Evaluation of the Victorian Bushfire Case Management Service. Prepared for the Department of Human Services

Transcription

1 Evaluation of the Victorian Bushfire Case Management Service Prepared for the Department of Human Services

2 AUTHORS: Director Claire Grealy Associate Director Duncan Rintoul Senior Consultant Jessie Connell, Ginette Anile Expert Advisors Christine Healy, Dr Gail Winkworth Specialist Sub-consultant Dr Kristen Murray Group Support Lauren Butterfield Job Code KAJ Acknowledgement The evaluation team would like to acknowledge the hundreds of community members who participated in the evaluation of the VBCMS. The voices of community members have been central to the evaluation. Their experience with the service and ideas for providing support to families in the future were given generously. Copies of this report are available from: Urbis Social Planning and Social Research team has received ISO certification, the new international quality standard for Market and Social Research, for the provision of social policy research and evaluation, social planning, community consultation, market and communications research. URBIS Australia Asia Middle East

3 TABLE OF CONTENTS Abbreviations and notes...1 Executive summary...2 Overview of the evaluation findings...4 Implications for case management in recovery responses Introduction Purpose of the evaluation Methodology for stage two Validity of findings Structure of the report The Victorian Bushfire Case Management Service Establishment of the VBCMS Finding out about the VBCMS Utilisation of the VBCMS Demand over time Monitoring of demand Calibrating the service to the level of demand How need changed over time The enduring nature of need The impact of the VBCMS for clients Intended and overall impact on clients Drivers of satisfaction Feedback to the service Satisfaction improved over time Understanding what is effective The impact of the VBCMS for vulnerable groups Introduction Needs of specific groups Impact of the VBCMS on providers and the broader service system Anticipated and actual impact Providers of the VBCMS Potential impact of no VBCMS Conclusion Implications...73 VBCMS evaluation report

4 TABLE OF CONTENTS Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Status of recommendations from Stage One Evaluation tools Survey tables Evaluation participants VBCMS providers Letter to clients FIGURES: TABLES: Figure 1 Number of cases by month February 2009 June Figure 2 Open cases (active and transition) by region, Mar 2009 Apr Figure 3 Case management by LGA as at May Figure 4 Property damage by LGA Figure 5 Case managers EFT by month February 2009 June Figure 6 Delivery agencies by region Figure 7 Maximum case manager EFT reached and month in which it was reached Figure 8 Scale of need and demand for the service, September 2009 May Figure 9 What impact, if any, has your case manager(s) had on your emotional wellbeing (that is how you are feeling) since the 2009 Victorian Bushfires? Figure 10 How would you rate your case manager in the following areas? Figure 11 How satisfied have you been with your case manager(s) assistance in this area? Figure 12 Thinking about your overall impression of changing case managers, would you rate the process of changing case managers as Figure 13 What was the impact on you, if any, of having two or more case managers? Table 1 Gender balance in Urbis client survey and VBCMS client database as at 3 May Table 2 Case status in Urbis client survey and VBCMS client database as at 3 May Table 3 Client feedback to DHS in Urbis client survey and VBCMS client database as at June Table 4 How did you find out about the case management service? Table 5 Practical need requirements over time September 2009 May 2010 (proportional split within the practical needs category, five selected fortnights) Table 6 Emotional-social need requirements over time September 2009 May 2010 (proportional split within the practical needs category, five selected fortnights) Table 7 Household need requirements over time September 2009 May 2010 (proportional split within the practical needs category, five selected fortnights) Table 8 What kind of economic loss did you experience as a result of the bushfires? Table 9 Overall, how satisfied are you with the case management service Table 10 Generally speaking, which of these areas were made clear to you? Table 11 Was your case manager knowledgeable and good at following up on information for you? Table 12 You may have had help or contact with a number of services during this time (such as case management, GROCON, grants, appeal funds, donated goods, local government). How well do you think services have worked together? Table 13 Why are you no longer using the case management service? Table 14 Which of the following issues was your case manager unable to help you with? VBCMS evaluation report

5 ABBREVIATIONS AND NOTES Abbreviations and notes Abbreviations AGS Australian Government Services DHS Department of Human Services, Victoria DPI Department of Primary Industry EFT equivalent full time LGAs Local Government Areas N&WMR Northern and Western Metro Region PTSD Post-Traumatic Stress Disorder TQM Team Quality Manager VBCMS Victorian Bushfire Case Management Service VBAF Victorian Bushfire Appeals Fund VBRRA Victorian Bushfire Reconstruction and Recovery Authority Notes At the time of this report the VBCMS has been in place for some 15 months and is intended to continue operation until March Despite the ongoing nature of the service, the report uses the past tense for ease of reading. For the purposes of this report, and specifically in the analysis of data, some LGAs have been collapsed in a group other. This has been necessary where there is too little data from which to draw meaning for the purposes of the report, or where there is a risk of identifying individual respondents who participated in the evaluation. VBCMS evaluation report Page 1

