TIME TRUST RESPECT. Case Management in Emergency Relief: The Doorways Model

Transcription

1 TIME Case Management in Emergency Relief: TRUST The Doorways Model RESPECT

2 TIME Case Management in Emergency Relief: TRUST The Doorways Model RESPECT Dr. Nicola Brackertz

3 This study was conducted for The Salvation Army by researchers at the Swinburne Institute, Swinburne University of Technology (Melbourne) and has been cleared by the University s Human Research Ethics Committee. The Salvation Army Australia Southern Territory 2014 All rights reserved. Except for fair dealing permitted under the Copyright Act. No part of this book may be reproduced by any means without the permission in writing from the author/publisher.

4 Acknowledgements The author would like to thank the many managers, case managers, emergency relief workers and clients who contributed to this study. Thank you for welcoming me in your place of work, taking the time to talk to me and being forthcoming with information and support. At The Salvation Army territorial headquarters, special thanks goes to Elli McGavin (Territorial Social Policy and Programme Development Manager) and Pamela Hanney (Doorways Coordinator), who were active supporters and collaborators throughout the research process. The Salvation Army acknowledges the ongoing support of Westpac in the development of the Doorways philosophy that underpins this research.

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6 Contents Executive summary... 1 Findings...3 Recommendations...5 Introduction... 7 What is Emergency Relief?...9 Who seeks ER? and why?...9 The Doorways philosophy...13 Case management definitions and models...14 Doorways case management...15 Research process Conceptual framework...18 Research findings...19 Transitioning from transactional to relational ER...19 Creating pathways from ER to case management...19 Shifting client attitudes and perceptions...22 Mechanisms for Doorways case management...23 Client-case manager relationship...23 Case management philosophy...23 The Doorways case management model...24 Context of Doorways case management Staff skills Supervision and support Community sector design, capacity and referral Outcomes and evaluation Policy context and resources...32 Findings...33 Conclusion and recommendations...35 Recommendations...35 Appendices...37 Appendix 1 - Doorways guiding principles...37 Appendix 2 - Doorways key features Appendix 3: Doorways hub - satellite model References... 40

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8 Executive summary The Salvation Army is a major provider of Emergency Relief (ER) services in Australia. In 2013, the organisation provided ER to over 157,000 individuals and their families nationally. Historically, ER services have provided crisis support and assistance for disadvantaged families and individuals through the provision of material aid (e.g. food, assistance paying bills, general household goods and clothing) and information, referral and advocacy. In recent years, however, people have been presenting to ER with more complex needs and there has also been a rise in the number of people seeking aid. Rather than acting as a way to alleviate short term financial stress, ER services now see many clients who are experiencing long term financial hardship due to a combination of factors, including inadequate income support, unemployment or retrenchment, mental health issues, disability, housing stress and social exclusion. Clients often present repeatedly to ER services and use multiple agencies to help them get by. In response to this, The Salvation Army has, over recent years, piloted and implemented a more holistic approach to the delivery of ER the Doorways philosophy. Through this philosophical approach, ER addresses the client s immediate needs and provides a model for intensive assessment of the underlying causes of poverty. The introduction of the Doorways case management model, in conjunction with ER, is one of the mechanisms employed to facilitate more holistic responses to client needs. Under the Doorways philosophy, ER and case management complement each other to address the symptoms, as well as causes of financial hardship. The model aims to assist clients to break the cycle of repeated crisis, facilitate personal growth and social inclusion, and link them into the greater service system so they can access the services and supports they need. Doorways provides: 1. Basic transactional safety net services, such as food and material aid; 2. Advocacy, information and referral; and 3. A comprehensive wraparound service that uses a relational case management model (strengths based and capacity building). The Doorways philosophy is not a prescriptive model and recognises the need for flexibility and the capacity to be responsive to place based client needs. While the Doorways philosophy is expressed differently in different locations, it still enables consistent principles to be applied. In late 2012, The Salvation Army commissioned Swinburne University to undertake an initial exploratory study of selected ER sites operating under the Doorways philosophy in order to answer the question: What does case management under Doorways look like? and identify the key characteristics of a case management model suited to the ER context. To inform the research, interviews and case studies were conducted with Doorways managers, staff and clients in Victoria, Tasmania and South Australia. The introduction of case management into ER is a recent phenomenon and there is, as yet, limited data on the kinds of case management models that may be appropriate. Consequently this study is pioneering in many ways; in terms of discovering how case management can be successfully integrated into ER and also in terms of the models and mechanisms that may be suitable. The study found that Doorways case management is a strengths based relational model of case management, where time, trust and respect are key to facilitating successful client outcomes. Within the Doorways context, case management is a continuation of the relationship already established as part of the preliminary ER assessment and support process. Its success depends on the quality of the relationship between the case manager and the client. This mechanism can be understood in terms of a move from traditional transactional ER and a new model of relational ER. 1

