care coordination v partners in recovery€¦ · nous group.com.au 5 • many people with severe...

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Care Coordination v Partners in Recovery

VICSERV Seminar

November 2012

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Contents

1. Care Coordination v Partners in Recovery

2. Care Coordination insights

3. How partnerships work

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Contents




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Care Coordination for people with severe

mental illness and multiple needs (delivered

through selected PDRSS)

• Care Coordination was part of a 2009-10

State Budget reform package

• Care Coordination aimed to address priority

pressures, risks and opportunities

associated with high risk/high need adult

clients (16-64 years) of the specialist public

mental health service system

• Care Coordination provides the practical

support to access and remain engaged with

the range of mental health and general

health and social support services they need

CC and PIR came about because of a lack of coordinated and integrated care available for people with severe and persistent mental illness.

Source: Department of Health and Department of Health and Ageing

PIR aims to improve the system response to,

and outcomes for, people with severe and

persistent mental illness who have complex

needs (delivered through Medicare Local

regions)

• PIRs is part of the 2011/12 Federal Budget

which has provided $549.8 million from

2011/12 to 2015/16

• PIR will get the services and supports from

multiple sectors to work in a more

collaborative, coordinated, and integrated

way

The scale of PIRs

dwarfs CC but they are

the very similar

programs

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• Many people with severe mental health illness and psychiatric disability have multiple and complex

needs such as co-existing substance misuse problems, co-occurring physical health problems and/or

intellectual disability and Acquired Brain Injury.

• This client group require a response from a range of service sectors such as health, housing,

homelessness, drug and alcohol treatment, family support and justice.

• It is estimated that one third of all clients of the clinical specialist mental health service system

(approximately 20,000 clients) require dedicated assistance to access the these services, and would

significantly benefit from the development of an integrated, comprehensive care plan that is able to be

modified over time to reflect their changing needs.

• These clients have a high level of dysfunction across several life areas and a limited capacity for self

management, making it very difficulty for them to navigate the complexities of multiple service systems,

particularly when they are unwell.

• The need for sustained support recognises the episodic and enduring nature of serious mental illness.

• In the absence of coordinated tailored packages of support, these individuals are at high risk of falling

‘between the cracks’ of highly siloed service systems.

• This can lead to negative client outcomes such as repeated crises and hospitalisation, entrenched

isolation and poverty, recurring homelessness, long term unemployment, poor physical health and

frequent interactions with the police with a higher risk of incarceration.

CC and PIR tackle the same problem. Below is the background to CC but the same could be read to PIRs….just on a national scale.

Source: Department of Health

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There is overlap between Care Coordinators, Support Facilitators and….Clinical Case Managers.

Differential role of care coordinators, case managers and support facilitators

Care Coordinators Clinical Case Managers Support Facilitators

� Service system coordination - Operates more like

‘service coordination’ or ‘service hub’ - works with, and

guides, the service team process and tasks while building

collaboration with all parties involved with the client

� Long-term focus - Takes a long-term planning focus.

Supports the care team, coordinates the broader

community-level service plan, provides guidance around

service delivery and may help to coordinate crisis

intervention activity

� No direct engagement – Care Coordination does not

include the provision of psychosocial supports and the

Care Coordinator does not engage in direct day to day

work with the client. Client engagement is through

assessment or review of the care plan and focus on how

the client perceives the services to be working. Typically

only meets the client with one of their direct support

workers, Case Manager or in a case conferencing

environment

� Clinical service guidance - Works with

and guides the service needs of the

client specific to that agency, and does

provide direct clinical support to the

client

� Direct engagement - Does have a

component of service coordination and

hence there is some overlap with Care

Coordination

� Long-term focus - Similar to Care

Coordination, takes a long-term

planning focus, but also works with the

client, providing direct support and

involvement, develops an agency

specific or treatment plan and is

directly involved in crisis interventions

� Deliver the benefits of system

collaboration

� Support facilitation with a

coordination focus;

� Manage referrals, assess client

needs

� Develop, monitor and regularly

review PIR Action Plans

� Work with existing case managers

(not replacing them)

� Build service pathways, networks

of services and supports needed

� Be a point of contact for PIR

clients, their families and carers.

