The Integrated Services Project (ISP): An inclusive model of intensive, transitional support for individuals with complex needs Don Ferguson and James Lim Sydney, Australia 21 October 2009

Overview of presentation Introduction How the ISP was developed The structure of ISP What we have learned Q & A

Before we start We acknowledge your expertise We are here to share our experience What we have to say or suggest here may not be applicable to your circumstances, but We hope to provide you with some ideas to support your thinking in this challenging area of human service delivery.

Introduction Illustration : Aboriginal Dreaming

Australia Queensland NSW 6.8M Northern Territory South Aust. Western Australia Vic Tas Aust. Capital Territory Victoria Tasmania Total population = 22M NSW 800,640 sq km 10.4% of continent Sydney 7.6M sq/km

Human Service & Justice Agencies - NSW Government Department of Human Services HEALTH Community Services HOUSING Juvenile Justice Aboriginal Affairs Dept of Corrective Services Police DISABILITY (ISP Lead) Justice & Attorney General’s Department

How the ISP was developed First Steps

Timeline of model development 1999 Taskforce established 2001 Literature review commissioned 2003 Survey of Human service agencies 2005, April NSW Government approves trial 2005, September First participants accepted 2004, November Project Director appointed

Model development continued… Literature review confirmed local experience: Rigid service inclusion/exclusion criteria Lack of capacity and incentives to be flexible in meeting individual needs Lack of identified lead agency with responsibility for case management and coordination of multiple services Lack of knowledge across services – confusion about roles and responsibilities, and how to access services Lack of effective communication between service providers (crisis-driven responses; rigid boundaries) Lack of access to specialist multidisciplinary expertise and tailored treatment options (eg drug and alcohol) Lack of accommodation options

Model development continued… Whole of government endorsement of ISP Pilot funding of $26M over 3-years provided by state Treasury commencing July Catchment area determined as Greater Sydney Minimum age of entry determined as 18 years New legislation not considered necessary All NSW Government human service and justice agencies drawn in to support project development and identification of individuals of highest need

Project Catchment GREATER SYDNEY Key facts Population: 3,637,500 Average age of residents is 35 years Area Coverage: 6376sq/km

Target Group Adults with high risk challenging behaviour, with one or more of the following diagnoses: mental health disorder intellectual disability acquired brain injury/impairment substance abuse who are blocking an acute mental health unit or respite service, homeless, or in gaol and experiencing significant barriers to accessing services and securing coordinated multi- agency support, where local support options have been exhausted.

The ISP Approach The ISP aims to: Improve a person’s housing stability, behaviour and social networks Improve coordination and capacity of local supports Reduce cost and impact of behaviour on self, others and services Contribute to evidence base on supporting people with challenging behaviour

The ISP Approach continued This is achieved through: The direct and immediate provision of time limited housing and support, as required, while working in partnership with each individual and their support networks to understand, plan and establish a more sustainable range of support from across their community and the specialist services system.

The Structure of ISP Sculptures by the Sea – Bondi NSW 08

Organisational context The ISP is hosted by the Department of Human Services’ Ageing, Disability and Home Care Agency. Located within directorate responsible for agency and whole of government development in support to people with an intellectual disability and a mental health issue, those with complex needs and challenging behaviour and those in, or at risk of, contact with the criminal justice system. Also provides specialist state wide intellectual disability services via a tertiary behaviour intervention service and an accommodation and support services program for people with intellectual disability exiting the criminal justice system. Whilst ISP not focussed on people with an intellectual disability, the close alignment with the work of the directorate provides a clear avenue for influencing the wider service system.