9 Case management in ER is an emerging approach and requires the adoption of new delivery models suited to the ER context. In addition it is necessary to build organisational capacity and carefully manage organisational change in order to introduce these new service models. Doorways case management exhibits many of the characteristics of case management in homelessness services as identified by Gronda (2009). Consequently the models show similarities especially in their emphasis on the relationship as the active ingredient to successful case management. This lends support to the Doorways case management model and indicates that as case management in ER continues to evolve, the models used in homelessness services can act as a point of reference. Doorways is being gradually introduced across The Salvation Army, and steps are being taken to manage the organisational change required in terms of staff attitudes, knowledge, practices and available resources and supports. As with change in any large organisation, the change process offers challenges as well as opportunities to build capacity and improve processes. The development, trial and implementation of new training, tools and outcomes measures, as well as the continual refinements of Doorways case management, offers considerable opportunity to continue to develop an ER service that facilitates lasting benefits to clients into the future. 2

10 Findings Finding 1: ER and case management are complementary The key finding in relation to the mechanism for providing case management under Doorways is that ER and the provision of case management are complementary and operate on a continuum. The provision of material aid no longer acts merely as a means of tiding people over in a financial crisis (transactional ER). Rather, it becomes the facilitator for deeper engagement; that is, relational ER. Finding 2: Relational ER creates referral pathways into case management Building the relationship at the ER assessment level provides increased opportunity for referral into case management. Key changes that facilitate this include longer interview times and training of ER workers and volunteers in conducting assessments. Finding 3: The client-worker relationship is central to Doorways case management Doorways is based on a non-coercive relational model of case management that takes account of clients capacity, willingness and readiness to change. This relational model is characterised by time, trust and respect. Finding 4: Shared case management philosophy and flexible approach The Doorways model provides workers with a shared and consistent philosophy that allows for flexible case management approaches to client needs. Finding 5: Need for tools to support case workers The Doorways model requires the development of key governance frameworks supported by consistent policy and procedure. The Doorways model requires commitment to workforce development through targeted and ongoing training to support best practice case management. Finding 6: Staff skills, training and qualifications The ability to attract and retain qualified staff is a challenging aspect for all ER providers. Doorways relational model relies on staff engaging positively with clients via highly developed interpersonal skills, maturity and good communication skills. Doorways relies heavily on the support of volunteers due to limited funding. The training, skilling and retention of ER workers is, therefore, a significant challenge. ER workers require foundational skills, including assessment, interview skills, and the capacity to make appropriate referral. The Doorways model also employs case managers with formal qualifications. These qualifications vary between states. The Salvation Army is in the process of developing its own accredited training, which will lead to greater uniformity of skills across the organisation. 3

11 Finding 7: Supervision Supervision is a critical element of case management. Supervision and sharing of best practice enables staff to develop effective case management practices and the worker-client relationships. The research identified that to continue building best practice outcomes more resources need to be directed to the provision of supervision. Finding 8: Community sector design, capacity and referrals The need to build capacity and referral pathways in the broader community sector was noted as a concurrent external factor impacting on the capacity of Doorways services to meet client demand. Finding 9: Outcomes and evaluation Interviews with staff and clients indicated that Doorways was successful in facilitating positive client outcomes. The challenge in this new delivery model is to establish systematic methods of capturing longer term client outcomes. Finding 10: Policy context and resources Federal government policy and funding shifts have enabled The Salvation Army to move to a Doorways case management model. Further work needs to be undertaken to align the policy objectives and funding models. 4

12 Recommendations Recommendation 1: Scope and availability of Doorways case management The Salvation Army should continue to expand the scope and availability of Doorways case management where possible in line with government policy directions and funding. The Salvation Army should advocate for an expansion of case management within the ER sector. Recommendation 2: ER worker and volunteer training and qualifications The Salvation Army should continue to develop and deliver Doorways specific training for volunteers and workers within Doorways sites, including ER assessment, case management tools and procedures consistent with a Doorways model of relational ER. Recommendation 3: Case manager qualifications and training The Salvation Army should continue to support the introduction of a national minimum qualification requirement for case managers within Doorways services and the broader ER sector. Recommendation 4: Doorways Policy and Procedures Handbook development The Salvation Army should develop a comprehensive Doorways policy and procedures handbook which provides support and guidance on ER assessment and case management. The Doorways Policy and Procedures Handbook should provide guidelines for the development of referral networks and relationships to complementary Doorways case management activities and to increase the volume and variety of referral opportunities. Recommendation 5. Supervision The Salvation Army should continue to develop consistent models and strategies to ensure that all case managers receive sufficient and appropriate supervision. Recommendation 6: Outcomes and evaluation Common evaluation principles for case management should be developed for all Doorways centres to enable common client outcome measurements. A longitudinal study should be undertaken to measure client progress and outcomes through the Doorways case management model. Recommendation 7: Case management data The Salvation Army s Service and Mission Information System (SAMIS) should continue to expand existing data capture mechanisms for case management delivery within Doorways centres to enable the evaluation of longer term outcomes. 5

