SA HEALTH EVALUATION OF THE INDIVIDUAL PSYCHOSOCIAL REHABILITATION & SUPPORT SERVICES (IPRSS) PROGRAM

Transcription

1 SA HEALTH EVALUATION OF THE INDIVIDUAL PSYCHOSOCIAL REHABILITATION & SUPPORT SERVICES (IPRSS) PROGRAM FINAL REPORT MAY 2011 Health Outcomes International Suite 4, 51 Stephen Terrace, Kent Town SA 5069 Phone: Facsimile: ABN

2 C CONTENTS EXECUTIVE SUMMARY... 1 E.1 The IPRSS program... 1 E.1.1 Introduction... 1 E.1.2 Program description... 1 E.1.3 Program activity... 2 E.2 The evaluation objectives and design... 2 E.2.1 Evaluation objectives... 2 E.2.2 Evaluation design... 2 E.3 The consumer journey... 3 E.3.1 Needs identification, referral and allocation... 3 E.3.2 Access... 3 E.3.3 The individual support plan (ISP) process... 3 E.3.4 Exiting the program... 4 E.3.5 Recovery orientation... 4 E.4 The partnership... 4 E.5 Governance... 5 E.6 Consumer outcomes... 5 E.7 Recommendations... 6 INTRODUCTION Background to IPRSS Brief description of program IPRSS program objectives Evaluation objectives Evaluation design and methodology Report structure THE CONSUMER JOURNEY Key elements of service model Program activity Consumer characteristics Needs identification, referral and allocation i

3 2.5 Individual support plans and reviews Development of ISPs ISP reviews Carers perspective Exiting the program Discharges Readmission Recovery orientation Recovery Consumer involvement Carer involvement Service approaches Accessibility Aboriginal consumers CALD CARS data quality THE PARTNERSHIP IPRSS partnership survey introduction Key findings Detailed analysis Determining the need for the partnership Choosing partners Making sure partnerships work Planning collaborative action Implementing collaborative action Minimising the barriers to partnerships Reflecting on and continuing the partnership Building community relationships/capacity G OVERNANCE Key governance elements Program management committee Funding Regional allocation committees Quality Psychosocial rehabilitation service standards Workforce development ii

4 4.5.3 Workforce supervisory and support structures Key findings CONSUMER OUT COMES Introduction Approach to analysis Impact on NOCC assessment scores overall summary Impact on NOCC scores HONOS Impact on LSP Impact on K Impact on inpatient admissions Impact on government community mental health services Consumer case studies CONSUMER PERSP EC TIVES Introduction to REE survey Feedback on elements of recovery enhancement programs Achievement of recovery markets Organisational climate Consumer satisfaction surveys CONCLUSION APPENDICES ABBREVIATIONS -..I APPENDIX A PROGRAM STATEMENT... III APPENDIX B IPRSS PROGRAM LOGIC... III APPENDIX C ADDITIONAL PROGRAM ACTIVITY TABLES... IV APPENDIX D BRIEF DESCRIPTION OF OUTCOME TOOLS IN USE... VI APPENDIX E CONSUMER CASE STUDIES... XI APPENDIX F REE SURVEY ANALYSIS... XIV APPENDIX G- NGO PROVIDER CONSUMER SATISFACTION SURVEYS... XXXV APPENDIX H- CARS DATA QUALITY...XXXVIII iii

