particularly when partnerships is ‘forced’ on to a set of agencies with different cultures and practices Loss of the benefits of specialisation in service delivery.

Ends and means Service Integration Client Integration Client Outcomes Other factors

DAO Residential Outocmes Improvement in clients wellbeing (physical, mental, emotional, social, standard definition) in the: Short term(3-6 months post treatment) Long term (+6 months post treatment) Greater awareness/understanding of own drug use and factors impacting upon Improvement in the clients capacity to relate to family and function in the community Short term(3-6 months post treatment) Long term (+6 months post treatment) 31