Project Governance Structure Human Services CEO’s Chief Executive ADHC Project Director Support Team Area/ Regional CEOs Local Agencies Management Committee Reference Groups Senior Officer Groups Accom

Project Organisational Chart

Summary of Service Pathway 0 month 3 12 Timeline months

Service Pathway: Stage 1 of 3 Support TeamAccommodation In situ eg Corrections, Mental Health ISP acomm unit Assessment Individual Case Plan Interagency Agreement Behaviour and Health Support Local service supports Co-Case management and support as agreed through case plan Stage 1

Service Pathway: Stage 2 of 3 Support Team Accommodation In situ e.g. Corrections, Mental Health ISP accom unit Own home/ public housing Assessment Individual Case Plan Interagency Agreement Behaviour and Health Support Individual Case Plan Implementation Trial Support Strategies Reconnect/ Establish Support Network Local service supports Co-Case management and support as agreed through case plan Stage 1 Stage 2

Service Pathway: Stage 3 of 3 Support TeamAccommodation In situ eg Corrections, Mental Health ISP accom unit Own home/ public housing Assessment Individual Case Plan Interagency Agreement Behaviour and Health Support Individual Case Plan Implementation Trial Support Strategies Reconnect/ Establish Supports Phase out and exit Local service supports Co-Case management and support as agreed through case plan Stage 1 Stage 2 Stage 3 Supported accommodation Own home/ public housing

The role of substitute decision making NSW chose to rely upon existing legislation and decision making bodies for supporting people through the ISP. In particular: The Guardianship Tribunal The Mental Health Review Tribunal The NSW Public Trustee & Guardian They provide a strong source of advocacy for individual participants accountability for the ISP a significant role in shaping the project through membership of the ISP interagency reference group.

ISP Accommodation Models Assessment unit House with self contained unit Twin house A small block of units Semi rural house with on-site vocational training Drop in support and co tenancy Crisis accommodation Some properties purchased and some leased, all modified to some degree to better meet individual needs

Integrated Services Project – Accommodation Options

Accommodation Considerations What has worked? Diversity and immediacy of accommodation options Staffing model used to support complex needs Allocation of key workers, psychologist & other professionals for ongoing assessment and support during transitional placements.

Accommodation Considerations What has worked? Flexibility around support needs with focus on promoting choice within structure, development of life skills and vocational options Planning towards the development of consistency, stable accommodation and identification of longer term needs Cost effectiveness of pooling services and resources to support complex cases – these individuals are not our exceptions

Accommodation Considerations What has been some of the challenges? Assessment unit industrial issues too restrictive Too expensive became early unintended focus of program and all- consuming Community acceptance

Accommodation Considerations Some more challenges Timeframe restrictions and staggered release of funding due to pilot status of project, b ig impact on issues such as staff employment stability intake and placement planning Transition to next phase or locating appropriate service providers for service continuation On the flip side: ISP allows us to put individual need ahead of service access issues – service fit becomes our problem not the individual’s

Characteristics of participants 38 participants Mean 36 years, Median Women, 21 Men, Indigenous n = 3 CALD n = 12 ESB n = 23 30

Housing prior to ISP (n=38) 31

Characteristics of Participants continued Mental health disorder n = 33 (87%) Intellectual impairment n = 26 (66%) Alcohol and other drugs n = 22 (58%) Acquired brain injury n = 15 (39%) Physical disability n = 14 (37%)

Case Example 1 (NR) NR had a tendency to gravitate back to high risk environments She was very vulnerable to abuse and exploitation by others (i.e. persuaded to engage in offending behaviour – break and enter – used as the “fall guy”) She had frequent contact with the criminal justice system Soliciting / Prostitution Verbal aggression and property damage Extreme emotional lability Lack of impulse control

Case Example 1(NR) Assessment findings Poor short term memory and impulse control Negative impact of multiple placements No length of meaningful engagement with past providers Systems issues – coordination failure, police, courts, disabilities, mental health What we did Provided a stable place to live with skilled and supportive staff Introduced comprehensive behaviour support strategies Established roles and responsibilities of mental health and disability support services Developed cross agency response plans to reduce contact with criminal justice system Negotiated long term service provider and funding source Provided intensive training to service provider Handed over of responsibility of case plan and interagency collaboration Ultimately resulting in successful sustainable support model and exit of ISP

Case Example 1 (NR) Key individual outcomes Police reported a significant reduction in crime rate in local govt area and attribute much of this to one individual… NR has continued to spend greater lengths of time in the community and less time in custody. She has a higher engagement with her support services and has commenced work at supported employment, providing her a wonderful new source of income.

