Right intervention at the right time: working with complexity, mental health and disability in

Victorian compensation settings

Karen Sait, Health & Disability Strategy Group

4th Australasian Compensation Health Research Forum

19 November 2014

Focus of presentation

1. Victorian compensation schemes – the Transport Accident commission (TAC), and the Victorian Workcover Authority (VWA)

2. Complexity, mental health and disability 3. Strategy and implementation 4. Sharing learnings 5. Next steps

Systems approach “We know from national surveys that the public consistently rate mental health as one of the top priorities they want governments to tackle. The work of beyondblue, SANE, Mental Health Australia and others has ensured that mental illness is now out of the shadows. Everyone knows that mental ill health will affect us all one day” Professor Patrick McGorry, Executive Director Melbourne University’s Orygen Youth Health Research Centre

Compensation = Complexity Research shows poorer overall outcomes of individuals who have a compensation claim: – Barriers to treatment and recovery outcomes

due to pressures and uncertainty regarding claim acceptance

– Often compounded for those with mental health, pain, other issues → ongoing disability and dependence

Compensation Definitions

1. Primary mental injury (no physical injury) - post traumatic stress, nervous shock/stress (with or without proximity to the accident or injury), adjustment disorder, stress and related anxiety, depression

2. Secondary mental injury consequence of physical

injury and often related to pain – anxiety, depression

3. Persistent Pain - “constant daily pain for a period of 3 months or more”- may lead to secondary mental injury due to delay in identification/treatment; and requires different yet complementary treatments

4. TBI/ABI (traumatic/acquired brain injury) – may have pre-existing mental health and/or other issues

The TAC and the VWA 1. ‘No fault’ schemes underpinned by legislation:

‒ Transport Accident Act 1986 legislation

‒ Workplace Injury Rehabilitation and Compensation Act 2013 (plus safety legislation)

2. Similar health and disability issues and shared providers

3. Committed to efficiency and collaboration regarding expertise, capability and resources

4. Continually strive for outcomes for injured workers and clients through innovation and adaptation

Transport Accident Commission ‘Recovery’ and ‘Independence’ Branches. Annually: ~19,000+ new claims

~45,000 people supported with services and benefits

~Road trauma estimated to cost more than $4 billion

Independence - 3% of new claims and 70% of outstanding liabilities

Compulsory transport related personal injury insurance

Owned by Victorian Government with independent Board and ~800 staff. Headquarters Geelong. Key areas:

1. Prevention: promote road safety and reduce accidents

2. Response: internal claims management - treatment and benefits for people injured in transport accidents

Victorian Workcover Authority Primary role of regulator ~270,000 workplaces in Victoria

~3 million workers covered

~30,000 claims each year

~90% of claims musculoskeletal

~Payouts of about $1.5 billion

Owned by Victorian Government with independent Board and ~1000 staff. Headquarters Melbourne. Self-funded from employer premiums. Key areas:

1. Enforcement: prevent workplace injuries

2. Prevention: OH&S and reduce injuries

3. Response: claims management by five Agents – Allianz, CGU, QBE, Gallagher Bassett and Xchanging plus TAC for those with catastrophic injuries

Health & Disability Strategy Group (HDSG)

Shared TAC and VWA service to meet corporate

objectives of both: • client outcomes; • client experience; and • scheme viability

Collaboration and partnerships:

internally and with health and disability sectors to develop and implement new

models and strategies

Evidence and research: internal and external health

and disability data, research, trends, and client and provider evaluations

Outcomes focussed: rehabilitation and support at reasonable and sustainable costs - focused on return to

work, health and independence: ”life back on track”

Emerging Scheme Issues

– Mental injury claims up from 36% to 80% ~7 years; 1 in 3 clients with physical injury and 4 of 5 pain claims secondary

– Referral post injury 12 months (median of 7 months);

more females (54%) than males (46%) and ~25% by 30 – 49 years

– TAC clients <30% impairment who also claim some

mental injury benefits: cost on average double their peers 3 times more likely to claim income post 12 weeks 10 times more likely to claim income for full 3 years

Snapshot Scheme Experience: overlap of return to work, mental health, pain

(TAC Recovery Branch 2012/13)