6 EXECUTIVE SUMMARY Executive summary The 2009 Victorian Bushfires The devastating bushfires experienced in Victoria in 2009 were unprecedented in Australia s history. Seventy-eight communities were directly affected and 173 people lost their lives in horrific circumstances. The response of the Victorian and broader Australian community was also unprecedented, with an extraordinary outpouring of support in both gesture and financial contribution. The response from government was immediate, with local, Victorian and Australian governments committing substantial resources to support social, economic, infrastructure and environmental recovery. In the days following 7 February 2009, known as Black Saturday, the Victorian Premier and the Federal Minister for Families, Housing, Community Services and Indigenous Affairs jointly announced that a case management system would be introduced so that each household affected by the fires would have support through their recovery. 1 Responsibility for the establishment of the case management service was vested in the Victorian Department of Human Services (DHS) as the agency responsible under Victoria s Emergency Management Framework for, amongst other domains, the social, health and community effects of an emergency. Since the Victorian Bushfire Case Management Service (VBCMS) opened on 13 February 2009 support had been provided to 5506 households by June At the peak of demand in April/May 2009, 393 case managers were working with 4365 families. By June 2010, 1311 families continued to be supported. The objective of the VBCMS was to ease access to the plethora of services, grants and information available to people; to strengthen the capacity of traumatised people over time; and to contribute to a reduction in the stressors affecting people through their recovery. With the investment in a skilled workforce, a sound case management model and a well-resourced set of management systems, it was anticipated that over a two-year period these objectives would be achieved. The quality of the evidence available to guide governments and policy makers in responding to disasters is limited. At present, governments are responding to natural and human made disasters without any roadmap to intervention. 3 The view taken by many experts in disaster recovery research, however, is that while policy may not yet be evidence-based in this area it can be evidence-informed by drawing on the studies that have been published. Case management is considered to be an effective and appropriate response to disaster in the literature because it provides a single point of contact for survivors, whose experience of the disaster may reduce their ability to navigate the complex systems surrounding recovery. For the service system, the use of case managers as a dedicated point of contact provides a pathway through services which would otherwise be awash with individual survivors separately negotiating this complex environment. The evaluation of the VBCMS The evaluation was commissioned by DHS, which was responsible for the design, management and implementation of the VBCMS. The terms of reference called for a two-stage evaluation. Stage one identified information, policy and further steps required to strengthen performance monitoring and improve the program s future development and operations. Stage one was conducted over a five-week period from mid-november to mid-december 2009, approximately ten months into the planned two-year period of service provision, and was reported on in January Participants in stage one were all The Hon. Jenny Macklin, Bushfires Doorstep Parliament House, Media Release, 13 February DHS, VBCMS data June 2010 Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Gerson BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev A Y, Solomon Z, Steinberg A M, Ursano RJ (2007), Five essential elements of immediate and mid-term mass trauma intervention: Empirical Evidence, Psychiatry 70(4) at VBCMS evaluation report Page 2

7 EXECUTIVE SUMMARY people in professional roles associated with the VBCMS. Stage one utilised a survey of professionals involved in the delivery and management of the VBCMS, as well as people in surrounding services. Focus groups were also held with case managers, and a series on in-depth interviews were undertaken with senior stakeholders within and outside of government 4. Stage two of the evaluation has focused on the impact for the people utilising the service, as well as other stakeholders, and the implications for future responses to disasters. Stage two engaged directly with fire-affected community members as well as people in professional roles. The consultation phase of the evaluation was conducted between February and June Clients were invited to complete a survey and/or attend a focus group: 510 people completed the survey and over 80 attended focus groups. The views of case managers and Team Quality Managers (TQMs) were also gathered through focus groups. Parallel to the data collection in stages one and two, an international literature review was undertaken to inform the evaluation of the VBCMS. The review focused on identifying models of intervention following disaster events, especially case management models, which are considered good or best known practice and/or are supported by evidence. The literature is drawn on throughout this report, and available as a separate document. Ethics approval was sought and received from the Department of Health Human Research Ethics Committee for stage two. This is the report of stage two, incorporating the overall findings and recommendations from both stage one and two. An evaluation reference group was convened by the Bushfire Recovery Services Unit to support the evaluation, and provided advice and feedback on the evaluation approach, findings and final reports. The evaluation findings The overall finding of the evaluation is that the VBCMS has met its objectives for the vast majority of the people who utilised the service. The story of success is supported by the strong willingness by clients to recommend such a case management service in the event of a future emergency. Just over 90% of clients participating in the evaluation indicated that they would definitely (76.9%) or probably (13.3%) recommend such a case management service to others in an emergency event. Stakeholders in professional roles strongly believe the service has succeeded in meeting its aims. Ninety eight percent of the professionals who completed the stage one survey indicated that the service was either very successful (65.9%) or fairly successful (31.7%) in helping the majority of clients to access the information and support they needed for recovery. Over the two stages of the evaluation, answers to several key questions were sought. In the next section the results of these inquiries are reported in brief, and then detailed throughout the report. The implications of the findings are then provided. 4 A status report provided by the VBCMS program managers on the recommendations from stage one is also available in Appendix A. VBCMS evaluation report Page 3