Overlap with planning.

Leave clinical care

plans to clinicians. Take

a load off clinicians

Source: The Nous Group and Department of Health and Ageing

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• Case management delivered by specialist clinical mental health service (as defined in the

Framework for Service Delivery ) was intended to provide holistic care, assisting the clients in

all life domains, such as support to develop daily living skills and access social support

services.

• In practice, clinical mental health services do not have capacity (or in some instances

knowledge of referral pathways) to effectively perform this function for all clients, mainly

due to increased complexity and sustained demand pressures.

• As a result, case management is variable and ad hoc.

• It is also acknowledged that clinicians’ skills would be more efficiently and effectively used to

deliver clinical treatment and interventions.

• The introduction of a dedicated non clinical care coordinators function would (subject to

adequate investment over time) allow the redevelopment of treatment and support is

coordinated for clients with severe and enduring mental illness.

Care Coordination aimed to free up clinical services to focus on providing clinical treatment and treatment planning, review and medical monitoring of high need clients.

Source: Department of Health

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Contents




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Care Coordination seeks to support targeted clients with multiple needs to access and remain engaged with the range of health, community and social support services.

CLIENT OUTCOMES

Health

• Improved self-management of illness, medication and treatment compliance, relapse prevention and symptom stability

• Improved physical health and engagement with GP services

• Decreased psychiatric crisis, suicide, self-harm and other

• Sustained engagement with health, drug and alcohol, primary mental health and medical services as appropriate

• Improved client and carer experience of care, improved client and carer input into treatment care planning

Social:

• Sustained stable housing

• Increased social and community engagement/connectedness

• Improved social relationships, including with significant others

Economic:

• Engagement in educational and vocational training, and employment

Brokerage funding

($500 per client)

OUTPUTS OUTCOMESACTIVITIES NEED/PURPOSEINPUTS

• $2M per annum

• 20 new positions

• Indicative worker to

client ratio - 1:15

• Selected PDRS service

providers

efficiency effectiveness appropriateness

AMHS registered clients aged 16-64 who have a severe, enduring mental illness and psychiatric disability and:

• multiple, unmet service needs

• a history of accessing a range of services in an ad hoc and often chaotic way.

Note: Clients who are currently receiving SECU diversion and substitution or IHBOS are not eligible for this response

• Improve treatment and care of multiple need/high need clients

• Reduce system

pressures

SYSTEM OUTCOMES

• Improved service coordination and strengthened accountability at the local level

• Increased capacity for specialist (clinical and PDRSS) mental health services to manage service demand

• Reduced repeated contacts with other service systems i.e. hospital, corrections, homelessness, and emergency contacts (police and ambulance)

Brokerage services

Links to wide range of clinical,

psychosocial, rehab, physical health and

social services.

Case Conferencing

Assessment, development, coordination

and review of personalised Integrated

Care Plan

System advocacy

System outcomes

Health, social and economic

client outcomes

Standardised intake and assessment framework

20 Care Coordinators

delivering up to 300 Integrated Care plans at any one time

Source: Nous Group and Department of Health

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The Nous evaluation has two components:

1. The formative evaluation component – this

examines issues related to implementation. The

key question is: “Is the initiative being

implemented as planned?”. This covers:

• overall governance

• client intake, referral and discharge

• service models

• staffing arrangements

• key Enablers/Challenges

• local delivery arrangements

• involvement in care.

2. The summative evaluation component – this

assesses whether the intended client and

system outcomes have been achieved. The key

question is: “Has the initiative produced the

planned client and system outcomes?”

Nous has evaluated Care Coordination since inception.


Data source Comment

Document

reviewProvider models of care.

Service

provider survey

The content covered in the survey covers:

� intake, referral and discharge criteria and processes

� engagement model

� local delivery arrangements

� enablers and challenges.

Service

provider

interviews

Interviews cover:

� changes in roles, staffing, etc. since the last interview

� client and carer experience and involvement

� system impacts.

Case studies Provider provided case studies

Service

provider

supplementary

data

Service providers submit data for each client about housing

type, employment type, and interactions with other services

Service providers submit BASIS32 scores for clients when these

are not recorded in the CMI-ODS

CMI-ODSUse of beds and ambulatory services by each client

BASIS32, HONOS and LSP scores for each client

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All services have established governance structures to monitor the Care Coordination that include pathways for receipt of referrals and consideration of client eligibility.


