1. Department of Human Services Multiple and Complex Needs Initiative Victoria, Australia Outside In Conference, St John’s, NL, Canada 20-21 October 2009

2. Department of Human Services

3. The Victorian Department of Human Services -Regions

4. Questions

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

6. MACNI funding Department of Human Services  Disability  Child Protection  Youth Justice  Housing and Community Building Department of Health  Mental Health  Alcohol and Drugs Department of Justice

7. Early scoping work Two years of consultation and data collection 2002-2004 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

8. 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  91% socially isolated, little family contact  55% chronic health problems

9. 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

10. What we wanted from the system Greater collaboration, partnership, flexibility (“seamless”, “joined up”) Better use of service resources – “capacity building” Better use of financial resources – cost effectiveness

11. Elements of MACNI Regional coordination mechanisms (within government) A legislative framework Assessment, planning, and intensive case management function (in the funded sector) Time-limited Client attached dollars

12. 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

13. 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.

14. 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

15. The MACNI service model V1 Existing Service System DHS Region Regional Gateway contact Regional Co-ordinator (consultation/problem solving, referral, local panel consideration, RD sign off) Multiple and Complex Needs Panel (Eligibility, Care Plan, Care Plan Coordinator, Care Plan Review) 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 3 2 4 5 1

16. 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, leading to..

17. 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

18. 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

19. 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

20. Referral characteristics Appearance of a mental disorder – 88% Substance abuse issues – 72% Intellectual impairment – 59% ABI – 50% Some form of homelessness – almost 40% In custody/prison – 20%

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

22. Questions

23. The model in action (1) Some practice benefits  Care plan coordination  State-wide focus  Information sharing provisions

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

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

26. Questions

27. External evaluation - KPMG 4 reports over 3 years Final report February 2008 4 “evaluation questions”

28. External evaluation (2) Improvement in individual outcomes? Yes Improvement in service coordination? Yes Adequacy of legislation? Yes Achievement of cost-benefit? Not clear..

29. External evaluation (3) External evaluation (3) 76% reduction in presentations to hospital emergency departments 34% reduction in number of hospital admissions 57% reduction in hospital bed days

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

31. Snapshot study (2) - background data Mental Health Services the largest referrer - 31% Age:  31% - under 25 years,  53% - 26-45 years,  16% - over 45 years 3:1 ratio males to females

32. Snapshot study (3) 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

33. OUTCOMES - Comparative data – key findings

34. Key Findings (1) Successful client outcomes for 13 of the 19 57% overall improvement across all 4 platforms Pre- MACNI Post- MACNI % improve Stable Accomm 0%63% Health/ Wellbeing 10.5%80%69.5% Social Connect 4%55%51% Safety28%74%46%

35. Key Findings (2) Service system:  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

36. More about the unsuccessful outcomes 4 males & 2 females 4 out of 6 transitioning from youth to adult services 3 out of 6 - indigenous backgrounds 5 out of 6 - histories of Youth Justice/Child Protection 5 out of 6 had non-Indigo Care Plan Coord. 4 - jail, 1 – streets, 1 – hospital – EVEN SO: ALL showed improvement during MACNI

37. 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

38. 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

39. 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

40. 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

41. MACNI service model V2

42. 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

43. 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

44. 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

45. Some things we haven’t done yet A good job for people from indigenous backgrounds A review from the perspective of service users

46. Questions