The Salvation Ar my. Victoria State Council PSYCHIATRIC DISABILITY REHABILITATION AND SUPPORT SERVICES REFORM FRAMEWORK

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1 The Salvation Ar my Victoria State Council PSYCHIATRIC DISABILITY REHABILITATION AND SUPPORT SERVICES REFORM FRAMEWORK Submission prepared by The Salvation Army Victoria State Council. June 2012 For further information on this submission, please contact: Major Graeme Rigley The Salvation Army Chair, Victoria State Council PO Box 288 Coburg 3058 (03)

2 PSYCHIATRIC DISABILITY REHABILITATION AND SUPPORT SERVICES REFORM FRAMEWORK Submission prepared by The Salvation Army Victoria State Council. Contents 1. Introduction About The Salvation Army The Salvation Army Victoria Mental Health Services PDRSS Reform Framework Response to the Consultation Paper Key issues Program remodelling Workforce development and sustainability Remodeling programs and funding streams Funding streams Alignments with broader health sector Recommendations and conclusions of 16

3 1. INTRODUCTION The Salvation Army Victoria State Council (VSC) welcomes the opportunity to respond to the Victorian Government s reform framework for the Psychiatric Disability Rehabilitation and Support Services (PDRSS). As a significant provider of services to the homeless and highly marginalised and disadvantaged members of our community, The Salvation Army commends the state reform agenda that seeks to provide more focused, equitable and accessible tailored service responses to people and their families, whilst concurrently considering national mental health reform. 1.1 About The Salvation Army The Salvation Army is one of the largest national providers of welfare services. Operating for over 130 years in Australia, The Salvation Army has a significant history working with and advocating for the rights and needs of disadvantaged people in our community. Consistent with the organisation s values of human dignity, justice, hope, compassion and community, The Salvation Army is committed to the promotion of social justice and protection of the rights of disadvantaged and vulnerable people. The Salvation Army Australia Southern Territory (AUS), with an annual operating budget of approximately $300 million, provides over 600 social programs and activities through a network of social support services, community centres and churches located throughout Victoria, South Australia, Western Australia, the Northern Territory and Tasmania. In 2010, The Salvation Army (AUS) provided over 550,000 occasions of service, including over 600 crisis and 4,000 non-crisis accommodation beds every night of the year and over 80,000 meals. Key services provided by The Salvation Army (AUS) network include: Drug and alcohol support and treatment services Family and domestic violence support and accommodation services Youth services, including out of home care options Youth, adult and aged accommodation and homelessness services Aged care services Emergency disaster responses Education, training and employment support services Material aid and emergency relief Financial counselling and assistance Personal counselling and support. The Salvation Army is an accredited organisation under the Quality Improvement Council (QIC) Health and Community Services Standards, and takes seriously its commitment to quality service provision within clear governance frameworks and practice standards. 2 of 16

4 1.2 The Salvation Army Victoria Mental Health Services. The Salvation Army has a long history of providing support and services for the most disadvantaged people in our communities who experience homelessness, violence, substance use issues, poverty and significant deprivation. In addition, many of these people also experience severe and persistent mental illness which is further compromised by significant impairments in social, personal and occupational functioning that requires intensive, ongoing health and community based support to enable them to live within the community. Indeed it is our experience that many clients, whilst exhibiting signs and behaviours consistent with mental illness, do not identify or acknowledge such nor do they have a diagnosis of a mental illness. This cohort of individuals is significantly represented within The Salvation Army homelessness support services. For example, in the 10 months to May 2012, 15% (N=31,896) of all clients accessing the Victorian social programmes network identified as having a mental illness, with ten percent receiving ongoing treatment through clinical mental health services. Consistent with our experience of non acknowledgement of mental illness, the actual figure will be higher. In addition, The Salvation Army recognises the importance of family and carers within the sector. However, it is our experience that the majority of clients with complex and multiple needs accessing our services have no contact with family members, have no family at all or have no supporting carer of any description other than a service provider. These clients are significantly excluded from the social connections that most people enjoy. The Salvation Army s social programmes network provides a variety of crisis and long term interventions and support across range of domains including housing, substance use, personal health and wellbeing. In Victoria, the social programmes networks are run through four discrete regional divisions - Melbourne Central, Eastern, Western and Northern Victoria. The Salvation Army s mental health services stream is located within the networks homelessness programs, providing a targeted response for those clients with persistent and severe mental health issues. Adult Services, EastCare and Kardinia receive PDRSS and Personal Helpers and Mentors funds (PHaMS; federal Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA)) to provide intensive outreach case management and support, group work and individual psycho-social rehabilitation. Mental health service provision is integrated within the broader homelessness programs thereby concurrently addressing the complex needs of housing, substance use, and family and community connections through the provision of crisis and moderate to long term intensive case management support. PDRSS funds complement and provide a specialist support component within The Salvation Army intensive support programs as part of a continuum of care. 3 of 16