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Client load is between 8 – 10. The plan was for 15.

• Average client number per Care Coordinator increased to 8.75 (from 8)

• Reasons not to take on more clients are:

• clients require more time due to their complexity

• insufficient referrals from providers.

Waitlists are not used

• Only one provider has a waitlist, they operate with a caseload of 10

• Providers state that caseloads could increase if referral process improves

Eligibility is tightly managed

• Providers have kept with the Government criteria

• Some providers noted that eligible clients are not in the program because:

• clinical staff members reluctant as it may create more work for them

• Care Coordinators are challenged by the level of complexity of clients

• the benefit of Care Coordination is still under-appreciated.

Care Coordination case loads vary and referral processes have been problematic.

PIRs has a

similar case

load

requirement

Waitlist

should be big

in PIRs

Managing

eligibility will

be a

challenge in

PIRs


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18 months to mature

• Service delivery in terms of client intake, referral and discharge, and the promotion of

the initiative to local AMHS have taken 18 months to mature. Components include:

• Area mental health staff understanding of the role of care coordination staff

• Clinical governance structures to support delivery of this initiative

• Referral protocols within each area mental health service

• Joint planning and decision making

• The area mental health service sharing client information with your agency

• Common tools with our area mental health service

• Joint service delivery protocols.

• Once an effective working relationship between a PDRSS and AMHS provider has been

established then it seems to work well

A range of set-up challenges exist

• Issues that sit behind this include:

• Poor history between providers

• AMHS don’t refer to PDRSS

• Client complexity

• Staff turnover and lack of a system approach

• Overlap between Care Coordinators and Clinical Case Managers

Care Coordination intake, referral and discharge processes have taken more than 18 months to mature.

PIRs will

demand even

more from the

service

delivery model

Manage the

risks and

escalate

quickly, where

necessary

Systems

thinking and

managing

personal

relationships is

key


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Housing providers are the most important provider of non-mental health services.


Importance of other services in the provision of care for clientsRelative ranking

PIRs will be similar in

profile & therefore tells

you about who you need

to connect with and the

skills to do this with

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With Care Coordination, clients increasingly use private housing but their employment status doesn’t seem to change.

Data is presented as the percentage of clients occupying each housing or employment type in the time period since entry to the initiative. The number of

clients for which data is available in each time period is presented above each column.

Source: Supplementary evaluation data provided by agencies

Proportion of clients (%) Proportion of clients (%)

Housing type Employment status

3231 19 14 11

42

34 1917

213

8 73

1

9

2 1229

14 8 4 37 6 4 3 2

0%

20%

40%

60%

80%

100%

0 - 3 3 - 6 6 - 9 9 - 12 12 - 15

Supported residential Private housing

Psychiatric inpatient / rehab Homeless

Crisis or transitional housing Private boarding rooms

160 138 88 62 51

0%

20%

40%

60%

80%

100%

0 - 3 3 - 6 6 - 9 9 - 12 12 - 15

Unemployed Paid Part Time Volunteer Paid Casual

months since entry into initiative months since entry into initiative

PIRs will be

similar in

profile

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60-80% of time in the initial period is focused on network set up

• The complexity and high level of needs of the target group means that Care

Coordinators have to spend a lot of time in the initial stages to establish a range

of support networks for the client.

• In addition, the Care Coordinator has to establish many more relationships than

other roles, including multiple contacts across all bed-based and community-

based clinical services, and across a wide range of external providers.

• This can be very time consuming particularly while the role itself is being

established.

Once set-up, 10%-30% of time is spent on maintaining networks and referrals

• Most of that time is spent developing and maintaining relationships with

healthcare providers with some time spent with housing providers.

• The allocation of time is closely reflected in the amount of client referrals and

contacts with each of these service providers, particularly for GPs, allied health

and housing

Establishing service support networks has taken more time than anticipated.

PIRs will have

the similar

establishment

challenges

PIRs will

probably have

a similar profile


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Most of that time is spent with healthcare, housing and social participation providers.

