the integrated services project (isp): an inclusive model of intensive, transitional support for...
TRANSCRIPT
The Integrated Services Project (ISP): An inclusive model of intensive, transitional support for individuals with complex needs
Don Ferguson and James LimSydney, Australia
21 October 2009
Overview of presentation
Introduction How the ISP was developed The structure of ISP What we have learned Q & A
Before we start
We acknowledge your expertise
We are here to share our experience
What we have to say or suggest here may not be applicable to your circumstances, but
We hope to provide you with some ideas to support your thinking in this challenging area of human service delivery.
Australia
Queensland
NSW 6.8M
Northern Territory
South Aust.
Western Australia
Vic
Tas
Aust. Capital Territory
Victoria Tasmania
Total population = 22M
NSW
800,640 sq km
10.4% of continent
Sydney
7.6M sq/km
Human Service & Justice Agencies- NSW Government
Department of
Human Services
HEALTH Community
Services
HOUSING Juvenile
Justice
Aboriginal
Affairs
Dept of Corrective
Services
Police
DISABILITY(ISP Lead)
Justice & Attorney General’s Department
Timeline of model development
1999
Taskforce established
2001
Literature review commissioned
2003
Survey of Human service agencies
2005, April
NSW Government approves trial
2005, September
First participants accepted
2004, November
Project Director appointed
Model development continued…
Literature review confirmed local experience:
Rigid service inclusion/exclusion criteria Lack of capacity and incentives to be flexible in meeting
individual needs Lack of identified lead agency with responsibility for case
management and coordination of multiple services Lack of knowledge across services – confusion about roles
and responsibilities, and how to access services Lack of effective communication between service providers
(crisis-driven responses; rigid boundaries) Lack of access to specialist multidisciplinary expertise and
tailored treatment options (eg drug and alcohol) Lack of accommodation options
Model development continued…
Whole of government endorsement of ISP Pilot funding of $26M over 3-years provided by
state Treasury commencing July 2005 -2009 Catchment area determined as Greater Sydney Minimum age of entry determined as 18 years New legislation not considered necessary All NSW Government human service and justice
agencies drawn in to support project development and identification of individuals of highest need
Project Catchment
GREATER SYDNEY Key facts
Population: 3,637,500
Average age of residents is 35 years
Area Coverage: 6376sq/km
Target Group
Adults with high risk challenging behaviour, with one or more of the following diagnoses:
mental health disorder intellectual disability acquired brain injury/impairment substance abuse
who are blocking an acute mental health unit or
respite service, homeless, or in gaol and experiencing significant barriers to accessing services and securing
coordinated multi- agency support, where local support options have been exhausted.
The ISP Approach
The ISP aims to: Improve a person’s housing stability, behaviour
and social networks Improve coordination and capacity of local
supports Reduce cost and impact of behaviour on self,
others and services Contribute to evidence base on supporting people
with challenging behaviour
The ISP Approach continued
This is achieved through:
The direct and immediate provision of time limited housing and support, as required,
while
working in partnership with each individual and their support networks to understand, plan and establish a more sustainable range of support from across their community and the specialist services system.
Organisational context
The ISP is hosted by the Department of Human Services’ Ageing, Disability and Home Care Agency.
Located within directorate responsible for agency and whole of government development in support to people with an intellectual disability and a mental health issue, those with complex needs and challenging behaviour and those in, or at risk of, contact with the criminal justice system.
Also provides specialist state wide intellectual disability services via a tertiary behaviour intervention service and an accommodation and support services program for people with
intellectual disability exiting the criminal justice system.
Whilst ISP not focussed on people with an intellectual disability, the close alignment with the work of the directorate provides a clear avenue for influencing the wider service system.