8 OVERVIEW OF THE EVALUATION FINDINGS Overview of the evaluation findings 1 The interventions that were of most assistance to which clients Aspects of the model The assertive outreach model where case managers worked in the location of the client s preference, actively followed up details on client s behalf, and made regular contact has proven to be effective in meeting client needs. The rationale for this approach was to make it as easy as possible for a client of the service to take up the support on offer, and thereby make the best use of the range of supports available to fire-affected individuals and families. The professionals involved in delivering the service and clients of the service universally supported the value of an assertive outreach model of support. It is an approach which is also supported in the literature, where early assertive engagement with people impacted by a disaster has been seen to provide benefit in the recovery process. The availability of case managers over a lengthy period of time was also an important aspect of the model. The commitment to a two year case management service provided certainty for some clients, particularly those who lacked informal supports, and also allowed people to utilise the service at the time of their choosing. For some, case management support was useful immediately following the fires, but for others the benefit was realised some months later after personal resources were exhausted. This is discussed further below. Drawing on the experiences of people who attended focus groups, case managers were valued in particular ways by people who had lost their home. The availability of an objective third party with whom to test ideas while reaching critical decisions regarding reconstruction was one important role. The support provided at critical points, such as when land was cleared, was also highly valued. The preparedness of clients to recommend a case management service in future emergency response is a further affirmation of the overall model. The literature supports the early availability of individually focused support to people affected by a disaster. In this event there has been discussion amongst professional stakeholders as to whether the service was activated too early, in that case managers were deployed so quickly that they became involved in the provision of relief, for example, providing essential goods to clients such as water. An implication of this very early engagement was the expectation of some clients, and some services that case managers would be knowledgeable and equipped to engage in immediate relief tasks relevant to this emergency. In the first instance this involved shelter, location of family and friends, and attending to the immediate tasks of securing livestock and other critical requirements. Generally a case management service would fall into the recovery rather than the relief phase of a disaster response. But a similar decision of early activation may be made again based on the scale of a future emergency. The proximity to the relief phase of the recovery effort will in part indicate the nature of skill and knowledge needed by the case management workforce, and the resources to which they will need access to be of most benefit to affected community members. Client satisfaction and drivers of satisfaction The top driver of overall satisfaction with the VBCMS lay with the frequency with which case managers communicated with their clients, and the efforts made by case managers to advocate on their clients behalf. The next driver of overall satisfaction was the support provided to access government grants/victorian Bushfire Appeal Fund, and finally, the assistance provided to clients to access counselling services. Equally, where these components of service delivery were not in place, satisfaction was not as highly rated. Clients generally rated positively the impact of the service on their emotional wellbeing, with 69% of the 510 clients surveyed reporting that having a case manager had had either a very positive (39%) or fairly positive (30%) impact on their emotional well-being. VBCMS evaluation report Page 4

9 OVERVIEW OF THE EVALUATION FINDINGS The evaluation has considered the question what were the interventions that were of most assistance to which clients and why? The analysis of survey data provides an interesting result. There are virtually no separations across demographic factors, or the nature of the loss experienced in the fires, observable in client s indication of what they found to be most useful. Overall, the skill and attributes of the individual case manager and the factors indicated above (frequency of contact, advocacy, reduced administrative burden concerning grants, and ease of access to counselling services) were common themes across the client group. The small separations that were apparent showed a slight tendency for those who did not experience a personal loss to be about 10% more likely to definitely recommend the service than those who did. However, those who lost a family member were slightly more likely to report a very positive impact on their emotional well being. Women and older clients did have a slight tendency to give more positive assessments of the service, however, consumer research on satisfaction and intention to recommend do tend to show the same minor but consistent trends. Reach of the service The VBCMS was well utilised by the community members who were the most severely impacted by the bushfires, in particular those who had lost their home and or a family member. The case management approach utilised was based on one case manager to a household, with a decision made by the program not to allocate case managers to children or young people, but rather to work with the parent/s to support all members of the family. This decision was aimed at supporting the integrity of the family unit, particularly post a disaster, where supporting parent confidence and capacity can be important aspects of the work. For the majority of survey respondents, there was a high level of satisfaction with case managers attention to the needs of other members of their household. This reflects the VBCMS data recorded by case managers that within each household they may have been engaging in the needs of several family members. Drawing on this limited data it would seem that the service was effective in providing reach into households, through a single case manager. The extent of the support provided specifically to children and young people was not a primary focus of the evaluation, and there is therefore only limited qualitative data on which to draw. Focus groups with clients provided some insight into how case managers provided this support. From the perspective of parents there was a wide range of experiences. Some case managers were said to be proactive, skilful and helpful, for example providing good referrals to counselling for whole families or children, and ensuring families were linked in to school-based supports, and material aid of particular relevance to a child. For other parents the experience was less positive, with little to report in the way of general discussion of what children s needs might be, trauma signs to watch for, or where support may be available in the broader recovery system. It is recognised in the literature that children are not well catered for in disaster recovery and that specific arrangements for children led by experienced practitioners are appropriate. Key experts in the field have identified the importance of specific tailored psycho-social support and interventions for children and adolescents who may initially appear to be coping, but often experience more serious longer term impacts. 5 2 Contribution of the quality assurance measures to the quality of the service delivered Quality assurance measures The VBCMS has operated under a continuous improvement model. This is reflected in the ongoing development and improvement of the structures, documentation, policy and practice supports over time, as well as the responsiveness of the service to the changing needs of clients. 5 Winkworth G, (2007), Disaster Recovery A Review of the Literature, Institute of Child Protection Studies, prepared for the then Department of Families, Community Services and Indigenous Affairs (FaCSIA), August at 31. VBCMS evaluation report Page 5