5 T TABLES Table 1.1: Report structure...12 Table 2.1: Gender by provider...16 Table 2.2: IPRSS consumer complexity...16 Table 2.3: Average days from referral to first contact Table 2.4: Hours per consumer...21 Table 2.5: Goal profile - August Table 2.6: Number of ISP reviews recorded on CARS compared to expected...23 Table 2.7: ATSI status by region...30 Table 2.8: CALD consumers by region...31 Table 3.1: Categorisation of total scores...33 Table 3.2: Determining the need for the partnership...35 Table 3.3: Choosing partners...36 Table 3.4: Making sure partnerships work...37 Table 3.5: Planning collaborative action...37 Table 3.6: Implementing collaborative action...38 Table 3.7: Minimising the barriers to partnerships...39 Table 3.8: Reflecting on and continuing the partnership...39 Table 4.1: IPRSS funding...43 Table 4.2: Quality review status...44 Table 4.3: Qualification profile Table 4.4: Summary of additional training opportunities offered...47 Table 5.1: Change in NOCC assessment scores pre and post IPRSS commencement...51 Table 5.2: Change in per item and subscale HoNOS score pre and post IPRSS commencement 1,2, Table 5.3: Change in per item and subscale HONOS 65+score pre and post IPRSS commencement...53 Table 5.4: Change in adult per item and sub scale LSP-16 score a pre and post IPRSS commencement...54 Table 5.5: Change in older people per item LSP-16 score pre and post IPRSS commencement...55 Table 5.6: Change in adult per item K 10 score pre and post IPRSS commencement...56 Table 5.7: Change in older people per item K 10 score pre and post IPRSS commencement...56 Table 5.8: Change in acute mental health admissions and LOS pre and post IPRSS commencement per consumer...57 iv

6 Table 5.9: Change in non mental health total admissions and LOS pre and post IPRSS commencement per consumer Table 5.10: Change in total admissions pre and post IPRSS commencement per consumer Table 5.11: Change in LOS for all admissions pre and post IPRSS commencement per consumer Table 5.12: Change in government community health service contacts pre and post IPRSS Table 5.13: Areas of improvement from IPRSS consumer case studies Table 6.1: Overview of consumer feedback v

7 F FIGURES Figure 2.1: IPRSS program service model overview Figure 2.2: Number of consumers by provider April 09 to August Figure 2.3: Total consumer hours by each provider April 2009 to August Figure 2.4: Regional distribution of consumers Figure 2.5: Age profile Figure 2.6: Overall gender distribution Figure 2.7: Referrals per month Figure 2.8: Average service hours per consumer per month Figure 2.9: Average length of stay by provider Figure 2.10: Discharges per month Figure 2.11: ATSI consumers Figure 2.12: CALD consumers Figure 3.1 Overall strength of partnership vi

8 E EXECUTIVE SUMMARY appointed Health Outcomes International (HOI) on 10 May 2010 to undertake an evaluation of the Individual Psychosocial Rehabilitation and Support Services (IPRSS) program. E.1 THE IPRSS PROGRAM E.1.1 INTRODUCTION The non-government sector is an integral component of an effective mental health system recognised for its distinctive contribution in many jurisdictions both nationally and internationally. Within South Australia there is an increasing emphasis on funding to the non-government sector for the provision of community mental health services and the IPRSS program in particular, in line with Social Inclusion Board recommendations. There are seven non-government organisation (NGO) providers involved in the delivery of the IPRSS program. E.1.2 PROGRAM DESCRIPTION The IPRSS program is based on an evidence based model of care and supports people with severe mental illness and a high level psychiatric disability on their recovery journey. It commenced on 1 April A key element of the IPRSS program is the partnership between NGO providers and government mental health services (MHS) with the needs of the shared consumers being central to decision making. A recovery philosophy underpins the delivery of psychosocial rehabilitation and support services. IPRSS NGO providers and government MHS work in partnership with other key stakeholders including housing to provide structured, goal focused and individually tailored services at a level of intensity and duration appropriate to consumers needs. An important component of individual psychosocial rehabilitation is community capacity building. Service types include: services delivered to assist the consumer engage in meaningful daytime activity and employment; services delivering combined housing and support programs provided the service is not facility based; services delivered in community settings intended to promote community engagement and social connectedness; independent living skills support and training to enable day to day living in the community; and transition from facility based services to home and community living. The service model is summarised in the following diagram. 1