5 Although PDRSS funding to The Salvation Army Victoria represents a small percentage of total service funding (averaging 2-4% across the three PDRSS funded services), it provides a significant core component integral to the provision of support and care needs of the client group, supplementing the range of wrap around support services available. Typically, the mental health service streams are not stand alone but integrated into larger homelessness and outreach support services, providing specialist and targeted support to people with mental illness who are homeless or at risk of homelessness. In addition, these services operate in active collaboration with area mental health services, clinical and PDRSS alliances and community support services to provide a continuum of services to meet the multiple needs of the client group. The Salvation Army - A model of integrated care for responding to complex needs. The Salvation Army Adult Services Intensive Support Program (ISP) provides intensive outreach support services to people with high and complex needs who find it difficult to live independently and maintain stable accommodation with the community. The relationship between the Intensive Support Program and SANS, Oasis and the Homelessness and Drug and Alcohol Program is defined by collaboration and mutual obligation between the services. There exists a shared responsibility for identifying existing clients within Adult Services who needs are beyond the normal bounds of service delivery. Such clients are identified for specific support through the ISP. There may be partnerships in terms of delivering direct client services There may be partnerships in case management. There will be partnerships between programs and between organisations. These roles will develop over time, but are underpinned by the guiding principles mutual respect and compassion, individual empowerment and control, collaborative partnerships between client and services, and holistic and client driven planning, service provision and evaluation. Note: Although the Intensive Support Program no longer exists, this type of integrated model of service delivery is a fundamental component of The Salvation Army social programs. Melbourne Central Division Adult Services. The SANS, Oasis and ASPHaMs programs provide services predominantly to people residing in the Western region of Melbourne. The Oasis Intensive Support Program is an integrated housing and support service for homeless men who exhibit challenging and extreme behaviour exiting Flagstaff Crisis Accommodation (a component of The Salvation Army Adult Services). The SANS Program focus is to provide and maintain housing stability via psychosocial rehabilitation for people experiencing recurring homelessness who endure a psychiatric disability. Participants in both programs present with additional complex needs and comorbidities, including, acquired brain injury (ABI), drug and alcohol abuse, disability. 4 of 16

6 Both programs are jointly funded by Specialist Housing Services (SHS, formerly SAAP) and PDRSS 1, and recognise that clients in the target group may have a broad range of experiences and needs, that an integrated network response is best able to meet. In addition, and with reference to EastCare and Kardinia below, these programs are supplemented by and act as a referral point to the Personal Helpers and Mentors programs. A snap shot of client demographics SANS and OASIS Programs (Period: 1/7/11 15/6/12 on entry) SANS Program (N= 23) OASIS Program (N=22) Age range years years years years 22% 13% 52% 13% 32% 36% 28% 5% Gender Male: 74%; Female: 26% Male: 100% Family Composition Sole client 100% Sole client 91% Couple with child 4% Couple 4% Main Presenting issues Mental Health Issues Psychiatric illness (formal diagnosis) Itinerant/ Accommodation Issues Problematic Substance Use Other Income Source Disability Support Pension Newstart Allowance Parenting Payment No income Accommodation type (prior to entry) Dwelling boarding house, hostel etc Rough street, squat, park etc Short term/emergency Institution Other 35% 26% 22% 4% 13% 50% 23% 5% 23% Adult Services also receives PDRSS funding for workers with two specific programs: Prison post release program PDRSS funded worker to assist people exiting Thomas Embling Hospital with accommodation and other needs. Homeless and Drug Dependency Program PDRSS funded counseling position, which compliments a clinical position funded to the clinical area mental health services (AMHS). 87% 4% 4% 4% 53% 18% 9% - 17% 95% 5% 37% - 36% 9% 9% 1 SANS is 50% PDRSS:50% SHS; Oasis is 75% SHS:25% PDRSS. 5 of 16