Data is presented as the number of clients that have the indicated number of contacts/referrals. Only clients for which more than 6 months have elapsed

since entry into the initiative are included in the sample.

Source: Supplementary evaluation data provided by agencies

Number of clients

0

20

40

60

80

100

120

140

160

180

None 1 to 6 7 or more

Health services

D&A services

Homelessness/

housing services

Employment/education/

participation services

Number of contacts/referrals


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Care Coordination clients’ carers are increasingly involved in client care.


Carer engagement in IHBOSType of engagement

0 2 4 6 8 10 12 14 16

Service planning and development

Coordination of care

Decisions relating to client's care/support

Governance structures

Recipients of information and referral for carer’s support needs

Other

Number of responses

Round 3

Round 2

PIRs is an

opportunity to

do something

different with

carers

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Carers have expressed views on specific challenges

• Actively increase carer involvement

• Strengthen links to family support services

• Conduct carer forums

• Deliver information sessions

Providers have suggested improvements

• Understanding the mental and community health systems

• Finding contact points within the service system

• Carer fatigue due to inadequate support available

• Disjointed and inconsistent service delivery

• Managing the behaviour of the person they care for

Carers have expressed views on specific challenges, and providers have suggested improvements.

Again…PIRs is an

opportunity to do

something

different with

carers


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Providers use different recovery models

• Most Care Coordination providers refer to their use of the Collaborative Recovery Model and the Recovery Star Models

as important aspects of client engagement.

Clients are involved in recovery planning 40-60% of the time

• Clients and carers are routinely invited to attend case conference/care team meetings (though attendance is

infrequent).

• Some providers have their case conferencing meetings with the client present others don’t

• Most providers meet with clients on a monthly or longer basis

• Most Care Coordinators meet with the client to set up and review their goals, go through the care plan with them, and

invite them to case conferences, often based on the client’s self-determination and wishes.

Clients tend to raise service access issues rather than support issues

• Common issues raised by clients (which are similar to those raised by carers) include:

• Housing

• Finances

• Employment

• Availability of clinical AMHS

• Family relationships.

Clients involvement is mixed and they want assistance with service access issues.

PIR clients will want

assistance on service

access rather than

mental health support


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Regardless of the recovery method, Care Coordination clients have provided care with no adverse impact on client outcome measures.

BASIS32, HONOS and LSP scores

presented in ~ 3 month intervals

before and after entry into Care

Coordination.

Relative BASIS32, HONOS and LSP at

entry and exit to and from Care

Coordination.

Outcome measures results for Care Coordination clients

0

20

40

60

80

BASIS 32 HONOS LSP

Entry

Exit

0

8

16

24

32

40

48

-12

to -9

-9 to

-6

-6 to

-3

-3 to

0

0 to 33 to 66 to 9 9 to

12

0

8

16

24

32

40

48

-12

to -9

-9 to

-6

-6 to

-3

-3 to

0

0 to 33 to 66 to 9 9 to

12

0

1

2

3

4

-12 to

-9

-9 to -

6

-6 to -

3

-3 to

0

0 to 3 3 to 6 6 to 9 9 to

12

-12 -9 -6 -3 +3 +6 +9 +12

BASIS 32

postpre

HONOS

postpre

-12 -9 -6 -3 +3 +6 +9 +12

-12 -9 -6 -3 +3 +6 +9 +12

LSP

postpre

Entry and exit scores

Sco

re

Sco

re

Sco

re

Pre

cen

t m

axi

mu

m s

core

The data presents the BASIS32, HONOS and LSP scores of clients in ~3 month periods prior to and post entry to the initiative. Data is

presented as the mean ± standard error (number of clients). An improvement in mental health is represented by a decrease in the

score.

Sources: CMI-ODS, Supplementary evaluation data provided by agencies

Time from entry (months) Time from entry (months)

Time from entry (months)

(18) (24) (25)(20)

(25)(38) (23) (20) (123)

(102) (95) (68)(112) (127)

(133) (143)

(96) (99) (100) (100) (110) (80) (88) (59)

(12)

(75)

(53)

(15)(10)

(0) Each PIR

arrangement will

require a common

recovery method/

language

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• The staff initially recruited had a high turnover rate as

they did not have the required skillset (local provider

knowledge and relationships, communication and

negotiation skills)

• Providers have tended to appoint staff with:

• clinical qualifications (such as nursing and allied

health) to these roles

• often with cross–sector experience (especially drug

and alcohol or housing)

• preferably with existing relationships with a wide

range of local providers.

