A Summary Report of the Implementation of

Occupational Therapy and Personal Care Growth

Funding in the Loddon Mallee Region, Victoria.

February 2015

Home and Community Care

(HACC) Organisations Working

Together to Improve Client

Outcomes

Home and Community Care Program, Victorian

Department of Health & Human Services

Prepared by Julie Cairns

Project Officer

Cobaw Community Health

Cobaw Community Health

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Introduction ............................................................................................................................................ 2

Background ......................................................................................................................................... 2

A Loddon Mallee Regional Approach to HACC Growth Funding ............................................................ 3

Supporting partnership work – a local approach ............................................................................... 3

Project Objectives for the First 12 Months ......................................................................................... 3

The Project Officer Role ...................................................................................................................... 4

Introducing the Partnerships .............................................................................................................. 4

An overview of approaches and progress across the region .................................................................. 5

Building Partnerships .......................................................................................................................... 5

Unique approaches to collaborative practice ..................................................................................... 6

Client Intake and Assessment ............................................................................................................. 7

Client Planning .................................................................................................................................... 7

Working with clients ........................................................................................................................... 8

Staff capacity building ......................................................................................................................... 9

Key Achievement .................................................................................................................................. 10

Barriers and Challenges ........................................................................................................................ 10

Enablers ................................................................................................................................................. 11

Future Opportunities ............................................................................................................................ 11

Acknowledgements:.............................................................................................................................. 12

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Introduction

This report offers a summary of the implementation of funding to support local partnerships between Home and Community Care (HACC) service providers in the Loddon Mallee region of Victoria, with a focus on Occupational Therapy and Personal Care. The report captures the work undertaken by participating organisations, and summarises the strategies put in place to support local planning and build positive client outcomes.

Two detailed project reports were developed, offering a comprehensive over view of the implementation of the funding in the north and south of the Loddon Mallee Region. This report provides a snapshot of the work, highlighting some of the common themes emerging across the region.

Background

$7.4 million of HACC growth funding was allocated to Occupational Therapy (OT) and Personal Care (PC) across all local government areas in Victoria in 2013. These funds were allocated to health services and councils to expand capacity to deliver the Active Service Model (ASM). In the Loddon Mallee Region this capacity building focus has not only considered expanding the amount of OT and PC service being delivered to HACC clients, but also building the capacity of all staff to work according to the ASM practice principles ie. doing more and doing differently. A facilitated planning approach has supported HACC agencies to work together to build the capacity of the local service system to meet client needs, translating the principles of the ASM more fully into practice.

Across Victoria the funding enabled health services to employ an OT to work in partnership with HACC assessment and personal care services in local government, along with additional funded hours for PC. The growth funding recognised that OT participation in assessment and planning can value add to the development of effective, person centred plans, and can support personal care staff to implement these plans.

The Active Service Model at a Glance “The Victorian HACC Active Service Model (ASM) is a quality improvement initiative that explicitly focuses on promoting person centred care, capacity building and restorative care in service delivery.” (ASM Prepare, 2010). The core principles which underpin the ASM Approach are:

People wish to remain autonomous

People have the potential to improve their capacity

People’s needs should be viewed in a holistic way

HACC services should be organised around the person and his or her carer

A person’s needs are best met where there are strong partnerships and collaborative working relationships between the person, their carer and family, support worker and between the service providers.

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A Loddon Mallee Regional Approach to HACC Growth Funding

One of the recognised barriers to the shift from ‘doing for’ clients to ‘working with’ clients was the translation of ASM principles into real service delivery changes. Whilst most HACC staff in the region had participated in training around the ASM, there remained work to do around considering what the ASM meant for allied health, personal care and domestic assistance services on the ground. The growth funding was viewed as a new resource to move further towards reablement approaches in HACC services. Building the capacity of partnerships, services and organisations for the benefit of clients was seen as a positive place to focus effort.