7 The programs aim to ensure that clients have increased access to appropriate support services at the right time, improved co-ordination of care, increased personal capacity and self-reliance, and increased community participation. Both programs work within a collaborative system of care, engaging client participation through the development and delivery of integrated recovery plans and practicing within the National Mental Health Guidelines. Eastern Victoria Division Eastcare Network of housing, homelessness and specialist support services offers a range of program options to assist people who are homeless and/or at risk of homelessness. EastCare have a range of programs that specifically target marginalised individuals with a range of disabilities including mental health, intellectual, ABI, and AOD issues, for example the Hawthorn Outreach Project and the Community Connections Program. The latter Community Connections Program links with a range of community based services including RDNS to provide specialist support and care. A snap shot of client demographics EastCare Mental Health Services (Period: 1/7/11 15/6/12 on entry N=123) Gender Male: 50%; Female: 50% Mental Health as primary issue 90% Mental Health Issues Psychotic disorders Affective disorders (depression, anxiety) Borderline Personality Disorders Other diagnoses Not diagnosed Other presenting issues and comorbidities AOD Health Financial issues Legal Issues Domestic violence Suicidality 17% 54% 11% 13% 5% 39% 38% 31% 16% 16% 10% Within this network of services, EastCare receives PDRSS funding to provide home based outreach support to people who are homeless or at risk of homelessness in the Boroondara LGA. EastCare mental health services are also complemented by PHaMS funding. Western Victoria Division Kardinia Mental Health PDRSS is a core component of a comprehensive and integrated network of services that work together to address the impact of mental illness on clients daily activities and the resultant social disadvantage. Kardinia Mental Health Services provide home based outreach support (standard and moderate) and a mix of structured and semi structured psycho-social rehabilitation. The degree of structure and the mix of service elements varies according to the needs identified by the service and its participants, and emphasises social and recreational activities to 6 of 16

8 promote peer networks and reduce community isolation. These services are accessed by a wide range of clients from the area. Kardinia is likewise in receipt of PHaMS funds. In addition, Kardinia Mental Health Service has been allocated funding by the Victorian Department of Health to support complex clients with a mental illness and comorbidities including substance use issues The following case study highlights the importance and impact of a networked service approach to addressing clients multiple and complex issues. This approach supports facilitated access across program types and case consultation, ability to respond proactively to multiple needs within the one service, partnerships in cross program case management and ability to address complex issues through systematic and comprehensive network of services referral and governance processes. The benefits of this service framework is a comprehensive, whole of person approach to an individual s needs and issues, coordinated through one organisation. This approach is common throughout The Salvation Army social programmes. 7 of 16