PersistentPain

MentalHealth

RTW$20K

$36K$32K

$79K $81K

$77K

$151K

No Complexities

RecoveryAve cost per claim per year

% of claims

32%

2%

2%3%

3%

1%

2%

54%

$9K

PersistentPain

MentalHealth

RTW

No Complexities

RecoveryTotal ave cost per year

$54M

$17M

$7M

$22M

$26M

$8M

$7M

$41MTotal ave no. of claims

per year 2,8004,600

260

270

175

210

85

180

Service provision “alarms” In 2009 our journey began: Clients not satisfied with available options; and providers unclear re their roles We were: 1. Focused on outputs rather than outcomes 2. Had low expectations: return to work, health,

independence 3. Using biomedical rather than psychosocial and

interdisciplinary models - outreach and flexible services not utilised

4. Not leveraging off contemporary public sector 5. Locked into a fee for service that often disincentivised

discharge and created dependency

Research and listening – External “advisory think tank” of experts – Foundation piece – Mental Health Framework – Researched best practice mental health, pain,

disability and complexity models and options – Reviewed internal processes, tools, staff

capability and most importantly communicated, consulted, and reviewed

– Endorsed joint Board TAC/VWA Strategy 2010/2011

– Commenced implementation in 2011/2012

Mental Health Strategy 3 – 5 Years……

Vision: TAC clients and injured workers with mental injuries or at risk, have access to the right intervention at the right time to enable

return to work, health and independence

Claims capability

Improve staff capability to manage

mental injury and pain claims, with a

focus on identifying clients at risk earlier, and integrating with claims management

processes

Client capability

Empower clients to take control of their

journey through facilitating awareness and self-management

Provider capability

Develop the capability of providers to

effectively work with TAC clients and injured workers

Intervention options

Expand the range of evidence-based

services available to clients based on a

stepped care approach

Enablers: Research/Partnerships/Data Mental Health Framework

Key initiatives Achievements to date

Claims capability

• Information, resources, training and tools • Model of ‘stepped interventions’ • Screening process based on current TAC Longitudinal Study • Purpose designed service catalogue

Client capability

• Information sheets and links to national e-therapy services

Provider capability

• Provider capability framework • New partnerships for example community managed mental

health sector • Disability Service Reform Working Group and Primary Care

Advisory Group

New Intervention options

• Psychosocial outreach services • Intensive outreach Services • Peer support • Partnership with Austin Health re PTSD program

Psychosocial outreach support Community managed mental health sector is a valued

component of a modern system based on recovery principles, care coordination and community connections

Implemented within TAC early 2014 - 36 referrals to date

Example of a client outcome: Prior to receiving outreach services unable to use public transport or attend community activities due to anxiety and panic attacks post transport accident. After engagement with the local outreach service, this client now has strategies to deal with her anxiety and has overcome her fear of using public transport. She has reconnected with family, friends and attending health appointments and community activities independently.

Screening process Research also indicates early intervention leads to better outcomes. The screening process draws on research from the TAC Longitudinal Study and is a two-stage process for new clients:

Initial screen identifies clients most likely in need of assistance and screens out about 60% of clients (0-3 months post-accident)

Second screen validates the first screen for remaining 40% and provides a pathway to the most appropriate services and actions (3-5 months post-accident)

Initial Screen (at the first call)

Low 60% Med 20% High 20%

Low ~8% / Med ~12% / High ~12% / Severe ~8% Second Screen (~3 months post accident)

Information / Supports

Range of treatment, referral, support options

Client risk of mental health or pain issues

Return on Investment Undertaken significant work that demonstrates early and positive outcomes: 1. Improved scheme viability

2. Potential common law benefits

3. Contribution to improved client outcomes

4. Improved client experience

Key Learnings Positives of note Lessons to note

1. Paradigm shift for clients and providers 2. Claims capability and new intervention

options positively impacted staff 3. Gave rise to ‘champions’ at all levels 4. New data set on mental injury and pain 5. Screening process and new support

options → to better meet client needs 6. Potential to reduce common law due to

earlier identification of claims at risk 7. Screening process may inform and

influence NDIA models for clients with psychosocial needs and/or psychiatric disability

1. Compensation system is not a health system –competing demands

2. Collaboration is challenging - find ways to work and complement strengths

3. Earlier focus on change management 4. Amount of resources and input required 5. Priorities shift and staff move–remain

optimistic and constantly communicate 6. Screening tool is ‘only a tool’ - capability

of claims managers is critical 7. Screening may identify increase in

numbers of clients at risk and initially increase liability costs - need to be upfront

8. MOST IMPORTANTLY there are many benefits in shifting from a model of compliance to a culture of care and trust with assurance

Next Steps 1. Embed, evaluate and refine the screening process 2. Implement psychosocial outreach and e-therapy

within VWA and develop targeted approaches 3. Expand client self-management 4. Collaborate with GPs on pain and mental health

issues for compensable clients and link to our other initiatives for example, the health benefits of safe work

5. Review high risk pharmaceutical use 6. Standardise multi-disciplinary pain services 7. Continue to develop new partnerships and

models for compensable clients

Further Information Victorian WorkCover Authority (VWA)

vwa.vic.gov.au Phone: 1800 136 089

Transport Accident Commission (TAC)

tac.vic.gov.au Phone: 1300 654 329

Provider Feedback

Hdsg_provider_support@tac.vic.gov.au