9 E.1.3 PROGRAM ACTIVITY For the period 1 April 2009 and 31 August 2010 (the period for which data was made available) a total of 936 consumers received an IPRSS service. The total hours recorded were 169,363 compared to 172,380 funded hours, a variation of 1.8% which we consider to be minor in the context of the evaluation. Fifty one percent of consumers were serviced by NGO providers operating in the central and northern regions, which correlates with the 52% of funds being allocated to NGO providers in those regions. The majority of consumers fall within the 20 to 49 year age bracket (73%). There were 21 consumers less than 20 years of age which reflects the fact that the program is not focused on younger consumers. For adult services, males comprise the greater share of consumers (59%) and for older people services females comprise 74% of consumers, the higher percentage being attributed to higher male mortality rates. The complexity of IPRSS consumers (as measured by HoNOS), is significantly greater than the average national ambulatory mental health consumer for both adults and older people. This indicates that IPRSS is reaching the target group. E.2 THE EVALUATION OBJECTIVES AND DESIGN E.2.1 EVALUATION OBJECTIVES The evaluation aims to build a strong evidence base for the provision of best practice psychosocial rehabilitation and support services in South Australia and specifically sought to: E.2.2 assess whether the IPRSS program was implemented as planned determine whether consumer outcomes were optimised improve IPRSS program arrangements and performance inform future service planning, delivery and funding and make recommendations regarding specific aspects of the service that require review or development. EVALUATION DESIGN A number of qualitative and quantitative processes have been utilised to evaluate the program. These include: an analysis of Consumer Activity Reporting System (CARS) program data in respect to consumer demography, access to the program, and program activity an analysis of government community mental health outcome data and inpatient admission data to review the potential impact of the program an analysis of consumer perspectives obtained from the REE tool survey administration of the partnership analysis survey tool developed by VicHealth designed to test various aspects of the partnership attendance at regional allocation committee meetings in all metropolitan areas and two country regions (Murray Bridge and Port Pirie) as an observer and having group discussions about the program where time permitted (i.e. Eastern, Murray Bridge and Port Pirie) stakeholder consultations with government MHS team leaders and managers, NGO providers and the Mental Health Carer Advisory Group. 2

10 E.3 THE CONSUMER JOURNEY E.3.1 NEEDS IDENTIFICATION, REFERRAL AND ALLOCAT ION Regional allocation committee meetings are resource intensive but provide a valuable role based on the current program structure. They are a key element of the service partnership. Regional allocation committee meetings and associated processes help to ensure the program is reaching the right consumers. Allocation committees that cover multiple programs facilitate a streamlined service approach for the consumer. Regional allocation committees vary in the priority setting process for consumers entering the IPRSS program. There can be significant waiting lists and it is not clear how consumers who have been on the list for some time are reprioritised when a vacancy arises. There is limited discussion on the capacity of NGO providers to accept referrals, and the provision, for example, of an NGO provider regional monthly report to allocation committee meetings, incorporating current consumers and hours allocated per consumer, would further strengthen the service partnership and help to prioritise need. E.3.2 ACCESS Aboriginal and Torres Straight Islanders (ATSI) currently comprise 5.3% of IPRSS consumers and this is relatively constant between regions, although the number of unknowns recorded in country is high (27%). Overall 13% of consumers identified as having a CALD background, relatively consistent across regions. ATSI and CALD groups access the program to the extent that they are referred by government MHS and some regions have implemented innovative solutions to ensure ATSI have access to the program. It is not clear whether the IPRSS program is the most suitable model for ATSI people experiencing psychological distress and there is no benchmark for the percentage of ATSI IPRSS consumers. E.3.3 THE I NDIVIDUAL SUPPORT PL AN PROCESS In the majority of instances the development and review of Individual Support Plans (ISPs) works well. The average time from referral to first conact was 16.9 days. Variations between providers and other data held by the Department of Health are likley to reflect recording and definitional issues. There are no benchmarks established for the program in this area. When setting benchmarks, the time from the need being identifed to the time support begins to be provided is the key. Any benchmark or indicator established would need to take into account the steps and responsibilities across this pathway. In a number of situations it is possible that the Mental Health Care Plan and the Individual Support Plan are not compatible potentially causing conflict between the non-government and government service provider. ISPs set consumer goals across a range of domains. Supporting and promoting self-management/health and wellbeing is the most frequent goal domain with 93% of consumers having a goal in this area. The average hours of NGO provided service per consumer per month is 18.6 hours (median 15 hours). There are significant variations between NGO providers. While it is reasonable that there are variations between consumers, the overall average variation between NGO providers needs to be investigated. Overall the average length of stay in the IPRSS program is 333 days (11 months). There are some significant variations between NGO providers for which there are no obvious explanations and this requires further investigation. 3