9 Case Study a network approach to providing services. Presenting issues: 56 year old male with diagnosis of paranoid schizophrenia and multiple admissions to psychiatric inpatient unit; a 20 year history of unstable housing and recurring homelessness, characterised by evictions from rooming houses for anti-social behaviour, significant daily substance use. Current situation: client lives in a private rooming house but this is tenuous due to ongoing issues with behaviour. Currently case manages by EastCare housing services Actions: Referred by EastCare Housing Services to the EastCare Mental Health Services. Referrals to external services have not been successful due to the client s level of agitation and aggression and complexity of presenting issues. Currently the client is linked to the Area Mental Health Services Community Mental Health Services. PDRSS Worker: In collaboration with EastCare Housing Services, the PDRSS worker provides intensive case management support to the client, including: Working in partnership with the area mental health service to ensure compliance with medications, attendance at reviews and monitoring of mental state; Case consultation with area mental health service (AMHS) clinicians to develop behaviour management plans for the PDRSS worker to implement and monitor with client; Consultation with EastCare AOD Services regarding substance use issues and harm minimisation strategies client unwilling to see AOD counselor; Continued liaison with EastCare housing support worker to assist client complete and submit public housing application (successful); Facilitated clients access to furniture and house hold set up through The Salvation Army Emergency Relief centre. Assist client with vouchers and material aid and clothing and links client to activities within local community (this is supported by PHaMS worker); Assist client to explore employment and education options Outcomes: Client is successfully housed in public housing. Client continues to be compliant with medications and appointments with AMHS and has reduced his substance use. There has been no psychiatric crisis or admission or police involvement since involvement of the PDRSS worker. The client has gained part-time work as a window cleaner. Key learnings: The Salvation Army provides a linked network of services that enables facilitation of cross referral, engaging a range of workers to address specific needs, rather than operating as siloed services. Given the range of services within our Networks, this case management approach enables referral to and consultation with in-house specialist services right through to practical supports such as clothing and furniture. The Salvation Army has a solid reputation for partnership development and supporting cross sector collaborations with tertiary services, e.g. AMHS, and other community based services. 8 of 16

10 2. PDRSS REFORM FRAMEWORK RESPONSE TO THE CONSULTATION PAPER A determination not to lose sight of those with complex needs is clear from the reform agenda. The Reform Framework consultation paper, in line with the Department of Human Services Human Services: The case for change (DHS, 2011) and the Productivity Commission final report on Disability Care and Support (Commonwealth of Australia, 2011), all evidence the multiple and complex needs of people with mental health, especially those who are homeless, and the importance of the funding and service sector to address these needs in a coordinated way. 2.1 Key issues The Salvation Army supports the Victorian Department of Health s moves to reform the PDRSS sector with the view to making these services more accessible, flexible and individually tailored to individual circumstances and needs. Redevelopment of the sector in line with the proposed reform framework will be a long term goal, but in the opinion of The Salvation Army is dependent on building capacity and capability, without losing specificity of specialist services as identified above. With a focus on our experience and expertise with our client cohort, The Salvation Army highlights the following key issues in relation to the Consultation Paper: The importance of ensuring that these services are available for the most marginalised and disadvantaged individuals, and that provision of such services is linked directly to services that work with and have demonstrated expertise with this client cohort. The Salvation Army strongly advocates for the retention of PDRSS funding within specialist homelessness support services to ensure a comprehensive service response to the complex needs of this client group. Whilst the principles of client directed funding is a commendable program aim, in reality it is, in our experience, very difficult to manage with this client group, due to the severity, complexity and range of presenting issues, the multiple service links and relationships required, the lack of supporting family or carer assisting in care and management, the highly transient nature of the clients and client relocation as a direct result of availability of housing options. Client directed funding does not address the funding required for basic service level infrastructure from which to provide services. The proposed funding model does not recognise the importance of the development of the therapeutic relationship, without which clients may not engage with services. This is a fundamental activity and central to The Salvation Army s success in working with this client group. 9 of 16