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14 Introduction The Salvation Army has been providing community services, including emergency relief (ER) in Australia for over 130 years. ER services are funded variously through local, state and federal governments. In 2013, The Salvation Army 1 provided ER to approximately 157,000 people nationally, delivering over 320,000 occasions of support. 2 As the name suggests, ER provides immediate support to individuals and families in times of crisis. Initially conceived as a way to address short term financial problems, the need for food is one of the primary reasons why people seek ER. In recent years there has been an increase in the number of people requesting ER (Homel & Ryan 2013) and clients have been presenting with increasingly complex needs (Nguyen 2011; Richard Watts & Associates 2011; Uniting Care 2009). Consequently, rather than acting as a way to alleviate short term or intermittent financial crises, ER services now contend with many clients who are experiencing long term financial stress. This is due to a combination of factors, including inadequate income support (ACOSS 2012), unemployment or retrenchment, mental health issues and disability, housing stress, and social and service exclusion. ER has become, in some instances, a way to supplement inadequate pensions, benefits and allowances (Nguyen 2011; Uniting Care 2009). Symptoms of this include clients repeatedly presenting to ER services, often using multiple agencies to help them get by. Clients are also seeking assistance for a wider range of issues, such as education costs, fuel costs, housing stress (Richard Watts & Associates 2011) and utility costs. As a consequence, ER has evolved from being a basic safety-net service to becoming a primary support entry point, a doorway, for people living at, or below, the poverty line who are often disconnected from the wider service system. In response, while the need for food remains the primary reason people make contact with ER organisations, the complexity of presenting issues has led to an increasing number of providers now offering a range of integrated services aimed at re-engaging clients with the economic mainstream, as well as providing pathways to social inclusion and a better quality of life (Richard Watts & Associates 2011: 5). The Salvation Army s Doorways philosophy is one such model and was introduced in Tasmania in In subsequent years, the Doorways delivery model has been extended to 81 centres across Australia. Doorways has three levels of service delivery, and provides: 1. Basic transactional safety net services such as food and material aid; 2. Advocacy, information and referral; and 3. A comprehensive wraparound service that uses a case management model that aims to break the cycle of disadvantage and deprivation. Levels 1 and 2 are the minimum level of support provided under Doorways. Where clients have complex needs and are willing to address these, and where funding allows, Doorways also provides the option of referral into case management, and a range of services that aim to assist with financial literacy, living skills, health and wellbeing issues (including mental health), self-esteem, personal capacity building, increased community engagement and social inclusion (fig. 1). The key mechanism underpinning this service delivery approach is the establishment of trusting, respectful and enduring relationships between those in need and those providing the service. In this way Doorways works with clients on underlying and systemic issues alongside the immediate emergency. 1 In Australia, The Salvation Army has an Australia Southern Territory that encompasses Victoria, Tasmania, South Australia, Western Australia and the Northern Territory, and an Australia Eastern Territory (New South Wales, ACT and Queensland). Each territory is subdivided into a number of divisions. For simplicity s sake this report refers to divisions in terms of the states within which they are located. 2 All Salvation Army specific data is provided through The Salvation Army Service and Mission Information System (SAMIS). SAMIS is a customised, in-depth and unique client management, data collection, information and reporting system used by most Salvation Army social programs across Australia. 7

15 Figure 1 The Doorways model Strengths-based case management that it is holistic, client centred and aims to build the client s capacity for selfcare is a critical element of the Doorways model. The challenge is that existing case management models may not fit the historical ER context and that to date there are few examples and limited evidence of the application of case management in ER (Nguyen 2011). This report presents the findings of an exploratory study that asks What does case management in an emergency relief context under Doorways look like? The research investigated the mechanism and context for The Salvation Army s case management model under Doorways, as well as opportunities and constraints. The research was conducted by Swinburne University for The Salvation Army and draws on a series of case studies, which included site visits and interviews with managers, staff, volunteers and clients at Salvation Army Doorways centres in Tasmania, South Australia and Victoria. The report aims to establish the key characteristics of a case management model suited to the ER context. It presents an initial view of The Salvation Army s Doorways philosophy in practice. 8