10 OVERVIEW OF THE EVALUATION FINDINGS Significant investments were made in quality assurance systems, with the aim of providing an accountable and high quality case management service. The quality assurance mechanisms built into the program included: continuous tracking, monitoring and reporting on client demand was enabled by the VBCMS program managers direct access to electronic casework files on the VBCMS client data base the appointment of Team Quality Managers (TQMs) employed by DHS across the regions case manager surveys of client needs providing insight to emerging and projected needs, eg the Winter Needs survey direct engagement between the program managers and the workforce through electronic and direct communication, eg Case Manager Forums regular visits by VBCMS program managers to the service providers to discuss the delivery of the service and identify any issues arising a learning and development plan. The contribution made The value of the investment made in quality assurance is reflected in the continuous improvement of the service. Specifically, the survey of clients indicates there has been improvement in the service over time. Clients who were using the service at the time of the survey, in contrast to those whose support had been finalised, consistently reported higher satisfaction in virtually all of the measures used in the evaluation. They reported more positive experiences when making a complaint; were more likely to indicate their case manager had been encouraging them to stay connected with informal networks; and were slightly more likely to report that they would recommend case management as part of a future response. Given this groups length of time with the service, they were more likely to have experienced one or more changes in case manager, but this did not negatively impact their overall satisfaction with the service. Notably, they were much more satisfied than past clients with the process of changing case managers. The points of difference between the experience of clients who used the service previously, and those who were current clients, reflect well on the strengthening of key aspects of the model over time, including: the complaints process transition between case managers the provision of individual support combined with the promotion of community connections. The contribution of the TQM role was explored in the evaluation. Skilled TQMs were seen to add value to the service where they provided support regarding complex needs; where they reviewed case work; and where they provided secondary consultations for those clients that required ongoing risk assessment. The overall benefit was the promotion of consistency in practice across the agencies providing case management, the communication between the program itself and the workforce, as well as the communication of emerging issues from the field, back to the program managers. The area of quality assurance where some case managers indicated they could be better supported was in access to quality supervision. Amongst the 177 case managers who participated in the stage one survey, one in four rated supervision and support as problematic. These case managers were more likely to be working in agencies which did not usually provide case management services and therefore did not have experience supporting and supervising case management practice. As a result of this finding, further training in the role of supervisors in the context of the VBCMS was built into the learning and development plan, and will be an important consideration in future case management services. VBCMS evaluation report Page 6

11 OVERVIEW OF THE EVALUATION FINDINGS 3 How clients needs changed over time and how the VBCMS responded Change over time Unlike a traditional support service where the needs of the client group tend to fall within a predictable range, the needs presenting to the VBCMS changed over time. The service had to detect these changes, and be quite nimble in adapting and responding. Emerging themes in client need were identified by the service through analysis of the client database records; through trends observed and reported by the agencies employing case managers; and through direct contact with case managers through forums convened by the VBCMS program managers. Drawing on the items recorded by case managers in case plans, it was the practicalities associated with recovery that comprised the majority of demand on the service. Support to access grants, followed by assistance with material aid remained constant through the period February 2009 May 2010, with grant assistance beginning to decline in May Clients with property damage or substantial property loss who attended the focus groups were likely to report unresolved practical problems, with fencing and land clearing most often cited. In some cases the case manager had appropriately linked people into the relevant services regarding these issues; for others there was a sense of isolation that there was no dedicated support to address their remaining practical issues, which were generally seen as beyond the scope of the case management service. Needs in the emotional social domain made up an increasing proportion of needs over time. As the need for support concerning trauma/ grief and loss began to reduce, case managers started to indicate an increase in demand for general emotional support. Support in regard to mental health and well-being remained fairly constant over time. Clients in focus groups frequently identified the ongoing need for emotional support, with value placed on the support provided from a case manager over and above family members and friends. For some single people and for sole parents the role of the case manager remained critical as they engaged in difficult decisions, eg whether to rebuild or leave the area. A theme emerged through focus groups about the emotional support needs of older men. Drawing on qualitative evidence, it would seem that for this group the benefit of case management was likely to be experienced later than for other age groups. This finding is based on focus group participants who spoke of their engagement in the practical elements of the recovery effort for several months after the fires, who subsequently experienced severe physical and emotional exhaustion. For many this was the point at which support was sought or accepted from the VBCMS, and was reported to be highly valuable. It is important to note that older people did not register for the service any later than other age groups, and they registered in numbers reflecting the overall older population of the affected regions. This finding indicates, however, that they may be more likely to accept, and therefore experience the benefit of, case management later than other groups. This places them at risk of longer periods of post-trauma distress before support is utilised. VBCMS responsiveness In the survey of clients in stage two of the evaluation, 77% rated their case manager s understanding of their changing needs as either excellent (49%) or good (27%). Amongst the professionals surveyed in stage one confidence in the service s responsiveness was somewhat higher, with 90% reporting the service to be either very responsive (45%) or fairly responsive (45%) to the changing needs of clients. Responsiveness is tied closely to the quality assurance investment. Through a range of mechanisms the program managers gained insight into the emerging needs and trends in demand. In response the program addressed issues through written bulletins to the workforce; direct engagement with providers; communications via TQMs and through the learning and development strategy. VBCMS evaluation report Page 7