11 Government mental workers attendance at ISP reviews is variable in some cases. There has been an increased workload for government mental health workers because of the requirement to attend ISP reviews. There is a need for improved co-ordination of reviews and better articulation of roles and responsibilities in operational protocols and there should be a more concerted effort to involve carers in the ISP process where appropriate. There are instances when the IPRSS program does not effectively engage with consumers to achieve program outcomes through effective goal setting, the provision of meaningful activities and/or effective community connection. E.3.4 EXITING THE PROGRAM For consumers and carers a seamless transition between services and a clear service pathway is critical. The service partnership requires that there is timely communication around exiting consumers from the program which occurs in most, but not all, instances The empirical data indicates that the group of consumers within the evaluation period were being discharged appropriately (i.e. a low number of 11 readmissions with the average time from discharge to readmission being 6.3 months). Qualitative feedback indicated there may be a need for some adult consumers to receive time limited support while exiting the program when they are no longer an active consumer of the government MHS. Developing more specific exit guidelines would assist in strengthening the exit process and enhancing the consumer journey. E.3.5 RECOVERY ORIENTATION NGO providers have demonstrated an understanding of a recovery orientation and have incorporated it into their organisational culture. Care needs to be (and is) taken in the way that the philosophy and ideals are meaningfully translated to elderly consumers. Service providers are active in involving consumers at the service level and NGO providers are constantly working on ways to include consumers in program management. Service providers try and accommodate and encourage the involvement of carers to some degree. However as most consumers indicate that they do not have carer involvement, service providers are not as active as they could be in promoting carer involvement. E.4 THE PARTNERSHIP A key element of the IPRSS program is the partnership between NGO providers and government MHS. Approximately half of the manager level stakeholders (46%) felt a partnership based on genuine collaboration had been established with the challenge being to maintain its impetus and build on current success. The remaining 54% felt the partnership was moving in the right direction but will need more attention if it is going to be really successful. No one indicated that the whole idea of partnership should be rigorously reviewed. Overall there is a clear commitment to continuing and strengthening the collaboration in the medium term. Critical success factors identified by NGO providers who reported strong partnerships included: developing good working relationships at the senior and middle management level which then filters down to NGO support workers, government MHS providers and eventually the consumer 4