Supporting partnership work – a local approach

In the Loddon Mallee Region, the Department of Health developed a local approach to the implementation of growth funding informed by the following principles:

Capacity building – meaning both an increase in the amount of OT and PC services delivered to clients AND building the capacity of HACC staff to work from an ASM approach

Partnerships – HACC agencies working together, developing collaborative approaches and sharing skills and knowledge between organisational staff, will build services’ capacity to work from an ASM perspective and increase the amount and quality of service available to clients.

Local approaches – the local context is unique in each shire, therefore local approaches to the partnerships should be encouraged.

A project approach was introduced to support the implementation of the funding. The project aimed to support the development of local partnerships between OTs (and their employing agency) and Local Government HACC Assessment Services, and to identify and support the implementation of specific strategies to support health and wellbeing outcomes for HACC eligible clients. The project was funded for 12 months, employing two Project Officers – one in the Southern region and one in the Northern region. Both Project Officers were auspiced by a community health service, working 3 days a week. The southern Project Officer started earlier, finishing in July 2014, and the Southern Project Officer finished in November 2014.

Project Objectives for the First 12 Months

Five broad objectives for the implementation project were identified:

1. The OT/HACC assessment partnership is leading to improved outcomes for HACC eligible clients in line with the ASM.

2. Partnerships are strengthened to support HACC assessment and service provision to clients. 3. There is an increased understanding of the enablers and challenges impacting on the

implementation of the ASM and interdisciplinary practice, and strategies have been identified to address these issues – both within and across the LGAs if relevant.

4. There is an increase in knowledge/experience about the use of less formal staff learning experiences on the implementation of the ASM, including mentoring, reflective practice and peer support.

5. The project contributes to the knowledge base around ASM implementation in the HACC sector.

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The Project Officer Role

The following activities summarises the key elements of the work of the Project Officers over the 12 month period.

Communicating and exploring the intention of the funding with local partnerships.

Engaging stakeholders in the planning and implementation processes

Supporting partnership development and local planning.

Establishing two OT Networks (one in the North and one in the South) to share approaches, troubleshoot, resources, successes and general support.

Facilitating reflective processes with an emphasis on supporting local partnerships to notice change, consider what is working and why, and to identify and address challenges.

Capturing change: Supporting partnerships to notice their own achievements, and document the approach and outcomes of their work

Promoting sustainable practices.

Project Evaluation.

Although the Project Officers were employed by health organisations, working closely with key departmental staff was an important aspect supporting the work. The Project Officers worked as part of the HACC team at the regional office, and were in regular communication with the Program and Service Advisor and the ASM Industry Consultant. Consultation with these key staff around local approaches, and participating in broader HACC planning were two key (and valuable) activities supporting the work.

Introducing the Partnerships

In the Southern Loddon Mallee Region, there are six partnerships across 5 Shires:

Macedon Ranges Shire Council, Cobaw Community Health Service and Macedon Ranges Health Service

Mount Alexander Shire Council and Castlemaine Health

Central Goldfields Shire and Maryborough District Health Service

City of Greater Bendigo and Bendigo Health Care Group

Loddon Shire (South) and Bendigo Health Care Group

Loddon Shire (North) and Northern District Community Health

In the Northern Loddon Mallee Region, there are six partnerships across 5 Shires:

Buloke Shire Council and Bendigo Health Care Group

Campaspe Shire Council (North) and Echuca Regional Health

Campaspe Shire Council (South) and Rochester and Elmore District Health

Gannawarra Shire Council and Northern District Community Health

Mildura Rural City Council and Sunraysia Community Health Service

Swan Hill Rural City Council and Swan Hill District Health Service

Each Shire has a unique profile and the organisations involved had a varied history of working on joint projects together. At one end of the spectrum were organisations that had previously implemented successful co-location approaches in HACC, and at the other were organisations that had not undertaken a partnership approach at an operational level such as this in the recent past.

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The unique starting point for each organisation, required recognition from the outset that the implementation of the funding would look different in each shire. The remainder of this report captures some of the broad themes of the work across the region, including approaches to partnership development and collaboration, the work on the ground, what has been achieved and what has been challenging. This information has been gathered by the Project Officers through review conversations with each partnership. Detailed reports were developed for the north and south of the region and can be made available on request.