Project Governance StructureHuman Services
CEO’s
Chief Executive ADHC
Project Director
Support Team
Area/ Regional CEOs
Local Agencies
Management Committee
Reference Groups
Senior Officer Groups
Accom
Project Organisational Chart
Assessment Unit262 Victoria Rd
Rydalm ere - S ep t 05 *N u rs ing s ta ff
Residentia l UnitNurse manager
G lebeA p ril 2 0 07
KentlynD e c 2 0 06
Narw eeS ep t 2 006
4Cavey StM arrickville
Ja n 20 06
In Hom e SupportNetw ork
Netw ork M anagerN e tw ork m an a g er
S yd ne y S ou th W e st
HornsbyA u gu st 20 08
Rouse HillD e ce m be r 20 07
Parram attaA u gu st 20 07
12 a & b Charlotte StRooty HillF eb 20 06
In Hom e SupportNetw ork
Netw ork M anagerS yd n ey N o rth W e st
M anager Supported Living
Specialist Support Team4 C lin ica l C o nsu lta n ts
2 S p e cia lis t P sych o lo g is ts4 C ase S up p ort W orke rs
M anager Support Services Project M anagem ent2 S e n io r P ro je c t O ff ic e rs
DirectorIntegrated Services Project
Summary of Service Pathway
Intake
Nomination of Clients
ProjectManagementCommittee
Outcome
AssessmentCase
Planning
Clinical plans
InitialAssessment
Individual Case Plan
Individual Caseplan
Accommodation
AccomSystems
Transition New Service
Action plan
TransitionPlan
Proposed Servicemodel
Exit to NewService
Service Coordination Service Coordination Training & Development
ISP : Service Pathway from Intake to Exit of Service
0 month 3 12 Timeline 15 18 months
Service Pathway: Stage 1 of 3
Support TeamAccommodation
• In situ eg Corrections, Mental Health
• ISP acomm unit
• Assessment
•Individual Case Plan
•Interagency Agreement
•Behaviour and Health Support
Local service supports
Co-Case management and support as agreed through case plan
Stage 1
Service Pathway: Stage 2 of 3
Support TeamAccommodation
• In situ e.g. Corrections, Mental Health
• ISP accom unit
• ISP accom unit
• Own home/ public housing
• Assessment
• Individual Case Plan
• Interagency Agreement
• Behaviour and Health Support
• Individual Case Plan Implementation
• Trial Support Strategies
• Reconnect/ Establish Support Network
Local service supports
Co-Case management and support as agreed through case plan
Stage 1
Stage 2
Service Pathway: Stage 3 of 3
Support TeamAccommodation
• In situ eg Corrections, Mental Health
• ISP accom unit
•ISP accom unit
• Own home/ public housing
• Assessment
• Individual Case Plan
• Interagency Agreement
• Behaviour and Health Support
• Individual Case Plan Implementation
• Trial Support Strategies
• Reconnect/ Establish Supports
• Phase out and exit
Local service supports
Co-Case management and support as agreed through case plan
Stage 1
Stage 2
Stage 3 •Supported accommodation
•Own home/ public housing
The role of substitute decision making
NSW chose to rely upon existing legislation and decision making bodies for supporting people through the ISP.
In particular: The Guardianship Tribunal The Mental Health Review Tribunal The NSW Public Trustee & Guardian
They provide a strong source of advocacy for individual participants accountability for the ISP a significant role in shaping the project through membership
of the ISP interagency reference group.
ISP Accommodation Models
Assessment unit House with self contained unit Twin house A small block of units Semi rural house with on-site vocational
training Drop in support and co tenancy Crisis accommodation
Some properties purchased and some leased, all modified to some degree to better meet individual needs
Accommodation Considerations
What has worked?
Diversity and immediacy of accommodation options
Staffing model used to support complex needs
Allocation of key workers, psychologist & other professionals for ongoing assessment and support during transitional placements.
Accommodation Considerations
What has worked?
Flexibility around support needs with focus on promoting choice within structure, development of life skills and vocational options
Planning towards the development of consistency, stable accommodation and identification of longer term needs
Cost effectiveness of pooling services and resources to support complex cases – these individuals are not our exceptions
Accommodation Considerations
What has been some of the challenges?
Assessment unit industrial issues too restrictive Too expensive became early unintended focus of program and all-
consuming
Community acceptance
Accommodation Considerations
Some more challenges
Timeframe restrictions and staggered release of funding due to pilot status of project, big impact on issues such as staff employment stability intake and placement planning
Transition to next phase or locating appropriate service providers for service continuation On the flip side: ISP allows us to put individual need ahead
of service access issues – service fit becomes our problem not the individual’s
Characteristics of participants 38 participants Mean 36 years, Median 34 17 Women, 21 Men, Indigenous n = 3 CALD n = 12 ESB n = 23
30
Characteristics of Participants continued
Mental health disorder n = 33 (87%)
Intellectual impairment n = 26 (66%)
Alcohol and other drugs n = 22 (58%)
Acquired brain injury n = 15 (39%)
Physical disability n = 14 (37%)
Case Example 1 (NR)
NR had a tendency to gravitate back to high risk environments She was very vulnerable to abuse and exploitation by others
(i.e. persuaded to engage in offending behaviour – break and enter – used as the “fall guy”)
She had frequent contact with the criminal justice system Soliciting / Prostitution Verbal aggression and property damage Extreme emotional lability Lack of impulse control
Case Example 1(NR)
Assessment findings Poor short term memory and impulse control Negative impact of multiple placements No length of meaningful engagement with past providers Systems issues – coordination failure, police, courts, disabilities, mental
health
What we did Provided a stable place to live with skilled and supportive staff Introduced comprehensive behaviour support strategies Established roles and responsibilities of mental health and disability support
services Developed cross agency response plans to reduce contact with criminal
justice system Negotiated long term service provider and funding source Provided intensive training to service provider Handed over of responsibility of case plan and interagency collaboration Ultimately resulting in successful sustainable support model and exit of ISP
Case Example 1 (NR)
Key individual outcomes Police reported a significant reduction in crime rate in local govt area and
attribute much of this to one individual…
NR has continued to spend greater lengths of time in the community and less time in custody.