12 developing open and honest relationships at every management level where each partner recognises and respects the role and responsibilities of the other and adopts the intent of the operational protocols recognising from the start that the teams are not always going to agree but the consumers interests must always be at the heart of all decisions/ discussions. Where these success factors do not exist it can lead to NGO providers and the contribution they make being undervalued. The majority of people who felt that the partnership still needed some improvement, identified that many of the problems they were experiencing arose from different conceptual understandings of the recovery approach and the role of the NGO support worker in the IPRSS program. Partnership success could be improved by greater clarity of vision, roles and responsibilities, clearly articulated boundaries and concepts of recovery and recovery practice. One practical opportunity for improvement around which most agreed was the need to review and update the operational protocols and conduct joint training sessions on the recovery approach and further definition around the role of the NGO support worker, supplemented by action learning case studies. This would assist in developing a shared understanding of, and commitment to respective roles and responsibilities. E.5 GOVERNANCE The governance structure has served the program well since its inception Regional allocation committee meetings are resource intensive but provide a valuable role based on the current program structure. They are a key element of the service partnership. The program has been operating for two years and it is timely for the leadership i.e. the Program Management Committee (PMC), to recommit to the shared vision required to sustain the success of the program. There is no structured approach to monitor the performance of individual service providers or regions. HOI consider the program would benefit if an annual contract management meeting was conducted with each service provider. Regional allocation committee meetings could be utilised more strategically to assist the PMC in implementing strategic requirements at the local level and also to further strengthen the partnership. There is a strong demonstrated commitment to quality in the program. Consideration should be given to endorsing an approach where only one recognised quality process need be adopted. Overall 87.8% of the staff have a relevant qualification with 41% having a Bachelor degree and there is an active staff development program offered by NGO providers. Opportunities for joint training initiatives with government mental health providers should be explored. Promotion of the non-government support worker role as a career opportunity is an important strategy to improve service outcomes. NGO provider supervisory and support structures are satisfactory. E.6 CONSUMER OUTCOMES The IPRSS program has had a positive impact on consumer outcomes. There have been significant decreases in mean scores across all National Outcomes and Casemix Collection (NOCC) indicators. In particular: HoNOS adult score has improved by 14.3% to 12.3 HoNOS 65+ for older persons score has improved by 11% to

13 K10 adult score has improved by 8.7% to 20.1 K10 older persons score has improved by 12.2% to 19.4 (note very small sample) LSP 16 adult score has improved by 9.1% to 15.5 LSP 16 older persons score has improved by 19.4% to 9.0. An analysis of consumer outcomes from the case studies and feedback from consultations reflect that NGO providers are taking a holistic approach when goal setting. They are identifying issues across a wide range of domains and working with consumers to address them. Increased independence, improved health (both physical and mental) management, social connectedness, family relationships and improved domestic and self-care skills are common areas being addressed. Having said that, carer and consumer feedback indicates that while they are very positive about the program and its staff, they feel that it does not always: provide real choices, desirable options and opportunities for participants assist participants to become involved in meaningful activities support them in building or rebuilding positive relationship with family members or friendships with people outside the mental health system. and further analysis, discussion and training with staff around these issue needs to occur. The IPRSS program has had a very positive impact on the rate on mental health related hospital admissions and associated average length of stay (ALOS). The rate of mental health admissions have reduced by 39% and ALOS has reduced by 16%. The IPRSS program has had a positive impact on the rate of non-mental health related hospital admissions and associated ALOS in that consumers are more aware of their physical health needs and attending to them (increase in rate of admission of 20%), and when they are in hospital, they are more capable of being discharged home earlier than was the case previously (ALOS reduced by 60%). E.7 RECOMMENDATIONS 1. Regional allocation committees vary in the priority setting process utilised for consumers entering the IPRSS program. To ensure equity and consistency it is recommended that: The Department of Health (DH) and the PMC should review the current priority ranking process for entry into the program and establish an agreed state-wide approach. 2. Aboriginal and Torres Strait Islanders (ATSI) currently comprise 5.3% of IPRSS consumers. While this is greater than their overall percentage of the population, ATSI people are two and a half times as likely as non-indigenous people to have experienced high/very high levels of psychological distress. It is not clear whether the IPRSS program is the most suitable model for ATSI people experiencing psychological distress and what should be an appropriate number of ATSI consumers. Some regions are exploring innovative ways to increase ATSI access to the IPRSS program. It is recommended that: All partners should continue to explore innovative solutions to ensure Aboriginal and Torres Strait Islanders have ongoing and increased access to the program. 3. The average hours of service per consumer per month is 18.6 hours (median 15 hours). There are significant variations between providers in average hours of service per consumer per month and average length of stay on the program. While it is reasonable that there are variations between consumers, the size of the overall avearge variations needs to be investigated. It is recommended that: The DH investigates variations between providers in average hours of service per consumer per month and average length of stay on the program. 6