Note: It is important to note that this is the start of the story only, and future opportunities to build on the work have been identified by all partnerships.

An overview of approaches and progress across the region

Building Partnerships

A key opportunity supported by the growth funding was the opportunity for HACC services working in the same geographical area to consider how they could work more closely delivering services to HACC clients and sharing skills and knowledge to enhance practice. It is well recognised that for organisations to work effectively together time needs to be spent identifying and agreeing on the nature of the joint work and how this will be supported and monitored into the future. This work was described as partnership development, and the two Project Officers offered LGAs resource support for this planning.

The starting point for the work involved participating organisations in each shire coming together to consider the opportunity and together develop a local approach. For the majority of Shires, this was named as perhaps the most important and also the most challenging stage. A consistent theme during the review discussions was that the broad parameters for the funding provided by the Department of Health made it difficult to gain clarity around the expectations of the funding and what the work ought to look like on the ground.

With a varied history of working together, the organisations approached the development of partnerships in different ways. Some LGAs spent significant time planning the implementation of the work, and clarifying and documenting their partnership prior to commencing the work on the ground. Other LGAs had some initial planning meetings and decided to get going with the work and observe what opportunities emerged as staff from partnering organisations started working together. With this approach, the work got going more quickly on the ground but in most instances the supporting documentation was only beginning to ‘catch up’ towards the end of the 12 months.

Partnership experienced a range of challenges as they came together around this funding. These included:

Developing a shared vision for the work

Getting to know the capacities and constraints of the partnering organisation(s)

Geography and travel

Staff time to commit to the planning processes (given no additional funding was provided for this purpose)

Working with pre-existing funding boundaries that at times interrupted the opportunity for collaboration.

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At the end of the first 12 months, all 10 LGAs have commenced a collaborative approach to the work and are at varying points along the spectrum of supporting their work through documented partnership agreements. In some instances these partnership agreements are an attachment to an existing Memorandum of Understanding or protocol between the agencies, and in others a separate agreement has been negotiated. This documentation has been strongly encouraged by Project Officers as a key strategy towards supporting the sustainability of the work, and will continue to be monitored by the ASM Industry Consultants and Program and Service Advisers into the future.

Unique approaches to collaborative practice

Initially when the project scope was being developed by regional Department of Health staff there was an emphasis on co-location being the preferred method of approaching the joint work between agencies. Evidence indicates that co-location has been demonstrated to be an effective strategy to support interagency collaboration, as staff working alongside one another build effective working relationships, share knowledge and skills and develop systems and processes that work on the ground. By being based at the Shire offices, OTs would have the opportunity to get to know the teams of HACC staff, and participate in both formal and informal planning around clients and processes. There would be the opportunity for a two way exchange of skills and knowledge, supporting the capacity building of all staff involved in the work, and ultimately leading to improved service delivery to clients.

It quickly became evident that co-location was not an outcome in itself but was one of the identified methods to support collaborative practice. Some LGAs did take a co-location approach, and others developed different strategies to support staff from the two (or more) agencies to work together. Whilst the benefits of co-location have been recognised by those LGAs who chose this approach, perhaps the most significant factor identified to support the work moving forward has been the establishment of joint planning meetings. In all instances the key to developing a coordinated and collaborative approach to working with clients was establishing a regular, structured meeting time for OTs, Assessment Officers and in some instances community care team members to come together to plan their work around clients. This has included reviewing referrals, identifying opportunities/need for joint assessments between OTs and Assessment Offices; developing care plans; coordinating care and reviewing clients. The impacts of these meetings have included: better coordination of client assessment and planning; effective use of staff time; sharing skills and knowledge; increasing people’s understanding of other’s roles and the partner organisation; improved client care plans.

In one LGA, the establishment of a joint meeting was the clear turning point in the navigation of some challenging planning and partnership issues.