She has a higher engagement with her support services
and has commenced work at supported employment, providing her a wonderful new source of income.
Case Example 1 (NR)
Summary NR is a 29 year old female of Lebanese descent. She has a diagnosis of
Moderate Intellectual Disability, Borderline Personality Disorder and a Possible underlying mood disorder.
Oppositional behaviour and absconding from home at a young age. Living on ‘the streets’ by age 13yrs.
Frequent incarceration in Juvenile Justice detention centres and adult correctional facilities for theft related charges.
History of placement breakdown and disability services unable to provide adequate service model to meet client needs, new placement
Released on bail and charges dismissed over 50 times successive release from custody on grounds of unfitness to plea.
Disengaged from family.
Examples of the diversity of participants
Young women with no comprehension of English, native language undetermined, living in a short stay hostel with uncontrolled psychosis and no known supports or family
Homeless elderly male with repeated contact with police, aggression, AOD, previous self inflicted gun shot wound head injury, multiple untreated health conditions stuck on post surgical hospital ward.
Young women with a moderate intellectual impairment and personality disorder, long history of short periods in custody for low level offences and no stable community support
Young Indigenous male, mild cognitive impairment, IV drug use, HIV positive, living in unsustainable HIV related dementia service
Elderly male, 20+ years in custody for murder, previous diagnosis of anti social personality disorder, suffered brain trauma in custody with continued mental and physical deterioration
Indigenous participants
Over represented in criminal justice and welfare systems.
Recognition of past poor practices and tainted history
Focus on establishing trust Must change our thinking our
language and our engagement with individuals, families and community
ISP seeks support of Community Elders and
works in partnership with Indigenous services
Strives to establish culturally appropriate supports and individual outcomes.
National Sorry Day 26 May
Concepts of service fit and behavior:Description of all participants on entry to ISP
High level behaviour
Poor service fit
Concepts of service fit and behaviorWhat we found
Group 3: 22.5%
High level behaviourgood service fit
Group 4: 12.5%
High level behaviourpoor service fit
Group 1: 40%
Lower level behaviourgood service fit
Group 2: 25%
Lower level behaviourpoor service fit
Project evaluation: Some results to date
ISP has had a positive impact on individuals and services Behaviours, risk, health, quality of life and “service fit” 18 individuals have successfully moved through and
exited the Project to long term service options with clear agreements in place for an additional 12 participants
Flexible needs based approach has enabled trials of innovative service models
No appropriate service fit for 8 individuals A small number of recurrent individual funding packages have
been approved for release each year Aim is to help resource extra-ordinary support arrangements for
such individuals and reduce likelihood being stuck in the ISP
Project evaluation: Some results to date
Service Costs Approximately $200,000 per annum per person compared with
$375,000 average cost pre-ISP
Behaviours Reduction in frequency and severity, especially for those who have
exited (36-42% decreases)
Service Use Decrease in hospital bed days from 47 to 2 days on average over 12
months period and reduced presentations to Emergency Departments from 24 to 4 presentations for 12 months
Decrease in number of days of imprisonment of 108 to 21 for 12 months
Elements of an effective service model
Timely identification of people and response to need High quality, clear and accountable case management Stable and flexible supported accommodation options Specialist multidisciplinary assessment, formulation
clinical, and behavioural interventions Individualised treatments such as D&A, anger
management, community participation and vocational programs
Interagency agreements and collaboration based on effective communication
In others words, from our experience, what the literature said was True!
We encountered barriers Integrated model of service delivery – “one stop shop” Work force management (recruitment, retention and support
initiatives) Funding implications and impact on work force management Extra ordinary complex client – implication of service moulding /
replication of ISP with other providers Strategic alliance within the Dept. – level of “guided autonomy”
and program sponsorship, as ISP was charting into “risk prone and unfamiliar territories in human services
Sound risk management practices Timelines and intake processes – start small …
Results continued
Systems Change and ISP influence
Effective mechanisms for resolving service support issues at local and senior levels Instrumental in developing of MOU between Mental Health and
Disability Services Participate in Mental Health Complex Needs Standing Committee
System requires greater flexibility in funding and program boundaries Working to supplement and expand existing programs Supporting development of revised intake criteria to close the gaps
Skilled workforce and open minded decision making Promoting new mindsets and culture of inclusion through staff
training and sharing the learnings with key decision makers
Tree of Change and Influence
ISP
InnovativePractice
PolicyDevelopment
Mental health and ID MOU
OSP
WorkforceManagement
Strategic Policy and
Planning
FutureDirections
HumanServices
ClinicalReferenceGroup
InteragencyGroup
ISP
CriminalJusticeResource
Behaviourpolicies
Drug & Alcohol Task
Group
New Servicemodels
Building Capacity in
human services
Quality Riskmanagement
Model of Accom Units
Research andDevelopment
Costeffectiveness
Community Perception &
Acceptance
Tree of Change
Quality of life