11 The Salvation Army provides a number of specifically targeted PDRSS programs for a discrete client group (i.e. Oasis program, prison release program for clients exiting the Thomas Embling hospital; counseling program attached to the Homelessness and Drug Dependency Program). We would strongly advocate that these programs sit outside of the reform processes addressing configuration and service remodeling. Further to the above point, The Salvation Army strongly supports the retention and safe guarding of these discrete programs rather than locating them within a centralised intake process. It is our experience that clients experiencing the highest need with entrenched and multiple issues often fall through such systems due to the inflexibility of processes and intervention models. Recognition of value adding for services that are collocated or are embedded within a larger diverse organisation. For example, the Salvation Army AOD service in Adult Services is collocated with mental health programs, a community nurse, crisis accommodation, outreach housing and justice outreach. The broader network of services includes transitional, long term and aged care residential programs as well as Community Aged Care Packages and extensive chaplaincy support. A whole of government approach to meeting client need is more likely to be achieved in these circumstances. Concern about the extent to which AMHS clinical services accept and work with the PDRSS and community based sector on the basis of partnership and equality rather than superiority and distance. This appears, from our perspective to be a cultural factor that needs to shift to allow recognition of knowledge, experience and expertise from the community based sector. The Consultation Paper outlines three key areas from which the new framework for the PDRSS sector will emerge, and poses questions in each area: Building organisational and system capability and capacity Remodeling programs and funding streams Streamlining service system configuration The Salvation Army provides the following comments against these areas where relevant to our experience and expertise. 2.2 Program remodelling The directions for the home-based outreach support component, supporting more explicit focus on mental and physical health, economic participation through education and employment and social participation are to be supported. However, The Salvation Army is concerned that such outcomes, whilst not impossible, are difficult to achieve for clients with chronic, complex issues and funding packages must recognise this. a) Area based planning functions and approaches The Consultation Paper proposes a system of area based intake and assessment, aligned to the mechanisms proposed for the National Disability Insurance Scheme. Under this 10 of 16

12 proposal, the reform framework would also see the standardisation of assessment, referral, service coordination and exit processes and documentation, based on clear practice, quality and governance frameworks and models. The Salvation Army cautiously supports a move to area based assessment and treatment coordination model, with reference to key issues identified above, and would look for assurances that specifically funded service approaches be retained. Our concern, as addressed above, is the inflexibility of the processes and intervention models adopted within such a system. The risk is that clients with multiple and complex needs fall through such a system or do not come to the attention of such mainstream services. The Salvation Army supports the move to progress service benchmarks and the introduction of client outcome measures to support service monitoring, quality review and achievement of quality outcomes. The Salvation Army Adult Services Melbourne Street to Home program has adopted the Outcome Star as a case management and client progress monitoring tool in conjunction with the Department of Human Services Homeless Accommodation and Support Services and Programs Branch, Housing and Community Building Division, and would welcome an opportunity to discuss our experiences and learnings of this tool with Department representatives. The Salvation Army Social Programmes are currently compliant with and accredited against QIC Standards for Community Services, and notes that quality assurance is frequently an unfunded activity that organisations undertake which puts significant strain on budgets and staff capacity. The Salvation Army acknowledges that the Department of Human Services (DHS) has introduced a standards framework that integrates standards and accreditation processes across its programs divisions, including housing, disability services, children, youth and families. These standards come into effect 1 July 2012, and it is anticipated that PDRSS funded services will be required to report under this framework. The Salvation Army supports a standards framework streamlined across department program divisions. In moving to area based models, The Salvation Army provides the following insights based on our experience within the AOD sector: The benefits and challenges of a central intake model are quite distinct in rural and metropolitan areas due to the clustering of services in a metropolitan setting compared to the more dispersed nature of rural services. As a result, the application of a one-sizefits-all model is problematic, nor does it recognise specialised and targeted programs. The issue of how state based and specialist services fit within an area based model needs to be considered in relation to referral process and equity of access. In addition, where service capacity is limited (i.e. low case load ratios, bed base facilities), access criteria needs to be clear and transparent, to target those with complex needs and multiple diagnoses and/or disabilities. For example, the SANS program receives both SHS and PDRSS funding to work with an identical client cohort with a history of homelessness, multiple service exclusions, dual diagnoses and other disabilities, and health issues. It may be problematic that one client receives unit based funding while the next referral will be in receipt of a package within a different outcome based model. 11 of 16