One of the other early challenges concerned the identification of the most appropriate client group to target through this joint work. Every LGA took a different approach, and in nearly every case, this target has changed as the work progressed. Starting points included:

All new clients

“ASM” clients, meaning those client who had clear reablement goals/potential

People exiting hospital or coming off Transitional Care Packages or Post Acute Care packages

Shower assessments

Longer term clients due for care plan reviews

Complex clients who could benefit from an OT reassessment

Meals on Wheels recipients.

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The establishment of the care coordination meetings (discussed above) has largely meant that a specific client target group is no longer relevant. The teams discuss all relevant clients during these meetings and have the flexibility to tailor their approach accordingly – a strong example of client focused planning, and fitting the services around client need rather than the client into a service system.

Client Intake and Assessment

Connecting the OTs in with Council intake and assessment processes was an important part of establishing the work. Department of Health staff strongly encouraged OTs and Assessment Officers to undertake joint assessments. The intention of this approach was to support staff from the two HACC agencies to get to know one another and increase their understanding of one another’s roles and approaches.

At the outset it was unclear whether joint assessments would be an ongoing approach to the work, or only part of the establishment phase. During the evaluation conversations it was clear that joint assessments were an effective starting point for the work, and all LGAs have since moved to this being a less frequent occurrence. As staff have established relationships and developed their understanding of one another’s roles, joint assessments no longer need to happen as a matter of course. The establishment of relationships between staff, along with the creation of planning meetings (as discussed in the previous section) means that assessment staff are more clear about the role of the OT and when a joint assessment, or a separate OT assessment is appropriate, and they talk together on a regular basis about the best approach to take with a new client or a client being reviewed.

All LGAs have developed distinct approaches to the management of referrals between agencies and the documentation that needs to accompany these processes. Duplication of information gathering processes from the client has decreased in some instances as a result of the collaborative work. Some LGAs are sharing referral and assessment documentation in part or in full, decreasing the amount of times a client is required to provide the same information. However it has been difficult to avoid the need for double documentation at both the health organisation and the local government organisation. This is largely due to the use of different client records systems and the need for each organisation to keep their own data. This has been one of the challenges repeatedly named by the OTs and one which takes a significant amount of time.

Client Planning

The key outcome for the growth funding in the region concerned the improvement of client outcomes, with a particular focus on reablement – supporting clients to continue to, or recommence doing as much as they can for themselves. Clearly the development of effective client support plans based on sound assessments is a key step in this process.

Towards the beginning of the 12 month period, some of the issues identified by HACC staff in the area of client planning included:

The opportunity to develop more specific goal directed care plans

One of the significant

contributions of the OT, noted by

one Shire Council , was the

support the OT has given staff in

developing their knowledge and

skills around Individual Support

Plans. The OT has shifted goal

setting from broader goals, to

more specific goals/strategies to

support clients to maintain or

improve their independence. This

in turn results in a more

prescriptive care plan that the

Direct Care Workers can put into

proactive. Feedback from the

Direct Care Workers has been

positive.

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Developing care plans that could be easily implemented by community care workers (this considered specificity, readability, clarity)

Engaging community care workers in the review of care plans

Accessing and valuing the knowledge and expertise of community care workers more fully – an untapped resource.

There has been a varied approach to tackling some of these issues, and it must be said that the LGAs who are still establishing their approaches have not necessarily reached the point of addressing the broader issues around care plans, but it is on the agenda. Some examples of approaches:

OT input into the Council care plan

Individual OT and Council care plans but fully shared and saved on the client systems in both organisations

A single care plan

Working with clients

At the centre of the project – working with clients to identify their goals and maximise their independence. How has the approach taken impacted on clients?

Evaluating the outcomes for clients has been a challenge for the organisations involved, and at the end of the first 12 months, robust outcomes measurement processes are only beginning to be shaped by some of the participating organisations. Project Officers have supported organisations to reflect on their progress, and notice change. Case studies have also been gathered as some qualitative evidence on the impact of the partnership work on clients.

Some of the progress for clients identified by participating organisations included – quicker service response time for OT; better coordination of services; reduced duplication of information provision; reablement focus strengthened; keeping people in their homes longer; outcomes for some complex clients improved; some clients have been able to reduce or cease use of HACC services.