16 What is EMERGENCY RELIEF? The Australian Council of Social Services (ACOSS), the peak body representing social service providers in Australia and publishers of the Emergency Relief Handbook (ACOSS 2011), defines ER as: the provision of financial or material assistance to people in financial crisis. Some clients access ER to help them through a one-off episode; while for others ER becomes part of their solution to dealing with ongoing financial disadvantage. The aim of ER is to assist people experiencing financial crisis in a way that maintains dignity and encourages self-reliance. Assistance usually comprises: 1. Provision of financial or material aid to meet an immediate need - this may include cash assistance, assistance with paying utility bills, food vouchers, food parcels, clothing or household goods; and 2. Information and referrals that may help to resolve the underlying problems experienced by the client for example a referral to a financial counsellor. This is not always possible and clients may choose not to take up the referral option (ACOSS 2011: 4). The ACOSS definition is very similar to that used by the Department of Social Services (DSS) 3 which is the main funder of ER in Australia. Emergency Relief services provide support to address immediate needs in time of crisis. Assistance often includes food and clothing parcels or vouchers, transport, chemist vouchers, help with accommodation, payment of bills, budgeting assistance and sometimes cash. Importantly, Emergency Relief agencies provide appropriate referrals to other services that help to address the underlying causes of financial crisis and social and financial exclusion (FaHCSIA 2012: 5). Both definitions acknowledge that the main emphasis of ER is on alleviating an immediate crisis through material aid, but add that efforts must also be made to address the underlying issues that contribute to the crisis through referrals to other services and supports. However, while ACOSS acknowledges that for some people ER can become part of their solution to dealing with ongoing financial stress, the DSS focus is squarely on ER as a remedy in times of acute crisis. The question of how the causes of peoples financial stress may be resolved and whose responsibility it is to do so is also disputed territory. Engels and his colleagues (2012) describe ER as a contentious aspect of poverty relief in Australia, largely due to different opinions about how to tackle poverty relief cut ER and increase income support payments or alternatively, increase ER funding. Landvogt (2006) observes that ER is not a popular topic in social policy because it indicates systemic failures. Nevertheless, ER, and especially the provision of food aid to those most in need, is a direct and tangible aspect of giving that many Australians identify as the mark of a civilised society. Who seeks ER and why? Research on the need for ER paints a grim picture and shows that a large proportion of ER clients are experiencing severe financial stress. The Salvation Army s annual National Economic and Social Impact Survey (ESIS), which is based on responses from 2,700 ER clients Australia wide, found that in 2013, 51% of ER clients had gone without meals and 28% could not afford a decent meal at least once a day (The Salvation Army 2013). This is consistent with findings from a recent report by Anglicare Australia, which shows that 62% of adults who access ER consistently skip meals and 1 in 3 regularly miss out on food for an entire day due to a lack of access and resources (Wise & Wilks 2012). Overall, ESIS demonstrates unacceptably high levels of material deprivation among ER clients, including 3 In 2003, the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) was re-named the Department of Social Services (DSS). 9

17 a lack of heating, warm clothes and adequate housing. 4 The effect of material deprivation on children is most concerning, with ESIS finding that 39% of ER clients cannot afford up to date school books and new clothes for their children, 39% cannot afford a yearly dental check of for their children, 36% do not have a separate bedroom for each child over 10 years of age, and 37% cannot afford to have their children participate in school activities and outings (The Salvation Army 2013). The effect on children s nutrition is also severe, with 72% of children in the households of ER clients experiencing recurrent food insecurity or recurrent severe food insecurity, leading children to eat only a few kinds of low cost food, not eating a variety of food, or not eating enough food (Wise & Wilks 2012:38-40). As described in ESIS (2013), The Salvation Army s ER clients are predominantly: Women (61%) Aged (57%) Sole parents (33%) or a couple living with one or more children (13%) Living alone (29.3%) In receipt of an income support payment (90%) Unemployed (79%) or unable to find work (21%). The main reasons for unemployment are disability (41%), parenting (27%) and caring (10%) responsibilities. In 2013, The Salvation Army provided ER to 156, 913 persons and their families nationally (fig. 2) a total of 320,260 client contacts. The Salvation Army data also shows that over half of persons seeking assistance were not doing so for the first time in 2013 (Fig 3). On average, up to a third of clients sought ER assistance more than three times a year (Fig. 4), indicating that many were experiencing ongoing financial difficulties. 4 ESIS (The Salvation Army, 2013) and Anglicare Victoria s Hardship Survey (Wise and Wilks, 2012) both incorporate the essentials of life questionnaire used to assess the degree of deprivation, developed by Saunders and his colleagues (Saunders, Naidoo et al. 2007; Saunders & Wong 2009). 10