13 It is preferable for assessment to be face to face, and where possible in-reaching to where the client is most comfortable. In order to maximise accessibility for clients, the capacity for offsite assessments needs to be made available where a common assessment framework has been developed. b) Service reconfiguration In relation to the number and roles of service providers, The Salvation Army is concerned by the current number of providers and subsequent replication of service provisions within regions. The Salvation Army would support a reconfiguring of service capacity based on population demographics and gaps in service provision. In addition, The Salvation Army would strongly support consideration of specific funding for specialised services within high need services, such as homelessness and family and domestic violence services, given the strong links between homeless and mental health. Such a re-direction would have both a preventative function for those recently homeless (with mental health issues) and a long term supportive rehabilitation and reduction of the impact of long term disability. The Salvation Army supports the renaming of PDRSS to community mental health support services (CMHSS) as being more indicative of the focus of the type and context of services provided. 2.3 Workforce development and sustainability a) Development of core competency framework The Salvation Army strongly supports the development of a core competency framework, but cautions that their staff are not clinical and do not work within a clinical setting. As such a core competency framework must reflect the place and nature of the work the sector does, and how it complements and supports the work of clinical mental health services. A core competency framework that offers a series of pathways that are complimentary to a set of core competencies for working at different complexity levels would be viewed positively. There is general agreement from within The Salvation Army PDRSS sector that Certificate IV in Mental Health is generally inadequate as a standalone requirement for working with our specific client group. In reality and given the complexity of client presentations, PDRSS funded programs within The Salvation Army generally require and attract tertiary degree level qualified staff. An ongoing concern for the broader social welfare sector is the capacity of funding to cover the remuneration of staff at higher qualification levels. In addition, and as identified by the Productivity Commission, services within the broader social services sector are generally underfunded to provide the level of services required and often function on lower wages, requiring the use of additional organisational funds to supplement wages. Ongoing professional development options can only be realised if appropriate funding is available. The Psychiatric Disability Services of Victoria (VICSERV) provides PDRSS targeted training delivery core training (e.g. Certificate IV Mental Health, Orientation and Recovery Training), and training in partnership with specialist organisations and providers to community managed mental health staff. Through these training programs, the sector gains 12 of 16

14 access to key industry and sector experts 2. Fees are attached to training, and although relatively low cost, they may still be out of reach of services. The Salvation Army would strongly encourage The Department of Health to consider funding, or at the very least subsidising, mandated cross-sector training, within organisations (for example, area mental health services mandated to provide targeted training and or targeted case reviews to homelessness services on clinical governance issues). As indicated above in relation to area based service management, The Salvation Army would also suggest consideration of area based training program that could be coordinated by the lead PDRSS agency. Area mental health services currently provide area based coordinated training and development through their Education and Training Clusters 3 Training delivered through the clusters is free for clinicians within AMHS but attract a fee for others. The Salvation Army strongly advocates that this training be available free of charge to PDRSS funded services. In addition, The Salvation Army strongly advocates for the development of a common language between clinical and community based mental health services which would expedite improvements in coordination between the sectors. Cross sector training and professional develop activities often support this. b) Clinical governance systems A key concern for The Salvation Army is the increasing complexity of clients requiring staff and management to constantly balance an appropriate threshold of risk. The Salvation Army supports the contention outlined in the Consultation Paper that the development and management of quality clinical governance systems needs to be adopted within the new framework. Further, The Salvation Army would support this work being considered within the context that the issue of clinical risk governance. This is often a cause of significant frustration between clinical and community services where governance frameworks differ and relate to manifestly different frameworks of operation. This development work must be undertaken in partnership between The Department of Health and key sector providers, recognising the skills and experiences of all players. With the development of clinical risk management systems, the sector needs to consider supporting training, development and leadership within management, particularly with reference to practice and clinical governance, supervision and clinical review skills. Such skills development will support high quality client service delivery and outcomes. 2 Psychiatric Disability Services of Victoria (VICSERV) 3 The Mental Health Branch (MHB) has funded the State wide Education and Training Partnership (Cluster) Project since Three separate regional education and training clusters were established to coordinate and improve opportunities for mental health staff to access quality post employment education and training. Source: 13 of 16