Participating organisations noted that the changes to communication, client planning and the systems that support inter-agency work are leading to improved assessments and planning, and a broader suite of support types are being made to clients. The additional PC funding received by most council HACC services has been utilised in some instances to work in new ways. (?Gannawarra example?)

The OT received a referral to see

Daisy who had been previously

discharged from hospital. Daisy

had been independent with her

housework and personal care

prior to being in hospital and

wanted to get back to the same

level of independence. The OT

liaised with Daisy’s CCW about

idea’s to increase Daisy’s

independence with showering. As

a result Daisy progressed from

assistance with showering and

dressing to the CCW only

providing supervision. Daisy was

also able to shift from having her

washing done for her, through to

knowing how to work her new

washing machine from practicing

with her CCW. Daisy now does her

clothes washing and drying

independently.

This approach has ‘highlighted the

importance of acknowledging

CCW knowledge and valuing their

input with client intervention and

understanding the rapport the

carers already have with clients.”

OT

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Certainly this sphere of client outcomes evaluation is an area for improvement and future focus.

Staff capacity building

As mentioned in the introduction of this report, one of the hopes for the approach taken to implementing the growth funding was that staff capacity to work from the ASM perspective would be strengthened. The collaborative approach taken between organisations was the vehicle, sharing of skills and knowledge was the desired outcome.

The presumption appears to have been correct. One of the almost unanimous themes reported by HACC staff participating in this work has been an increase in skills and knowledge – about one another’s roles; about client assessment and planning; about new and different ways of doing things for the benefit of clients. Staff who have been involved so far recognise they have some new tools in their toolkit that will benefit their work with all clients into the future.

OTs and Assessment staff have been heavily involved in the partnership work so far, with community care staff involved to different degrees. LGAs have all identified the opportunity to build connections between the OT and the community care workers as important, with some LGAs having targeted this area more specifically than others. Examples include:

Formal information and training sessions by the OT at community care worker team meetings – including the role of an OT, ASM in practice, use of aids and equipment

Participation in smaller community care worker team discussions, offering secondary consultations or identifying opportunities for care plan reviews or an OT assessment

Joint home visits between CCWs and OTs – for review; to introduce a new session plan; use of equipment; build relationships between OT and CCWs.

OTs working from the council office at times when CCWs visit eg. to collect roster, creating opportunities for incidental conversations

CCW Team leaders/coordinators participate in the care coordination meetings in some LGAs

Whilst a formal evaluation of the effect of these approaches has not been undertaken, participating staff have commented that the OT input has supported CCWs in their role; has led to client concerns being addressed in a timely manner with new intervention ideas; has created opportunities for the CCWs to get to know the OT and increase their understanding of the OT role; and is better utilising the skills and knowledge of the CCWs in client planning and review.

The OT networks established to bring OTs together also became a valuable forum for OTs to share practice successes and challenges and provide peer support to one another. An important opportunity was created when the OTs involved in the work were invited to participate in the regional Assessment Officers forum in August 2014– a forum for all LGAs to hear about the work and trouble shoot any ideas. The feedback from this day was positive and has led to the development and implementation of key strategies to further enhance the work so far established.

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Key Achievement

Perhaps the most significant achievement to date has been the coming together of HACC organisations to explore new ways of working together – which in most instances has led to a more integrated and responsive approach than previously. This collaboration has built opportunities to share skills and knowledge between individual staff and between organisations, has led to systems and practice change and is influencing the way that services are being delivered to HACC eligible clients.

Barriers and Challenges

The first 12 months has seen participating organisations face a broad range of challenges, many of which have impacted on the commencement of the work on the group.