18 Set against this data, the traditional model of ER which only provides material aid is unlikely to engender long term benefits for clients or resolve their situations. Debt and income poverty are two factors in a complex web of disadvantage that combine to place people in financial stress (Brackertz 2012; Saunders & Wong 2009). 11

19 Leila is fairly typical of many people seeking ER. She works as a nurse, is recently divorced and is trying to re-establish her life in a new town. Her story shows the emotional toll high stress levels over an extended period can take and how a number of stress factors combine to put people into financial hardship. I am a nurse in aged care. I have a one year old. I am a single mum, not long having gone through a divorce. I first came to The Salvation Army because I was struggling financially and I had a lot of bills that were out of control. I needed some guidance and someone suggested I come here and I did. That was about six months ago. I was having a bit of anxiety with ringing power companies. I didn t know how to ring and explain my story because I felt they ve heard it all before and wouldn t believe me. But the case worker helped me ring them and organise payment plans or extensions, and assistance with budgeting. A few things happened that threw me off balance. It s been really hard. It s not an easy thing to come and ask for help for yourself. 12

20 The Doorways philosophy In response to the challenges presented by the increasingly complex needs of ER recipients The Salvation Army s Australia Southern Territory conducted a review of its community support services in (The Salvation Army, 2009a). The resulting Doorways philosophy now guides the delivery of many of The Salvation Army s ER services across Australia (The Salvation Army, 2009b). Doorways recognises that financial hardship is often a symptom of more complex issues and that persistent financial stress can cause other problems to accumulate, making it harder to resolve underlying issues (Brackertz 2012; Fitch, Hamilton et al. 2011; Kempson 2002; Pleasence, Buck et al. 2007; Wesley Mission 2009; Wesley Mission 2010). Doorways responds to this complexity by providing wraparound services to address not just the immediate crisis but also underlying causes. Doorways recognises that ER plays an important role as a primary entry point that addresses immediate needs (crisis) and through which clients can be connected to a wide range of services and supports. Doorways guiding principles centre on a holistic approach that aims to create pathways to help each individual to identify the goals they want to achieve and help them to map out a pathway to this destination. It does this by developing strategies for integrated services around shared arrangements, which maximise the support each agency provides to the client. Underpinning this is a process of appropriate assessment and triage, which aims to identify and prioritise client needs. 5 Doorways seeks to empower people and build individual human capacity, and recognises that ER is only the first step in helping clients. Adding case management expands services to support clients in dealing with a range of issues, including budgeting, household management, housing, health, relationships, employment, mental and emotional wellbeing, drug and alcohol and gambling issues. In this way, ER can become an entry point - a doorway - to access many other important services. Case management and ER lie at the heart of Doorways. While distinct, the two are provided side by side and are complementary, allowing clients to access services and supports as needed (fig.1). In order to operationalise this, new models for ER and case management are being developed. 5 Refer to Appendix 1 for a complete list of Doorways guiding principles and Appendix 2 for key features of the Doorways model. 13

21 Case management definitions and models Case management is a service delivery approach now widely adopted across diverse settings in the human services and health sectors, though its application in the ER setting is still new. Broadly case management can be described as a...collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual s holistic needs through communication and available resources to promote quality cost effective outcomes...[it is] a boundary spanning strategy to ensure service provision is client rather than organisationally driven (CMSA 2009). In the social services, case management can be viewed as a response to a fragmented social service and care system (Brooke 2010) and was understood as an entity (usually a person) or single point of contact, that coordinates, integrates and allocates care within limited resources (Rapp & Goscha 2004; Thornicroft 1991). Since the 1980s more differentiated models of case management have emerged, including assertive community treatment, rehabilitation, clinical and strengths-based case management, each with their own practices and structures. Many of the newer models, such as strengths-based case management, emphasise the importance of direct service provision and assistance with everyday living tasks, with referrals to specialist services as needed rather than a first port of call. Case management models differ depending on the settings within which they are implemented and the philosophies and skills of staff who practise it. 6 Key attributes tend to include a collaborative approach and integration of services and resources, aimed at improving clients planned outcomes. Best practice in case management requires...organisational arrangements to support service delivery, staff who have been trained for the approach and its application to the particular practice setting and strategies to ensure that the organisation can be responsive to evidence from practice and advocate for systemic and policy change to support service delivery (CMSA 2009). 6 For consistency and clarity, this report uses the term case manager to describe the paid workers who deliver case management under Doorways. It should be noted, however, that many Doorways centres do not use the term because of negative connotations in terms of managing clients. Some centres prefer case worker or case facilitator, but these terms are used fluidly and can be applied to both qualified paid case workers and volunteers who conduct intake assessments. 14

