1. B Miles Women’s Foundation is a newly formed entity following the unification of two previously separate organisations; City Women’s Hostel – opened in 1989 and B Miles Women’s Housing Scheme – opened in 1985 Both organisations provided accommodation and support to women in Sydney who were homeless and living with a mental illness. 1

2. July 2010 – June 2011: 13,142 beds were occupied at BMWF equals 13,142 times a woman slept in safe accommodation 2

3. Partner Organisations St Vincent’s Mental Health Eastern Suburbs Mental Health PHAMS NEAMI Mission Australia Women’s Housing Company Bridge Housing Metro Housing Family & Community Services 3

4. Networks and Collaboration Working with mental health services BMWF – Specialist Homeless Service (SHS) - Funded by Family & Community Services HASO – Residential Tenancy Agreement 2010 – tenants Presentation : Why is it necessary to establish networks and collaborate? One tenant’s story The process of establishing a network of services to address and support the tenant. Support Outcomes 4

5. Establishing networks and collaborating with other services: tenant support Tenant support Mental illness – life long condition can impact a person’s social, emotional, mental and physical well being. Continuity of care – throughout each stage of recovery (as the person’s needs change and they progress in their recovery we need to have resources available to provide appropriate support) Isolation - one of the effects of living with a mental illness (relapse prevention strategies need to include a network of resources to support the person – building a community, social group, service providers – collaboration 5

6. Establishing networks and collaborating with other services: service support Limitations – address the service limitations. Capacity building Build a model of continuous care Knowledge – increase our knowledge base by collaborating with wider networks. Enhances care options Risk Management – increases the opportunity to develop more robust risk management strategies. Managing risk internally: collaborate – what other resources and services are required to enable the organisation to support the tenant? Reduces exclusions 6

7. Establishing Networks : assessment of tenant and service Tenant Assessment - support needs, self management, existing supports Service Assessment (RAT 2005) - what does the service need to support the tenant? - what resources are required to manage potential risk? - what networks are required to address risk factors to develop an appropriate level of support? 7

8. Mary’s story Referred to HASO from a mental health rehabilitation service - six months stay 52 years of age. 20 year history of chronic homelessness – sleeping rough CBD, itinerant Mental Health: chronic Schizophrenia Physical health: diabetes T2, heart disease. ICU pneumonia and cardiac failure. difficulties recollecting life events. Family - five children and three siblings: no contact with family. NOK could not be confirmed. 8

9. continued Social supports – limited two friends Financial: Financial Management Order. Key card – access to account 2007 Housing History: public housing, home ownership (no records). Limited information from accommodation services. Mary believed she was legally ordered to remain homeless. Domestic living skills: assistance with cooking, cleaning and purchasing essential items Life skills: immense resilience and resourcefulness, social, open to support 9

10. Collaborative approach Acute care for one month Referral to mental health rehab – six months CTO and Financial Management First period of stability in 20 years Transition from rehabilitation Continuity of care: crucial to maintaining positive mental health recovery Important to source a network of services to develop an appropriate support plan An opportunity to end homelessness 10

11. Assessment Mary attended the HASO assessment with the SW and OT from the rehab unit. Occasionally appeared thought disordered and exhibited a limited understanding about the effects of her illness – consistent with her initial referral Mary advised she was in ICU as she had been injected with mustard and pepper. Mary articulated needing assistance with transport and shopping. Mary stated she was glad that her medication would be arranged for her in blister packs as it was confusing – nine medications. Mary stated she did not choose to be homeless and was looking forward to a place to stay. 11

12. Assessment continued Support staff advised Mary was at risk of de- compensation if structured routines weren’t in place Difficulties in regularly attending services and support Difficulties in self advocacy Limited insight into her illness and the impact this has on her functioning. Assessment Outcome – Mary required a high level of support due to her complex needs and lengthy history of homelessness. Mary was assessed to be at high risk of physical and mental health relapse if adequate support systems were not established. 12

13. Service assessment HASO low support provider 1- 2hrs a week * Mary required high support* The service needed to arrange a greater level of support. What we could provide – housing, access to a social network, support worker, limited transport, coordinate a support plan of services What we couldn’t provide – support beyond 1-2 hours a week, clinical support, daily cooking, transport to all appointments. 13

14. Network of Services Housing and Support Options: accommodation, social activities and follow up with long term housing application. NEAMI: lead case management, goal setting and planning, daily living activities. Maroubra Community Mental Health Centre: mental health case management, medication management, CTO communication, Psychiatrist. Bondi Community Rehab : cooking, shopping and community access. OPC: Financial management 14

15. Collaboration Effective collaboration required coordination, clarity and commitment. Coordination: organise meetings and follow up support plan. Transparent plan required to ensure no overlap of services MOU between HASO and NEAMI provided a commitment to collaborate and clearly defined the roles of each service. Regular reviews: between service providers and Mary 15

16. Collaboration continued Graded transition at each stage of recovery: - exiting rehabilitation - treatment management - financial management - levels of support - living skills progress (regular reviews prior to introducing change to ensure appropriate timing) 16

17. Outcomes 2 years on and Mary has maintained her housing, awaiting long term housing. Mary’s level of support has reduced to 2-3hrs a week. Mary attends most HASO social activities - art therapy, swimming, day trips, art gallery outings. Will continue to attend activities as an ex tenant – sense of community! Mary is no longer on a CTO Mary is managing her own finances Continues to be linked up with clinical supports Uses public transport and cooks independently 17

18. Outcomes continued Receives minimal assistance with shopping Mary has ongoing contact with her support networks and has nominated key support agencies. These agencies communicate with each other, so if Mary exhibits signs of potential relapse a prevention plan is followed. Mary has developed a few friendships with other tenants. 18

19. Mary HASO 1 – 2 Hours per week CTO MCMH Fortnightly BONDI REHAB Once a week OPC NEAMI / MISSION 5 Hours a day, 7 days a week Networks 19

20. Mary HASO -- Activities 1 – 2 hours per week -- regular phone contact CASE MANAGEMENT MISSION 1 – 2 hours per week MCMH CLINICAL SUPPORTS Fortnightly 20

21. Homelessness Prevention Physical health Mental health relapse Maintained housing Hospital visits Supported care model 21

22. Sense of a Goose In the fall when you see geese heading south for the winter flying along in the 'V" formation, you might be interested in knowing what science has discovered about why they fly that way. As each bird flaps its wings it creates an uplift for the bird immediately following. By flying in a "V" formation, the whole flock adds at least 71% greater flying range than if each bird flew on its own. People who share a common direction and sense of community can get where they are going more quickly and easily because they are travelling on the thrust of one another. Author Unknown 22

23. Contact City Women’s Supported Accommodation 02 9360 4881 kara@bmiles.org.au PO Box 1132 Darlinghurst NSW 2010 Housing and Support Options 02 9317 0400 zed@bmiles.org.au 345 Gardeners Road Rosebery NSW 2018 www.bmiles.org.au 23