12 OVERVIEW OF THE EVALUATION FINDINGS 4 The operational effectiveness of the model The model The model of case management utilised within the VBCMS reflects the key approaches from the literature about effective disaster case management practice. This is evident in: the principles underpinning the VBCMS and the phases of case management used within the model the rapid activation of the service immediately following the disaster which recognises the importance of individually focused interventions delivered as early as possible the use of proactive outreach to engage with and provide support to clients flexibility and responsiveness built into the model to meet clients changing needs. The case management model used in the VBCMS differs significantly from standard case management models utilised in general community service settings. Generally such models are constrained by service requirements, policy, and of course resources. In this emergency context, however, the case management approach was designed to be truly holistic, client-centred and client-led. The workforce While the VBCMS program has been the responsibility of DHS, the case management workforce has been employed by a range of community and health services, and in some areas by local government. As already mentioned above, a significant contingent of case managers was also provided by Commonwealth Government agencies. This was a critical factor in the early availability of the service while the long-term workforce was recruited. It is likely in a future large-scale emergency that a workforce would similarly need to be sourced quickly and from a range of providers. Drawing on the learning from this event, agencies with existing experience in the provision of case management, and with the human resources infrastructure to support and manage case managers, are best placed to work in partnership with DHS in the delivery of a case management service. 5 Factors that have supported or reduced the impact of the service Implementation phase The service being operationalised so quickly ensured early support to people affected by the fires. Stage one of the evaluation identified a number of contributing factors in the rapid establishment and early operation of the service. These included: the seniority of people involved in the design and implementation of the service, from both the Commonwealth and DHS, who collaborated to establish the service five days following its announcement the strength and quality of the existing partnerships between DHS and the community and health service sectors, which enabled a case management workforce to be rapidly identified and recruited resources from the Australian and Victorian governments, which facilitated the rapid establishment of systems, eg the registration line the quality of the relationship between DHS and the Commonwealth, including the capability of the senior Commonwealth contingent in working with a state coordinated response the flexibility and size of the Commonwealth contribution in being able to provide both the initial registration line and experienced and skilled case management staff where and when they were needed the goodwill from all partners and parts of the system VBCMS evaluation report Page 8

13 OVERVIEW OF THE EVALUATION FINDINGS the initial design and implementation phase having the right people in the room from the Commonwealth and DHS, with the appropriate skills, knowledge and authority to make decisions. Due to the contracted timeframe to establish the service a number of policies, procedures and lines of communication were not fully established. As a result, an initial period of uncertainty and some confusion was reported while the service was fully described and expectations established. In light of the speed at which the VBCMS was established, as well as its complexity and scale this finding is not unexpected. The investment made over time in defining the model and developing the supporting documentation, particularly the Practice Guide and Operational Instructions, will pay significant dividends in any future disaster recovery case management service. Strength of partnerships The pre-existing partnership relationships between DHS and community and health service organisations assisted in rapid negotiations with organisations to be providers of the case management service. While these arrangements were being put in place, Commonwealth staff were made available and comprised up to 30% of the workforce in the first several months. Skill of the case managers Moving on from the establishment phase, a primary factor in the impact of the service was the skill and knowledge of the case managers. The focus groups with clients explored in some depth the attributes of effective case managers. For clients the primary factors were the skill, knowledge and to some extent the experience of the case manager. From the case managers point of view a similar set of factors were identified as critical to having a positive impact, including outstanding communication skills and general life experience. Case managers also identified the importance of being adaptable to a constantly changing work environment, which is inherent in a disaster recovery context. Phases of support The evaluation has highlighted the critical importance of particular phases of the case management model. The beginning phase where the expectations are set about what a case manager can assist with have proved critical to achieving client satisfaction. The majority of clients reported that most aspects of the service were explained to them at the outset. Where there were unrealistic expectations of case managers it is possible this could have been avoided in some instances by clarity at the point of first engagement between the case manager and the client. For some clients the transition between case managers could have been managed more smoothly, with a more thorough briefing for the new case manager, reducing the burden on the client to start from the beginning with a new person. Given the nature of the service it is inevitable that people may experience more than one case manager through their period of support. Practices which enable this to be done seamlessly are reasonably simple to implement. The way in which case management support is finished with clients is another critical phase. The case managers were provided with a detailed process for the closure phase of their work with clients, and where this was observed clients reported a positive and skilful end to their exit from the VBCMS. For other clients the closure phase was reported to be handled less adeptly, and some had felt it was premature and rushed. In response to this finding the VBCMS program has implemented training and further quality assurance mechanism to ensure consistent good practice in the aspect of the service. Other areas where the impact was reduced simply reflect the absence of the factors which drove high levels of satisfaction: where case managers did not maintain frequent contact; where advocacy was not to the client s satisfaction; where assistance with the burden of administration (paperwork in particular) was not forthcoming. VBCMS evaluation report Page 9

14 OVERVIEW OF THE EVALUATION FINDINGS Communications The system of communications between the program management and the workforce has also been identified as a key strength. For the majority of the case managers, the community and health services and some DHS staff this was their first experience of providing a case management service in a recovery context. The bulletin prepared and distributed by the program managers was valued by case managers and others as a critical source of information and guidance. Over time daily bulletins changed to weekly and eventually to a lower frequency, providing updates only as any resources and supports changed. Parallel to the bulletins and the Practice Guide were the Resource Kits and Grants Guide, detailing specific eligibility, material aid and the plethora of resources available to affected communities. The workforce were therefore equipped with a great deal of information and access to the resources that were relevant and useful to their clients. Integration with the broader recovery system The VBCMS was one aspect of an extensive suite of relief and recovery services put in place to support fire-affected communities. There is a desire amongst stakeholders in professional roles and clients who were able to comment, to see a stronger integration between the services provided, for example, between individual and community support, and a greater level of confidence that case managers ensure they are aware of the full range of relevant services, eg child and youth focused activity and support. 6 How the service was understood and valued by clients of the VBCMS, staff and other stakeholders/service providers VBCMS clients The value placed on the service by clients is set out above in terms of their preparedness to recommend such a service; the positive impact of the service; and the reported satisfaction levels. Drawing on the perspectives of the clients who attended focus groups there was some variation in how the role of the case manager was understood, and ultimately this did seem to be linked with satisfaction with the service overall. Where the role of the case manager had been made clear as a support and resource for accessing information and services, and the case manager had been skilful, expectations of the service tended to be met. Where expectations were inaccurate or unrealistic, and/or the case manager had not been as skilful, understanding of the service and the value placed on the service, were negatively impacted. Staff and other professionals There is full support for case management remaining part of the range of responses available to government following an emergency. Drawing on the lessons learnt in establishing and managing the case management service, preparatory work is currently underway that is designed to ensure the greatest value is derived from any future service. Professionals involved in the VBCMS have expressed a strong sense of pride in their work, with almost 98% of 249 survey respondents in stage one reporting that the VBCMS had been either very successful (65.9%) or fairly successful (31.7%) in helping the majority of clients access the information and support they needed for recovery. An area where stakeholders did see opportunity was the extent to which recovery agencies in general, not just the VBCMS, were able to work together in the common interests of clients. Reference was made by external stakeholders in particular to recovery services reflecting the same silos of operation often seen in the general service system, which had particularly negative consequences for clients in the recovery context. VBCMS evaluation report Page 10

