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

The Victorian Department of The Victorian Department of Human ServicesHuman Services-Regions-Regions

QuestionsQuestions

The beginningThe 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

MACNI fundingMACNI funding

• Department of Human ServicesDisabilityChild ProtectionYouth JusticeHousing and Community Building

• Department of HealthMental HealthAlcohol and Drugs

• Department of Justice

Early scoping work 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

Early profiling – client Early profiling – client characteristics 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

What we wanted for What we wanted for individualsindividuals

• 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

What we wanted from the What we wanted from the systemsystem

• Greater collaboration, partnership, flexibility (“seamless”, “joined up”)

• Better use of service resources – “capacity building”

• Better use of financial resources – cost effectiveness

Elements of MACNIElements 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

The legislationThe 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

The eligibility criteriaThe 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.

The first model 2004-2009The 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

The MACNI service modelThe MACNI service model V1 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

Activity 1 June 04 to Activity 1 June 04 to 31 May 09 – regional level31 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..

Resolved at the regional Resolved at the regional levellevel-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

Case studyCase 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

Activity 1 June 04 to 31 May Activity 1 June 04 to 31 May 09 – MACN Panel09 – MACN Panel

• 84 referrals (from regions)• 79 determined eligible• 56 care plans determined• 39 care plans extended into second

year• 39 care plans concluded

Referral characteristicsReferral 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%

The first model – issues 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

QuestionsQuestions

The model in action (1)The model in action (1)

• Some practice benefits

Care plan coordinationState-wide focusInformation sharing provisions

The model in action (2)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

The model in action (3)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

QuestionsQuestions

External evaluation - KPMGExternal evaluation - KPMG

• 4 reports over 3 years• Final report February 2008• 4 “evaluation questions”

External evaluation (2)External evaluation (2)

• Improvement in individual outcomes? Yes

• Improvement in service coordination? Yes

• Adequacy of legislation? Yes• Achievement of cost-benefit? Not clear..

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

Internal review - snapshot Internal review - snapshot study (1)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

Snapshot study (2) - Snapshot study (2) - background databackground 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

Snapshot study (3)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

OUTCOMESOUTCOMES - Comparative data – key findings - Comparative data – key findings

0

20

40

60

80

100

Stable Housing Health & Well-Being

SocialConnectedness

Safety

MACNI Platform

%

Pre- MACNI

Post- MACNI

Key Findings (1)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%

Key Findings (2)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

More about the unsuccessful More about the unsuccessful outcomesoutcomes

• 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

What were the successes?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

What were the challenges?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

SustainabilitySustainability

• 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

The second model June 2009The 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

MACNI service model V2MACNI service model V2

The Future – the frameworkThe 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

The Future – making the The Future – making the decisionsdecisions

• 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

Some reflections on the Some reflections on the elements..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

Some things we haven’t Some things we haven’t done yetdone yet

• A good job for people from indigenous backgrounds

• A review from the perspective of service users

QuestionsQuestions