15 2.4 Remodeling programs and funding streams That PDRSS funding to specialist services that have the capacity to provide a wraparound service approach within an integrated framework be, at a minimum maintained and at best increased, to ensure that clients with entrenched mental health issues and complex needs are provided with holistic and integrated care. That PDRSS funding be extended to include people older than 65 years of age. In our experience, older people with mental health issues in specific aged care accommodation or in supported accommodation are often under serviced in relation to addressing multiple, entrenched and complex needs. As a consequence they are often significantly excluded from social and community supports. Additionally, as the demographic trends demonstrate, the sector will continue to experience a growth in the demand for services as the number of people aged 65 years and over increases. The Salvation Army s James Barker House for example, will provide 119 beds for older marginalised men and women with entrenched histories of homelessness, drug and alcohol abuse with or without a history of mental illness. 2.5 Funding streams The Salvation Army has experience of coordinating and brokering service responses for DHS clients with complex needs through the Multiple and Complex Needs Initiative MACN) across a number of programs, including SANS and the Melbourne Street to Home (MS2H) programs. The packages were specifically tailored to meet the needs and circumstances of the client but were not directed by the client. The funding paid for case management, service infrastructure (i.e. portion of vehicle expenses, phone calls as well as welfare spending and other particular services such as home help). The case coordination role included eliciting other complementary support services such as, AOD, CACP and recreation programs. Within our scope of experience, managing multiple client support packages can be difficult at times, particularly the juggle of program costs (i.e. fixed costs of setting up programs including staffing, vehicles and office infrastructure) against service delivery costs. This becomes even more pertinent with the transient nature of the clients (i.e. return to prison, institution) or the fixed funding timeframes. Client directed funding would potentially create more pressure on these fixed costs, and the issue of base funding (either within the client package or direct to a service) which support the infrastructure of programs needs to clarified. What is not clear from the Consultation Paper is the cost associated with implementing the reformed system configuration, and whether the proposed changes are based on the current funding levels or will require additional Department investment. The Salvation Army is concerned that such a significant reform cannot remain cost neutral, and consideration needs to be given to: o Costs associated with specific training and development issues, particularly in light of the development of standardised clinical governance process and practice models. 14 of 16

16 o Workforce development issues and the recommendation for the development of a competency framework that will set, above other things, worker remuneration, the Department must take into consideration the impact of the outcomes of the Fair Work Australia tribunal upholding the pay equity claim for community services workers. 2.6 Alignments with broader health sector The structure of service reform should align with Medicare Locals. Such alignment will support opportunity for direct collaboration with the area based PDRSS lead agency and support mapping of population demographics and needs. Indeed, such alignment makes practical sense in light of the direction for area based services and area based assessment and planning processes. 15 of 16

17 3. RECOMMENDATIONS AND CONCLUSIONS The Salvation Army supports the reform agenda as long as it does not compromise specialist mental health services within the homeless support sector. Whilst the Consultation Paper references clients with complex and multiple needs, it does not recognise that these clients tend not to access mainstream services and fall through inflexible and standardised system, structures and processes. Mainstreaming the context and funding of specialist services will further enhance this cohort s invisibility within the generic mental health and community based services. In light of the key issues and comments offered in relation to the Consultation Paper, The Salvation Army makes the following recommendations: Recommendation: that PDRSS funds are retained, and expanded, within specialist homelessness support services to ensure a comprehensive service response to the multiple and complex needs of this client group. Recommendation: that programs that specifically target population groups with multiple and complex needs are provided with alternative funding packages that recognise and reflect integrated service frameworks and linkages and partnerships, allowing for the packaging of service responses to meet client needs and reflecting service infrastructure costs. Recommendation: that PDRSS programs providing specialist and discrete service responses to highly marginalised individuals (i.e. prison release program, Homelessness and Drug Dependency Program) continue to operate as such, and are located outside of the mainstream service reconfiguration and modelling processes but responsive to the clinical governance and standards developments. Recommendation: that operation and clinical governance standards and frameworks be developed recognising the place and nature of community based mental health support services as complementary to and respectful of the role and practice of AHMS. Recommendation: that area based cross sector core competency skills training framework be developed and funds be provided to services to facilitate uptake, and that the current training provided through the AMHS Education and Training Clusters be made available cost free to PDRSS funded clinicians. The Salvation Army mental health service network managers and clinicians have considerable operational and practice experience and knowledge with the identified highly marginalised client cohort and would welcome the opportunity to work with the Department in progressing aspects of this reform agenda. The Salvation Army would welcome an opportunity to discuss the key issues and recommendations identified in this submission with Department of Health representatives. 16 of 16

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