14 Monitoring and review should highlight the need for further analysis and discussion if variations are significant and continual. It is important that the quality of the services being provided is analysed as well as indentification of the number of hours. 4. For consumers and carers a seamless transition between services and a clear service pathway is critical. In the majority of situations the quantitative and qualitative data indicates that consumers are being discharged appropriately. However the exit process and partnership would be strengthened if there were more specific exit guidelines to assist with the exit process and ensure there is always timely communication around the exit process. For adult consumers there may be a need for some consumers to receive time limited support while exiting the program, when they are no longer an active consumer of the government mental health service. It is recommended that: To strengthen the exit process, DH and PMC review the exit process and consider developing guidelines for staff. 5. Feedback from carers indicates that service providers could be more active in promoting carer involvement in the program and there should be a more concerted effort to involve carers in the ISP process where appropriate. It is recommended that: The operational protocols and their application are reviewed to enhance the involvement of carers in the program at all levels. 6. There are instances when the IPRSS program does not effectively engage with consumers to achieve program outcomes. Areas that were consistently raised as being problematic include: Goal Setting: consumer goals can be unrealistic and there is a perception that consumers could be more actively assisted to achieve goals Meaningful Activities: there is a pathway gap for consumers to be: o provided with real choices and opportunities o engage in relevant interests and activities Community Connection: that is supporting consumers to build or rebuild positive relationships with family members or friendships with people outside the mental health system. To a limited degree the regional allocation committees provide a forum for addressing and reviewing pathway gaps, however this requires further work. It is recommended that: A process is more clearly identified within the operational protocols for collecting and reviewing information pertaining to consumers long term outcomes after leaving the IPRSS program. This should be a partnership response that encourages services to review practices and achievement of objectives within the context of the program type. 7. There is a need for improved co-ordination of reviews and better articulation of roles and responsibilities in operational protocols. Partnership success could be improved by greater clarity of vision, roles and responsibilities, clearly articulated boundaries, concepts of recovery and recovery practice. The program has been operating for two years and it is timely for the leadership to recommit to the shared vision required to sustain the success of the program. It is recommended that: 7

15 The PMC recommit to the shared vision for IPRSS, review and update the operational protocols and conduct joint training sessions on the recovery approach and further definition around the role of the NGO support worker, supplemented by action learning case studies. This would assist in developing a shared understanding of, and commitment to respective roles and responsibilities. This will also assist in maintaining quality governance arrangements including high functioning allocation committees. 8. There is a strong demonstrated commitment to quality in the program with providers having more than one accreditation process which is time consuming and costly. It is recommended that: Consideration be given to endorsing an approach where only one recognised quality process need be adopted for NGO providers. 8