Case Example 1 (NR) Summary NR is a 29 year old female of Lebanese descent. She has a diagnosis of  Moderate Intellectual Disability,  Borderline Personality Disorder and a  Possible underlying mood disorder. Oppositional behaviour and absconding from home at a young age. Living on ‘the streets’ by age 13yrs. Frequent incarceration in Juvenile Justice detention centres and adult correctional facilities for theft related charges. History of placement breakdown and disability services unable to provide adequate service model to meet client needs, new placement Released on bail and charges dismissed over 50 times successive release from custody on grounds of unfitness to plea. Disengaged from family.

Examples of the diversity of participants Young women with no comprehension of English, native language undetermined, living in a short stay hostel with uncontrolled psychosis and no known supports or family Homeless elderly male with repeated contact with police, aggression, AOD, previous self inflicted gun shot wound head injury, multiple untreated health conditions stuck on post surgical hospital ward. Young women with a moderate intellectual impairment and personality disorder, long history of short periods in custody for low level offences and no stable community support Young Indigenous male, mild cognitive impairment, IV drug use, HIV positive, living in unsustainable HIV related dementia service Elderly male, 20+ years in custody for murder, previous diagnosis of anti social personality disorder, suffered brain trauma in custody with continued mental and physical deterioration

Indigenous participants Over represented in criminal justice and welfare systems. Recognition of past poor practices and tainted history Focus on establishing trust Must change our thinking our language and our engagement with individuals, families and community ISP seeks support of Community Elders and works in partnership with Indigenous services Strives to establish culturally appropriate supports and individual outcomes. National Sorry Day 26 May

What have we learned: Bridging our service gaps Sydney Harbour Bridge

Concepts of service fit and behavior: Description of all participants on entry to ISP High level behaviour Poor service fit

Concepts of service fit and behavior What we found Group 3: 22.5% High level behaviour good service fit Group 4: 12.5% High level behaviour poor service fit Group 1: 40% Lower level behaviour good service fit Group 2: 25% Lower level behaviour poor service fit

In other words No claim to be a silver bullet

Project evaluation: Some results to date ISP has had a positive impact on individuals and services Behaviours, risk, health, quality of life and “service fit” 18 individuals have successfully moved through and exited the Project to long term service options with clear agreements in place for an additional 12 participants Flexible needs based approach has enabled trials of innovative service models No appropriate service fit for 8 individuals A small number of recurrent individual funding packages have been approved for release each year Aim is to help resource extra-ordinary support arrangements for such individuals and reduce likelihood being stuck in the ISP

Project evaluation: Some results to date Service Costs Approximately $200,000 per annum per person compared with $375,000 average cost pre-ISP Behaviours Reduction in frequency and severity, especially for those who have exited (36-42% decreases) Service Use Decrease in hospital bed days from 47 to 2 days on average over 12 months period and reduced presentations to Emergency Departments from 24 to 4 presentations for 12 months Decrease in number of days of imprisonment of 108 to 21 for 12 months

Elements of an effective service model Timely identification of people and response to need High quality, clear and accountable case management Stable and flexible supported accommodation options Specialist multidisciplinary assessment, formulation clinical, and behavioural interventions Individualised treatments such as D&A, anger management, community participation and vocational programs Interagency agreements and collaboration based on effective communication In others words, from our experience, what the literature said was True!

We encountered barriers Integrated model of service delivery – “one stop shop” Work force management (recruitment, retention and support initiatives) Funding implications and impact on work force management Extra ordinary complex client – implication of service moulding / replication of ISP with other providers Strategic alliance within the Dept. – level of “guided autonomy” and program sponsorship, as ISP was charting into “risk prone and unfamiliar territories in human services Sound risk management practices Timelines and intake processes – start small … Results continued

Systems Change and ISP influence Effective mechanisms for resolving service support issues at local and senior levels Instrumental in developing of MOU between Mental Health and Disability Services Participate in Mental Health Complex Needs Standing Committee System requires greater flexibility in funding and program boundaries Working to supplement and expand existing programs Supporting development of revised intake criteria to close the gaps Skilled workforce and open minded decision making Promoting new mindsets and culture of inclusion through staff training and sharing the learnings with key decision makers

Tree of Change and Influence

Q & A session Questions