22 Doorways case management Research has shown that case management models that provide practical supports, education and advocacy are more successful than models that primarily have a coordination and referral function (Gronda 2009). This is consistent with Doorways, which uses a strengths-based approach that aims to provide a wraparound service including a range of practical supports, programs and services, many of which are provided internally by The Salvation Army, or by referral to external agencies. Strengths based case management lies at the heart of Doorways and builds on clients existing skills and resources and aims to help them to identify and achieve their personal goals. The relationship between the case manager and the client is the key engagement mechanism, and the process is driven by client self-determination, rather than the case manager deciding the actions they think are most appropriate. Doorways case management recognises that unless a person is ready for and willing to embrace change and take the necessary steps to address their underlying issues, then the result will not be sustainable. In practice, this can mean providing food and material aid to people in acute crisis until their situation has stabilised and they are ready and able to address other parts of their life that contribute to their crisis. At this stage clients are provided with the resources and support they need to be able to make their own choices; ideally, choices which will improve their opportunities. Identification of the points at which people are receptive to making changes in their lives is central to the success of Doorways, as are trust, respect and enduring relationships between workers and clients. The Doorways philosophy is not a prescriptive one size fits all model and can be adjusted to fit the particular circumstances of The Salvation Army s many community support services (some large, some small), the resources available to them and the unique demographics they serve. The central tenet underpinning Doorways is a desire to assist individuals and families repeatedly presenting in crisis to achieve their goals and to create pathways out of poverty, facilitated by intensive case work. Doorways case management does not replace traditional ER, but sits alongside it to provide additional social and practical supports to assist people to address specific needs, facilitate social inclusion and create pathways out of poverty. Key to this is an understanding that not all ER clients require or desire the same level or the same kind of support. 7 For some people their crisis is short term and presents with clear and tangible solutions and the provision of a small amount of material aid or advocacy will help to resolve their situation. Others face complex and recurring crises and may be overwhelmed by the circumstances facing them. In these instances, medium term interventions with the assistance of a case worker, financial counsellor or other specialist worker as well as referrals may be required to help the person to manage their crisis; often over a period of weeks or months. Some people presenting to ER require long term support, as they are caught up in circumstances that cannot be easily resolved and are constrained by very limited incomes (e.g. a reliance on government allowances and pensions), protracted or chronic health or other issues. These clients are in persistent financial stress or inter-generational poverty and are usually contending with a range of complex issues that prevent them from breaking the cycle of repeated crisis. This client group is perhaps the hardest to help, but also presents the greatest opportunity to assist them in building their capacity to make lasting changes in their lives. It is the latter two groups that have the most to gain from Doorways. In addition to providing internal supports and referral, the success of Doorways case management rests on the availability of appropriate and trusted referral pathways to internal and external services that will help address clients presenting issues and build their capacity. Many Doorways centres have established relationships with services in their local areas to enable referrals. Sometimes this is facilitated through formal networks of service providers, other times it occurs through informal or personal networks. Doorways hubs (Appendix 3) provide a number of services, though the nature and combination of these services differs across states. For example, Tasmanian Doorways hubs are required, at a minimum, to have sufficient funds to provide delivery of ER support and have a case worker, as well as offer the Positive Lifestyle Program 8 and 7 Compare: The Salvation Army 2009b. 8 The Positive Lifestyle Program (PLP) is a 10-module course that takes participants through a self-awareness-raising process, focusing on personal difficulties they may be unable to identify or address. PLP, in a non-invasive, non-judgmental way, encourages participants to consider the following 10 aspects of their lives: self-awareness, anger, depression, stress, loneliness, grief and loss, problem solving, assertiveness, self-esteem, and goal setting. 15

23 budgeting assistance. In South Australia, Doorways consists of emergency relief and three interrelated services, namely case management, the Positive Lifestyle Program and Salvos Psych. Salvos Psych is an example of a formalised referral network. Salvos Psych is a collaboration with the Australian Psychological Society, which provides pro bono support for mental health plans and a range of issues such as family violence, depression, addiction and family breakdown. The benefit of Salvos Psych as a part of Doorways is that it provides trusted referral pathways for clients who require assistance with mental health issues. In addition, many Doorways centres aim to co-locate services to minimise the stress and anxiety experienced by clients if they have to visit multiple services in multiple locations and have to re-tell their story each time. These services can include mental health, housing and homelessness supports. In summary, Doorways aims to provide long term sustainable solutions that go beyond the bandaid response of traditional ER. This includes prevention and early intervention where possible, and may take the form of medium term interventions and referral. However, a large proportion of ER clients are repeat clients (estimated to be between 50%-80%, depending on the centre), often experiencing entrenched or inter-generational poverty. These clients experience a complex range of issues that cannot be resolved quickly or easily, and they may be reluctant to fully engage with services. For this client group, Doorways offers the opportunity for ongoing engagement centred on building trusting and respectful relationships with a view to building clients capacity over the long term. The overarching goal is that Doorways will: Contribute to reducing poverty and disadvantage, particularly entrenched poverty; Prevent families who are at risk from spiralling into poverty; and Create community connectedness for people who are socially isolated. 16