• A typical award levels allocated for Care Coordinators is

SACS award SOC 2 year 1-3.

Recruitment of Care Coordinators is hard and getting the right competencies is critically important.

• The required competencies include:

• Tertiary qualifications with experience in the sector

of homelessness, mental health or D&A

• Intimate knowledge of the mental health service

system and inter-relationships between sectors

• Capacity to develop and sustain partnerships with

service providers

• Applied use of recovery models in social settings

combined with a humanistic attitude

• Comprehensive assessment skills and ability to

analyse and bring together a client's previous

history

• Advanced communication and written skills

• High level of interpersonal skills including

assertiveness, diplomacy, negotiation skills, active

listening and the ability to address and resolve

conflict

• Facilitation/leadership skills to chair meetings, lead

teams, and negotiate with other services.

Don’t recruit

clinicians. Recruit

system navigators

who understand

what recovery means


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Reduction of use of inpatient beds by Care Coordination clients.

Data presents the difference in use of each bed type based on each client’s historical average use over the year prior to entry to the initiative. Client’s that

have left the initiative continue to contribute to the availability of service hours. The number of clients included in each Collection Period is presented above

each column.

Sources: CMI-ODS, (Note that data for Collection Periods 4 and 5 may be absent from the system), Supplementary evaluation data provided by agencies

Time made available – total (days)

Estimated time of inpatient beds made available by the client group

since entry into the initiative– Care CoordinationTime made available – per client (days)

Collection Period

0

2

4

6

8

10

1 2 3 4 5

Bed days made

available per

client

85 103118

135 152

-500

0

500

1,000

1,500

1 2 3 4 5

PARC

CCU

SECU

Acute inpatient

Sample size

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Reduction in use of MST, CCT, and CAT.

Data presents the difference in use of each service type based on each client’s historical average use over the year prior to entry to the initiative. Client’s that

have left the initiative continue to contribute to the availability of service hours. The number of clients included in each Collection Period is presented above

each column.

Sources: CMI-ODS (Note that data for Collection Periods 4 and 5 may be absent from the system), Supplementary evaluation data provided by agencies

Time made available - total (hours)

Estimated reduction of ambulatory services use by the Care

Coordination client group since entry into the initiative. Time made available – per client (hours)

Collection Period

-10

-5

0

5

10

15

1 2 3 4 5

Service

hours made

available per

client

85 103118

135

152

-1,000

0

1,000

2,000

1 2 3 4 5

MST

CCT

CAT

Sample size

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Contents




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• Partnerships have captured the minds of many politicians, policy analysts and practitioners

with the partnership model touted as the best way forward to tackle social problems

• However, the notion of partnerships is not an uncontested idea.

• Judd (2000: 26) notes that partnerships ‘far from bringing coordination to tackling

social problems, partnership working is spinning off into a series of haphazard

initiatives without a clear set of priorities’.

• Hess and Adams (2001: 13) notes that rhetoric of partnerships has become a ‘muddle

of ideas’ in which ‘potentially useful concept is in danger of becoming just another

public policy reform fad’

• A growing body of literature has attempted to bring greater clarity to the confusion

surrounding partnerships

The notion of partnership has gained increasing currency in policy debates in recent years.

Source: The Agora Think Tank (which included the Nous Group)

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• A partnership implies a greater sense

of mutuality beyond service

agreements, referral or information

sharing.

• A number of common characteristics

emerge from these studies. These key

elements include:

• Common vision and goals

• Organisations from two or more

sectors

• Shared decision making and

responsibility

• Shared risks and resources

• Address social issue

• Agreed outcome

• Long term

• Autonomy

• New structures and process

• Equality and trust.

Key characteristics of partnerships differentiate partnership from the contractual end of the collaborative continuum.