15 IMPLICATIONS FOR CASE MANAGEMENT IN RECOVERY RESPONSES Implications for case management in recovery responses In order to draw out the implications for future case management responses, this section of the report brings together the findings of the evaluation itself, as well as the evidence derived from the literature review. The following ten areas are addressed: Case management as part of the emergency response Rationale and timing for activation Phased interventions Priority for vulnerable groups Integrate case management response with community recovery activity Case management workforce A practice framework for case management Privacy issues Quality assurance Beginning and ending: critical phases. 1 Case management as part of the emergency response A documented evidence-based case management service model should be available to government as part of a range of responses to disaster. Inter-agency agreements should be developed now so that each level of government and nongovernment agency is aware of their role in the response and recovery phases, according to an agreed plan. 1.1 Case management included in recovery planning The Victorian State Emergency Response Plan and the State Emergency Recovery Plan provide the framework within which multi-agency response and recovery plans operate in Victoria. The existing plans include a scaled approach in which different types of disaster activate different scales of government responses. The existing framework is underpinned by the principle that recovery is not the single domain of any one agency; it is a whole-of-government and a whole-of-community process. The agreed roles and responsibilities of agencies under these arrangements are contained in Part 7 of the Emergency Management Manual Victoria. 1.2 A scaled approach Preparation for a future event should be an inclusive process, whereby each level of government has articulated its potential contribution to a case management service, and agreements are in place with potential providers of case management should the service be activated. For disasters/emergencies which affect a local government area, LGAs would prepare for disaster recovery by: contracting appropriate organisations including non-government agencies, to provide pre-trained case managers and supervisors, preferably local staff who understand the local service system, and are well networked and well regarded within the community ensuring that case managers work alongside and in collaboration with local government and those parts of the state government recovery system that are put into place for the event VBCMS evaluation report Page 11

16 IMPLICATIONS FOR CASE MANAGEMENT IN RECOVERY RESPONSES establishing protocols regarding communication channels and collaboration arrangements between case managers and local government; these should be developed in consultation with those agencies which would be involved in the provision of case management services. For events that affect more than one area, the DHS region would undertake the coordinating role for the LGAs and the agency providing the case managers. Events across regions would be managed by a state government across government approach, drawing on the plans in place within the affected LGAs and DHS regions. 2 Rationale and timing for activation of the case management service Once the decision is made to activate a formal and ongoing case management service, it is ideally deployed as soon after the emergency as possible, with an open eligibility criteria for people affected by the event. 2.1 Criteria for activation Case management should be considered when the emergency event is of sufficient magnitude that the normal service delivery system is overwhelmed and unable to respond in the normal way. In making the decision to activate a case management service, key criteria for consideration include: where there is widespread disruption and loss of loved ones, abode, and widespread community dislocation (creating a diaspora) where many people have been injured and there is damage to homes and businesses where people feared they would die, or their loved ones would die (a major risk factor for Post- Traumatic Stress Disorder) the disaster event has a sudden onset, which is unexpected and traumatic and involves an aspect of horror children or other vulnerable people are involved (eg the frail-aged, people with disabilities) major convergence of donations and assistance, and people are uncertain about their eligibility and about how to gain access to assistance there is community anger about the lack of mitigation strategies in place to prevent or limit the extent of the disaster. 6 The decision to activate a case management service will also relate to the level of community interest in the event. For instance, a small event in terms of numbers of people affected might warrant activation because the level of horror is high or there may be intense community interest and advocacy for a case management service. Once the decision is made to activate the service, local or state government would begin working with the case management provider agency/ies to have the staff briefed and ready to move into the role of case management. 2.2 Timing of activation In the event that a case management service is activated, the timing would be dependant in part of the recovery activity already underway, and the nature of the emergency. In the first instance, the recovery effort would be staffed by recovery workers and volunteers who will be doing a range of tasks to respond to the immediate needs of those affected, e.g. emergency accommodation, food and clothing. 6 Buckle P (2005), Disaster: Mandated definitions, local knowledge and complexity in Perry, R W and Quarantelli, E L, What is a disaster? New answers to old questions, International Research Committee on Disasters at VBCMS evaluation report Page 12