24 Research process This report is based on a series of case studies with selected Doorways hubs in The Salvation Army s Australia Southern Territory. Centres were chosen to represent varying stages of Doorways implementation and success, as well as different geographic locations and the differences in client characteristics. In February and March 2013, the researcher conducted site visits to five Doorways hubs across Tasmania, South Australia and Victoria. The researcher also interviewed divisional Doorways managers in South Australia and Tasmania to establish the Doorways implementation model and gain an overview perspective. In addition a number of clients were interviewed about their experiences with Doorways. The research was approved by Swinburne University s ethics committee. Figure 5: The case management formula (adapted from Gronda 2009) 17

25 Conceptual framework Conceptually, case management can be understood as a mechanism for client engagement that operates within a certain context to provide positive client outcomes. 9 This can be visualised through the case management formula, as illustrated in Figure 5. In analysing the research conducted for this report, the case management formula provides the framework within which The Salvation Army s organisational responses to the Doorways philosophy are viewed. It should be noted that the organisation providing case management does not have the same amount of control over each of the components of the case management formula. This means the ways in which case management is delivered are shaped not only by the organisation s case management philosophy and practice, but also by systemic constraints external to the organisation. The case management delivery mechanism is the part of the case management formula the providing organisation is most able to shape, in terms of their underpinning philosophy and how case management is provided by their staff. In the model used here, which is consistent with the Doorways philosophy, and which is validated by research, the central mechanism for providing case management is the client-practitioner relationship (Bedell, Cohen et al. 2000; Chinman, Rosenheck et al. 1999; Chinman, Rosenheck et al. 2000; Howgego, Yellowlees et al. 2003; McCabe & Priebe 2004), which aims to provide to the practical support, education and advocacy to the client. Gronda (2009) identified the key elements for the success of this relationship as persistence (enduring), intimacy and respect. This finding resonates with Doorways emphasis on time, trust and respect. More broadly, the design and capacity of the community sector, in particular access to timely and appropriate specialist supports, as well as staff skills and support, provide the context for the mechanism. The organisation providing case management has only limited influence over the design and capacity of the broader community sector. However, the services and supports that are provided internally, e.g. employing case managers with the requisite high level skills in client assessment, relationship building and communication, as well as adequate supervision, training and recognition, are areas that can be influenced by the providing organisation. The mechanism and context for case management combine to produce client outcomes. In essence, case management aims to produce lasting change in the client by empowering the individual to choose to shift from one state or point to another, with the latter being characterised by an increased capacity for self-care. Success can mean that clients no longer require assistance, or require reduced assistance to access the services and supports they need. In the case of Doorways this would manifest in reduced reliance on ER by clients who have complex needs or are experiencing persistent or inter-generational poverty; improved client ability to access the services and supports needed; greater social connectedness (social inclusion); improvement in the general sense of wellbeing and self-esteem and a reduction in stress and anxiety. The policy context and resources (available funding) provide the environment within which case management takes place. It is important to consider the greater context, as policy goals can be at odds with priorities on the ground. This is applicable for case management models generally and for case management in the ER context in particular. 9 The conceptual framework used in the report is adapted from Gronda s (2009) synthesis of 17 studies that evidenced the effectiveness of case management in homelessness services. Gronda s study was chosen as a point of reference as case management in homelessness services is in many respects similar to case management in an ER context. 18

