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Department of Human Services
Multiple and Complex Needs Multiple and Complex Needs InitiativeInitiative Victoria, AustraliaVictoria, Australia
Outside In Conference, St John’s, NL, Canada 20-21 October 2009
Department of Human Services
33. The Victorian Department of . The Victorian Department of Human Services - RegionsHuman Services - Regions
4. Questions4. Questions
5. The beginning5. 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. Early scoping work 6. 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 paHighest cost package in 02/03 was $643,000
7. Early profiling 7. Early profiling – client characteristics – 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
8. What we wanted for individuals8. 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
9. What we wanted from the 9. What we wanted from the system (1)system (1)
• Greater collaboration, partnership, flexibility (“seamless”, “joined up”)
• Better use of service resources – “capacity building”
• Better use of financial resources – cost effectiveness
10. What we wanted from 10. What we wanted from the the system (2)system (2)
Capacity building means:Stepping up..crossing boundaries..Care plan coordination:• 50% provided by Indigo
- State-wide, auspiced by Western Region Health Centre
• 50% provided by local agencies
11. What are the most 11. What are the most important important things?things?
• Commitment
• Resource
12. Elements of MACNI12. Elements of MACNI
• Regional coordination mechanisms (within government)
• A legislative framework• Assessment, planning, and intensive case
management function (in the funded sector)• Time-limited• NOT a crisis response – planned intervention• Some client attached dollars
13. The legislation13. 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” level
14. The eligibility criteria14. 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.
15. The first model 2004-200915. 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
16. 16. The MACNI service modelThe MACNI service model V1V1Existing 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
17. Activity: 1 June 04 to 31 May 0917. Activity: 1 June 04 to 31 May 09- regional level- 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 by regions
18. Resolved at the regional level 18. Resolved at the regional level – Case study– 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
19. Case study19. Case study-What the region did-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
20. Activity: 1 June 04 to 31 May 09 20. Activity: 1 June 04 to 31 May 09 – MACN Panel– MACN Panel
• 84 referrals (from regions)• 79 determined eligible• 56 care plans determined• 39 care plans extended into second
year• 39 care plans concluded
21. The first model – issues 21. The first model – issues
• Very slow start up; steep learning curve
• Developing shared understanding of roles and responsibilities:PanelAssessment/care plan development/care plan
coordination Regional coordination and local capacity
22. Questions22. Questions
23. The model in action (1)23. The model in action (1)
• Some practice benefits
Care plan coordinationState-wide focusInformation sharing provisions
24. The model in action (2)24. The model in action (2)
• Care Plan Coordination
Is different from case management or direct service
Is vital when there are multiple services involvedHas “dual beneficiaries”: the clients, and the
system Is a good tool for sharing riskNeeds to be recognised and resourced1:5 worker to client ratio
25. The model in action (3)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 neededIts harder in the rural areas to do a good
job
26. Questions26. Questions
27. External evaluation - KPMG27. External evaluation - KPMG
• 4 reports over 3 years• Final report February 2008• 4 “evaluation questions”
28. External evaluation (2)28. External evaluation (2)
• Improvement in individual outcomes? Yes
• Improvement in service coordination? Yes
• Adequacy of legislation? Yes• Achievement of cost-benefit? Less clear
29. External evaluation (3)29. 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)30. Internal review - snapshot study(1)
• “Snapshot” July-Sept 08
• Client status pre and post MACNI was assessed against the four MACNI platforms:
Stable accommodationHealth and well-beingSocial connectednessSafety
31. Snapshot study (2)31. Snapshot study (2)
• 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
32. Outcomes: 32. Outcomes: Comparative data – key findingsComparative data – key findings
0
20
40
60
80
100
Stable Housing Health & Well-Being
SocialConnectedness
Safety
MACNI Platform
%
Pre- MACNI
Post- MACNI
33. Key Findings (1)33. Key Findings (1)
• Successful client outcomes for 13
of the 19 • 57% overall
improvement across all 4 platforms
Pre-MACNI
Post-MACNI
%improve
StableAccomm
0% 63% 63%
Health/Wellbeing
10.5% 80% 69.5%
SocialConnect
4% 55% 51%
Safety 28% 74% 46%
34. Key Findings (2)34. 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
35. More about the unsuccessful 35. More about the unsuccessful outcomesoutcomes
4 out of 6 transitioning from youth to adult services
5 out of 6 – histories of Youth Justice/Child Protection
• 3 out of 6 - indigenous backgrounds• 5 out of 6 had non-Indigo Care Plan Coord.
36. What were the successes?36. 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
37. What were the challenges?37. 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
38. Sustainability38. 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
39. The second model June 200939. 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
Existing service system
DHS Regions RCOsConsultationReferral to MACNI.
CentralDetermines
eligibility
DHS Regions Local Panels: Approve care plans Nominate plannerApprove $$
Planner local or state wide service providerup to 3 yrs
DHS RegionsReview and monitor care
plans
Existing service systemCentral
Extra $AdviceReview
40. MACNI service model V240. MACNI service model V2
41. The Future – the framework41. 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
42. The Future – making the decisions42. 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
43. Some reflections on the elements..43. 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
44. Some things we didn’t do44. Some things we didn’t do
• A good job for people with indigenous backgrounds
• A review from the perspective of service users
45. Questions45. Questions