17 IMPLICATIONS FOR CASE MANAGEMENT IN RECOVERY RESPONSES There is evidence available from the literature that there is benefit in initiating support as close to the event as possible. This depends in part on the scale of the disaster and the level of unmet need following the initial relief stages. 3 Phased interventions The case management service should be designed to be responsive to the phases of recovery likely to be experienced by the affected population. This requires program level anticipation and monitoring of needs as they change over time, and the equipping of case managers to respond effectively. Experts working in the field of disaster recovery have argued that there are critical differences in the stages of disaster recovery and there are different roles that case management or other support services should play at each stage, especially in differentiating between crisis relief and long term recovery. 7 Phase appropriate interventions and a stepped care approach have been recommended by experts identifying good practice humanitarian responses. 8 A stepped care approach involves providing early responses to help people in adaption and then more individualised and time-consuming interventions for a minority of people who require them later in the recovery process. 9 For example: establishing a sense of safety and engaging in activities that help people resolve concerns to promote calming are priorities in the immediate aftermath of trauma 10 large-scale pro-active outreach and personalised support for bereaved people and contact between those affected is considered most effective in the early stages after disaster information and activities which normalise reactions and identify further sources of support are important aspects of psycho-social responses. The literature on the impact of trauma emphasises that decisions about how domestic reconstruction will occur are affected by grief and take time to work through. As such, recovery can be viewed as a process rather than an end-point. 11 Community recovery will often take years and some services may need to be in place for extensive periods. An important consideration in the design of services that are tailored to different phases of recovery is the need to include effective processes for transitioning between phases so that a continuity of care is provided to clients. These processes should include agreements in relation to: how client preferences are reflected in transition arrangements sharing of information between the support agencies procedures for briefing new case managers who are taking over from recovery workers (where there is a change) the monitoring of the quality of transition points. 7 Camilleri P, Healy C, Macdonald E, Nicholls S., Sykes J, Winkworth G, Woodwood M, (2007), Recovering from the 2003 Canberra bushfire: A work in progress (Executive Summary), prepared for Emergency Management Australia at Eyre A, (2006), Literature and best practice review and assessment: Identifying people s needs in major emergencies and best practice in humanitarian response, Report commissioned by the Department for Culture, Media, and Sport, at 43; Watson P, (2007), Early intervention for trauma-related problems following mass trauma in Textbook of Disaster Psychiatry, Robert. J. Ursano, Carol S. Fullerton, Lars Weisaeth (eds), Cambridge University Press, Cambridge, at Watson P (2007), Early intervention for trauma-related problems following mass trauma in Textbook of Disaster Psychiatry, Robert. J. Ursano, Carol S. Fullerton, Lars Weisaeth (eds), Cambridge University Press, Cambridge, at Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, Gerson BP, de Jong JT, Layne CM, Maguen S, Neria Y, Norwood AE, Pynoos RS, Reissman D, Ruzek JI, Shalev A Y, Solomon Z, Steinberg A M, Ursano RJ (2007), Five essential elements of immediate and mid-term mass trauma intervention: Empirical Evidence, Psychiatry 70(4) at Winkworth G, (2007), Disaster Recovery A Review of the Literature, Institute of Child Protection Studies, prepared for the then Department of Families, Community Services and Indigenous Affairs (FaCSIA), August at 68. VBCMS evaluation report Page 13

18 IMPLICATIONS FOR CASE MANAGEMENT IN RECOVERY RESPONSES 4 Assessment of priority groups In planning for the case management activation, an analysis is required to identify any groups likely to be at risk of particular trauma in the context of the event. Once identified, the need for a tailored response can then be determined. Such groups may include those sustaining high personal losses and high exposure (those who thought they or their loved ones would die), and those with pre-existing vulnerabilities. In the case of children being identified as a vulnerable group, a dedicated senior child and youth specialist should be appointed to the program management team with the specific role of ensuring the inclusion of children and young people in the practice of case managers. Personal loss or fear of loss of loved ones, and high exposure to the disaster event are key factors in predicting PTSD and ongoing difficulties in adapting after severe adversity. 12 In a future event, the groups that are likely to be particularly vulnerable should be identified, and strategies implemented to optimise the take-up of support, for example: a case management service should, as a priority, allocate case managers skilled in persistent and patient practice to bereaved families; and these staff should be well trained in bereavement based on the VBCMS evaluation, bereaved people are likely to remain in the service for long periods of time; as far as possible, continuity of case managers should be prioritised for these groups so that a support person can stay in place with the family over time. It is recognised in the literature that children are not well catered for in disaster recovery and that specific arrangements for children led by experienced practitioners accustomed to working with children are appropriate. 13 Key experts in the field have identified the importance of specific tailored psychosocial support and interventions for children and adolescents who may initially appear to be coping, but often experience more serious longer term impacts. 14 The case management and disaster literature supports the approach that special procedures should be in place to identify vulnerable populations, particularly for children and adolescents and the frail and aged. Each disaster event will require an assessment of vulnerable groups for tailored or targeted response. In regard to children and young people, the appointment of a dedicated child and youth professional will ensure case managers meet their obligation to include a focus on the needs of children and young people Buckle P (2005), Disaster: Mandated definitions, local knowledge and complexity in Perry, R W and Quarantelli, E L, What is a disaster? New answers to old questions, International Research Committee on Disasters at Winkworth G, (2007), Disaster Recovery A Review of the Literature, Institute of Child Protection Studies, prepared for the then Department of Families, Community Services and Indigenous Affairs (FaCSIA), August at 31 Winkworth G, (2007), Disaster Recovery A Review of the Literature, Institute of Child Protection Studies, prepared for the then Department of Families, Community Services and Indigenous Affairs (FaCSIA), August at 31. VBCMS evaluation report Page 14