Getting clear about where to start – as mentioned previously, feedback from organisations indicates that the intentions of the funding were vague. Organisations knew there was an expectation that they needed to work together, but the focus of the work was unclear. This was a double edged sword. On the one hand the open ended aspect of the funding meant that local approaches could be adopted. On the other, developing a shared vision for the work was hard. A number of strategies were used to help resolve this issue:

Two workshops were planned (In Castlemaine and Swan Hill) to provide clear information about the funding and support organisations around partnership planning

PASAs became more directly involved in some partnership meetings to provide information about the funding

Project Officers provided support around planning

Organisations simply started, adopting an action reflection approach, funding that the needs and opportunities became clear once staff from the two organisations were working together.

Joint assessments between HACC Assessment Officers and OTs were a good starting point.

The challenge of change arose in many LGAs – change for staff, change of systems and processes, and changes to the way services are provided. Perhaps the most pervasive of these change management issues relates to client expectations of HACC services. Shifting from a ‘doing for’ approach to a reablement approach requires changing community expectations. This remains an unresolved challenge, but staff involved in this work had many examples of how this impacts on their work, and the need to respond to sometimes dissatisfied clients whose services are changing or are not what they were expecting.

Multiple partners in a single LGA was an issue in two LGAs, and the allocation of funding meant that more than one health service was involved. The challenge of developing some consistent processes whilst recognising the individual needs of each organisations has added a complexity to the planning for these shires.

Other challenges included:

“It is great having ready access to

an OT without having to wait.”

Assessment Officer

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the (unfunded) time taken to undertake the planning required for this work;

effective use of a 0.5 eft OT position in rural/remote regions;

ensuring that ASM is the business of all HACC staff

avoiding creating an ASM OT through this funding;

implementing goal directed care planning (moving beyond the training); capturing the work

Capturing the capacity building work/secondary consultation in the MDS (note: agencies were encouraged to keep a record of this time and include in the Annual Service Report)

Enablers

During review discussions with partnerships, a range of conditions were documented that assisted the implementation phase. These included:

• One size does not fit all – taking a local approach to a planning meant that each LGA could tailor their approach to their community and their local service system

• Making a start even when the focus had not yet become clear – simply getting going seemed to be an effective first step when organisations could not clearly see how the work could look on the ground. Front line staff were in the best position to see how the resources could best be applied to address needs

• Joint assessments often a key starting point in developing the relationship between organisations

• Establishing a structured communication meeting to discuss referrals, coordinate care and review clients (as discussed above)

• Formal and informal opportunities for staff conversations – equally important? The co-located OTs reported additional benefits to being based at the council offices, which included service provision opportunities that emerged from incidental conversations around the office. The co-located OTs described feeling like ‘one of the team’ at Council.

• Connecting with Community Care Workers built opportunities for information sharing, client review and capacity building (staff and clients)

• ‘Can do’ attitude – all staff at all levels • OT network meetings and OT participation in the Assessment Officers’ Forum

Future Opportunities

A number of opportunities for the future have been identified by agencies and inform their work for the next 12 months. As mentioned previously, Department of Health staff will continue to support and resource the local partnerships as they work towards some of the opportunities below:

• This work becomes business as usual, for all staff working in HACC • Ensuring partnership sustainability through clear agreements, policies and procedures • Broadening the scope of the OT role • More fully engaging community care workers in care plan reviews. • Building more networking opportunities for OTs and Assessment Officers • Ongoing education opportunities around ASM in practice • Share tools and documents developed through this work between participating agencies –

develop an accessible tool kit • Develop effective and manageable evaluation to measure the impact of this approach.

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Acknowledgements:

This report is a synopsis of many conversations and documents developed over the course of the last 18 months. The contribution and time of all partnering agencies, and of the many staff directly involved, is duly acknowledged.

Bendigo Health

Buloke Shire Council

Campaspe Shire Council

Castlemaine Health

Central Goldfields Shire Council

City of Greater Bendigo

Cobaw Community Health Service

Echuca Regional Health

Gannawarra Shire Council

Loddon Shire Council

Macedon Ranges Health Service

Macedon Ranges Shire Council

Maryborough District Health Service

Mildura Rural City Council

Mount Alexander Shire Council

Northern District Community Health Service

Rochester & Elmore District Health Service

Sunraysia Community Health Service

Swan Hill District Health

Swan Hill Rural City Council