26 Research findings Transitioning from transactional to relational ER The importance of relationships to successful case management is well established (Arnold, Walsh et al. 2007; Beresford, Croft et al. 2008; Bressi Nath, Alexander et al. 2012; Chen & Ogden 2011; Gronda 2009) and is consistent with the findings from this study. The most important theme to emerge from this research was the importance of the client-worker relationship as a mechanism to provide pathways from ER to case management and as the key feature of an enduring case management process. A relevant finding from this research is that in an ER context the client-er staff relationships which precede case management play a critical role in the success of the formal case management process. These relationships are instrumental in establishing the pathways that allow clients to transition from the crisis-driven need for ER to case management. The study also found that transitioning from a transactional to a relational model of ER presented challenges not only for the organisation, but also in terms of managing client expectations. Early indications are that while the process of transitioning to and implementing the new model of ER delivery is resource intensive, in terms of time and money, it is justified by the outcomes. Creating pathways from ER to case management Prior to the introduction of Doorways in Tasmania, ER used the traditional transactional model that consisted of minute assessment interviews, after which material aid was provided to clients. Clients could only access ER once every three months (or four times a year), and were requested to demonstrate their need by providing a variety of financial and Centrelink statements. This approach is consistent with a long held transactional model of charity, which disempowered people seeking assistance (Frederick & Goddard 2008; Toomey 2011). In 2009, The Salvation Army in Tasmania was the first state to replace transactional ER with a relational model centred on trust, respect and time. It is now the model for Doorways in other states. The manager observed: As I started to do the work, I realised there was a lack of dignity for clients. With the traditional model of service delivery we didn t demonstrate trust. For me, trust is integral to any relationship. Not all clients enter Doorways case management through referral from ER, but the pathways between ER and case management are critical to the success of the Doorways model. It is difficult to ascertain the exact proportion of ER clients who progress from ER to case management, but interviewees estimated it to be around 20%. A further 50% of Doorways case management clients can be referred through other Salvation Army programs, Centrelink, local GPs, schools and other service providers in the area. Many people hear about Doorways case management from other clients, family and community members and self-refer. Under Doorways a range of supports are provided alongside ER. The challenge lies in transitioning clients who rely on ER as a hand out to engage in case management to address underlying issues. This can be a delicate balancing act. The research identified two key factors in facilitating these transitions: the importance of establishing persistent, trusting and respectful relationships during of the ER process, even prior to case management; and changing the way ER assessments are conducted to allow these relationships to be built. To allow relationships to be established as part of the process of providing material aid, a number of changes were made to the way ER was provided. These included: Abolishing the requirement that clients have to show Centrelink statements to establish identity and need Removing the cap on the number of times a person can present to ER Scheduling longer times for ER interviews to allow sufficient time and opportunity to engage with the client to conduct a proper assessment and to refer clients to case management and other services 19

27 Providing a range of tools to facilitate assessment and triage An increased reliance on volunteers to meet the additional resource needs of the new model Training staff and volunteers in the Doorways philosophy Offering clients referral into case management, budgeting, financial counselling and a range of related services and supports. These changes aimed to shift ER from being a handout to becoming an entry point to case management and other necessary services. Continuing to provide ER alongside case management makes allowances for the fact that people presenting to ER tend to be crisis driven and are focused on their immediate needs. People in acute crisis may not be able to make the necessary changes to their lives to address the underlying issues. Consequently, Doorways aims to stabilise people in a crisis by supporting them financially and materially, providing advocacy and then engaging with the client and building a relationship over a period of time until they are ready for deeper engagement. Doorways also recognises that some clients may not be interested in deeper engagement even after their acute crisis is resolved. In these instances Doorways continues to provide a caring environment that welcomes people whether or not they are ready for change. This means that clients receive ongoing support and that opportunities for intervention continue to exist. The importance of a non-coercive, holistic approach built on trust is emphasised in one case manager s explanation of how pathways from ER to case management are created. ER is a bandaid solution, but also a warning that something else is going on. Most of our clients have very complex needs. Usually case management is a natural progression of ER, but one has to have the skill to build a trusting relationship. For me case management is more about facilitation from a strengths based approach and helping the client to identify what their needs are. What are they doing well? Then applying that to the problem. It s about meeting the client where they are at and providing a holistic approach. Walking alongside them. The following case study illustrates how the process works at a busy Tasmanian Doorways hub that provides ER. This hub has three phone lines and services walk-ins and people presenting in acute crisis. In addition, the centre case manages 26 clients per week. Most initial contact is by phone and staff use a triage system to determine the level of crisis and need. The initial phone contact can also be used to manage expectations that a food voucher will be provided, with the standard response to this enquiry being that receipt of a food voucher cannot be guaranteed and that assistance is determined based on individual need and circumstance. Appointments can be made in the morning on the day, but cannot be booked in advance. The policy is to not turn anyone away and if there are no appointment times available, staff at the centre will still provide an overnight pack of food and lend a listening ear. Intake interviews are conducted by a trained Doorways facilitator, who is a volunteer at the centre four days a week. Interviews last around 45 minutes, providing time to establish the beginnings of a relationship and to consider the current crisis, urgency and need, and provide advocacy, referrals and assistance as needed. The frequency of client contact is determined by need. Clients may come to the centre three times a month until they reach a point at which their crisis and lives 20