19 IMPLICATIONS FOR CASE MANAGEMENT IN RECOVERY RESPONSES 5 Connect case management and community recovery activity Develop a model of case management which aligns individual support with community recovery. Expand the role of case managers to include a focus on retaining and strengthening individual resilience through community engagement, with a particular focus on supporting new and positive community structures which emerge after disaster. The evidence available suggests that an effective strategy to assist individuals following disasters is to situate the focus of case management work in the community. This approach is consistent with the strengths-based and relationship-based model utilised in the VBCMS. These models reflect a shift in broader case management practice away from perceiving clients as cases that need to be managed, and instead promote the concept of partnership and empowerment in the client/worker relationship. Disasters create new structures which need to be supported in recovery, especially community groups which emerge as a direct result of the disaster, and other forms of social support. 15 The concentration in the VBCMS model on individual work may have precluded the case managers from identifying people with similar disaster-related interests who would benefit from meeting and sharing in a group. While there was parallel community development activity within the broader Victorian recovery response, the focus proposed here is on facilitating low-key informal social-connectedness. To this end the case manager s role should be expanded to include responsibility for identifying and activating opportunities for greater community engagement by and between clients, as a means of restoring and retaining resilience. This role will require close links between case managers and local community recovery workers, with the aim of supporting individual recovery, and the sustenance of effective emerging groups which may otherwise fade away Case management workforce Staff of a case management service should be skilled in case work/supervision of case workers in an interdisciplinary context, equipped with relevant qualifications and be familiar/become familiar with the local service systems. The incorporation of formal study units on disaster case management in undergraduate and postgraduate courses would further strengthen a future workforce. All case management staff should be thoroughly inducted to the specifics of each emergency context, including the place of case management in the overall recovery effort. The literature does not directly address the qualifications and professional background required to be an effective case manager, other than to reinforce the value of interdisciplinary approaches. Combined with the findings of the evaluation it could be extrapolated that people who are able to work in a way that is consistent with the principles of holistic, collaborative, relationship-based practice would be best qualified. An effective workforce would include: a workforce which is qualified, interdisciplinary, but where all have strong interpersonal skills, problem solving skills, and are skilled in collaborative practice a strong focus on collaboration with other parts of the recovery effort and the local service system Quarantelli, E. (2007). A Heuristic Approach to Future Disasters and Crises: New, Old and In-Between Types, in H. Rodriguez, Quarantelli, Enrico, L., Dynes, Russell R. (Ed.), Handbook of Disaster Research (pp ). New York: Springer. Hawe P, (2009), Community Recovery after the February 2009 Victorian Bushfires: A Rapid Review. An Evidence Check Review, brokered by the Sax Institute for the Public Health Branch, Victorian Government Department of Health, at 2; Winkworth G, (2007), Disaster Recovery A Review of the Literature, Institute of Child Protection Studies, prepared for the then Department of Families, Community Services and Indigenous Affairs (FaCSIA), August. VBCMS evaluation report Page 15

20 IMPLICATIONS FOR CASE MANAGEMENT IN RECOVERY RESPONSES an emphasis on good supervision structures to ensure that staff have the information they need, are accountable, and receive the personal support necessary to work in this context. A future workforce would be further strengthened through the introduction of formal study units in disaster case management in undergraduate and postgraduate courses for all professionals working in human services, including social work, nursing, education and youth work. Following on from the VBCMS workforce, there is the opportunity for DHS to hold a register of personnel with demonstrated capability, with the potential to be drawn on in a future case management response. Where the size or impact of an event requires case managers to be recruited from outside the local area, a detailed induction should be provided to orient case managers to the geography, the areas of impact and the local recovery systems. A key focus of the induction for all case management staff, local or otherwise, should be to orient workers to the whole of the recovery system, with the expectation set that case managers are to work alongside all other parts of the system, as part of the collaborative basis of the service. Planning and development of inductions for case management staff should take place prior to a disaster event occurring. The objective is to attain a common understanding of the role and service expectations, as well as interaction with key points in the broader recovery effort, for example, community recovery workers or expert advisors from local government or state government agencies. These strategies would assist to improve the capacity of case managers to work collaboratively in the delivery of a holistic service A practice framework for disaster case management Utilising the findings of this evaluation, the literature review, and the existing VBCMS Practice Guide and Operational Instructions, a comprehensive case management framework should be developed. In areas of complex service delivery it is increasingly standard practice to develop a practice framework to set the context and requirements for practice. Practice frameworks sit between highly prescriptive procedures and complete professional discretion. They commonly include: policy and legislative context a set of agreed principles the phases of intervention a set of related evidence-based tools that assist practitioners to do the work effectively the intersection of the practice with other parts of the service system. The context for disaster case management will almost always include a newly gathered workforce with a range of qualifications and experience, operating in a highly complex setting with a highly vulnerable population. Practice frameworks resource managers, supervisors, front line staff, educators and other services with a consistent understanding of the program. Drawing on the VBCMS Practice Guide, the literature and the evaluation findings, a practice framework would be a resource to Victoria, and of relevance to all states and territories. 17 Holly Bell, (2008) Case management with displaced survivors of Hurricane Katrina: A case study of one host community, Journal of Social Science Research, 34: 3, at 16. VBCMS evaluation report Page 16