Deg

ree

of in

tens

ity a

nd c

omm

itmen

t Low- involvement

- engagement

- empowerment

High- involvement

- empowerment

- engagement

Independent

Entities

Coordinated

Effort

Collaborative

Delivery

Integrated

Partnership

RELATIONSHIPS

Collaboration vs competition

• Shared vision• Commitment to

change• Sustainable

relationships• Formal agreements

(MoU)• Interdependence /

Integration• Detailed planning• Role clarity• Financial and

resource commitment• External focus

• New structures and processes

• Commitment of effort• Joint planning• Pooled or shared

resources

• No risk• Protect individual

boundaries• Competition for

funding & resources

Meeting of agencies for information sharing

Referral protocols and case management

Improvements to service systems

Agencies create new structures to address wider issues

• Shared intake or referral tools

• Little joint planning• Little change required


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Successful, sustainable partnerships create value for each party:

• For those experiencing disadvantage, the value comes from the opportunity to pursue more effective

and more sustainable pathways out of disadvantage.

• In local communities, value can be created in the form of greater social cohesion and community

capacity with the ability to prevent future disadvantage.

• For the not-for-profit sector, the value comes from the opportunity to better serve the disadvantaged

by contributing to services that are innovative, better resourced and better meet the needs of those

requiring them.

• For business, the value can come from an improved corporate reputation in its product and

employment markets, better engagement of existing employees and the opportunity to directly

improve economic returns.

• For the philanthropic sector, the value comes from a greater public return on its investment.

• For government, public value is created by solving problems in partnership and involvement of other

sectors.

The most valued partnerships clearly delivered lasting solutions to the prime beneficiaries – those experiencing disadvantage and their communities.


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• There are two major challenges:

1. It is easy to underestimate the scale and difficulty of the challenge. The target

population generally experiences complex problems; working to address social

disadvantage can be politically sensitive and partnership design and implementation

is complex.

2. Partners are typically diverse. The value that each partner is seeking to create may be

at odds with other and each partner will certainly bring a different culture,

organisational values and appetite for assuming risk.

• Successful partnerships do not underestimate the challenge, and work hard to harness their

diversity as a strength of, rather than a constraint to, their partnership.

Organisations from across all sectors have expressed an enthusiasm to partner, but can under-estimate the challenges.


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Partnerships designed to address disadvantage share the common ingredients such as shared vision, trust, respect and honesty.

These challenging partnerships have seven distinctive elements:

• Passionate leadership – A connecting passion among key individuals, complemented by strong support from organisational

leaders. The leadership roles and responsibilities are agreed and clearly defined.

• Flexible can-do mindset - There is flexibility and willingness to work around unforeseen barriers and difficulties. The funding

provided is flexible to accommodate solutions that are innovative and address a real need. Partners come seeking opportunity

rather than to overcome a problem. The values of openness, trust, honesty and transparency are agreed, shared and lived. It

is helpful where the partnership has grown from a pre-existing relationship where mutual trust and respect has already been

established.

• Value creation focus - Delivers value to each partner commensurate with their effort and risk, and avoids having low input

partners. There are agreed and defined outcomes, milestones, strategies, structures, decision making frameworks and

operating processes. The risks and the benefits are shared. All partners as members of the community participate in the

design of the solution not just the delivery.

• Intelligent resource usage - Draws on the distinctive capabilities, resources and business systems of partners. There are

dedicated and appropriately skilled resources, individuals or organisations that provide facilitation/brokerage support to

overcome some of the cultural barriers that can exist between sectors. There is equal contribution from partners/community

members and all contribution is respected.

• Loaded for success – designed for early wins and clear, reinforcing feedback on performance.

• Partnership investment - There is investment in the partnership and the solution. This includes time, energy, funding and

strengthening the relationships and connections between partners. There is willingness from all partners to engage in mutual

learning. The learnings are available and easily accessible to others.

• Sustainability – There is a persistence and commitment that develops beyond the original passionate few. The outcome is

sustainable because sustainability has been incorporated into the design of the solution. The time frames are medium to long

term.

There is a lot of research on what makes a good partnership. This is our take…


nousgroup.com.au 31

http://www.agorathinktank.org

http://thepartneringinitiative.org

For more information on parternership….

care coordination v partners in recovery€¦ · nous group.com.au 5 • many people with severe...

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