16 1 INTRODUCTION The South Australian Department of Health (DH) provides funding to non-government organisations (NGO providers) through a competitive tender process to provide individual psycho-social rehabilitation services working in partnership with government mental health services (MHS). The DH allocated funds through a contract arrangement to nine non-government organisations over the period 1 April 2009 to 30 June Health Outcomes International (HOI) was engaged to undertake the evaluation of the Individual Psychosocial; Rehabilitation and Support Services (IPRSS). The evaluation aims to build a strong evidence base for the provision of best practice psychosocial rehabilitation and support services in South Australia This chapter sets out the background to the IPRSS program, the program objectives, a brief description of the program, the purpose and objectives of this evaluation, an overview of the evaluation methodology, and an outline of the structure of this report. 1.1 BACKGROUND TO IPRSS The non-government sector is an integral component of an effective mental health system recognised for its distinctive contribution in many jurisdictions both nationally and internationally. Within South Australia there is an increasing emphasis on funding to the non-government sector for the provision of community mental health services. NGO providers are now providing a wider range of services to a larger number of mental health consumers than ever before. Many of these consumers have complex needs. The South Australian Government accepted the recommendations of the Social Inclusion Board s report Stepping Up: A Social Inclusion Action Plan for Mental Health Reform With regard to non-government sector the Board recommended that: South Australia should continue to build capacity in the non-government sector to deliver psychosocial rehabilitation and support services. The development should be framed within a partnership approach that builds on a system that will have community mental health at its centre. Rehabilitation and support services should be focussed on helping people to step down from formal care and on maintaining ordinary associations in society that support a meaningful life. Within South Australia, non-government community mental health services funded by the Department of Health would include Individual Psychosocial Rehabilitation Support Services BRIEF DESCRIPTION OF PROGRAM The IPRSS program is based on an evidence based model of care and supports people with severe mental illness and a high level psychiatric disability on their recovery journey. A key element of the IPRSS program is the partnership between NGO providers and government MHS with the needs of the shared consumers being central to decision making. A recovery philosophy underpins the delivery of Statewide Operation Protocol. Individual Psychosocial Rehabilitation and Support Services. Government of South Australia 9

17 psychosocial rehabilitation and support services. This philosophy is internationally and nationally recognised, having been developed by the mental health consumer movement. Services can operate over seven days (although they are usually provided on a five day basis) in accordance with the person s needs and are delivered regardless of where the person lives in the community, for example in private or public housing, a boarding house, Supported Residential Facility (SRF), an Aboriginal hostel, private hotel or caravan park. IPRSS NGO providers and government MHS work in partnership with other key stakeholders including housing to provide structured, goal focused and individually tailored services at a level of intensity and duration appropriate to the consumer s need. An important component of individual psychosocial rehabilitation is community capacity building. Services are generally targeted at adults (over the age of 18 years) and older people who have high and complex needs and are registered with the public mental health system. The program is underpinned by a service model, operational protocols and a formal governance structure, which includes local allocation processes and a state-wide Program Management Committee that provides operational leadership and broad oversight of the program. IPRSS NGO providers are required to work towards compliance with the formally endorsed South Australian Psychosocial Rehabilitation Support Services Standards (PRSSS) and minimum training requirements for the employment of staff. Service types include: services delivered to assist the consumer engage in meaningful daytime activity and employment services delivering combined housing and support programs provided the service is not facility based services delivered in community settings intended to promote community engagement and social connectedness independent living skills support and training to enable day to day living in the community transition from facility based services to home and community living. 1.3 IPRSS PROGRAM OBJECTIVES The Program objectives are outlined in the IPRSS service model and include to: assist people to self manage their own recovery and build on their interests, aspirations and strengths to live full and active lives develop skills to improve competence and confidence in community living improve health and well-being improve independence and resilience prevent relapse and limit severity of any crisis engage the consumer with desired community and social activities reduce social and physical dislocation by assisting people to sustain suitable housing and to develop improved social relationships increase opportunities to participate in the workforce reduce demand on acute and emergency services. Other Program objectives include: 10

18 to provide individually tailored services at a level of intensity and duration appropriate to the consumer s needs to provide services within a recovery oriented framework to enhance partnerships between government and non-government community mental health services, consumers and carers to enhance partnerships with the community to build capacity. 1.4 EVALUATION OBJECTIVES The evaluation aims to build a strong evidence base for the provision of best practice psychosocial rehabilitation and support services in South Australia and will specifically seek to: assess whether the IPRSS program was implemented as planned determine whether consumer outcomes were optimised improve IPRSS program arrangements and performance inform future service planning, delivery and funding make recommendations regarding specific aspects of the service that require review or development. More specifically the evaluation is required to undertake an assessment of the extent to which: 1. The services are achieving the aims and objectives of the program. 2. Consumer outcomes are being achieved and service delivery reflects a recovery orientation. 3. Each stage of the service model and operational protocols are implemented effectively with a particular focus on the consumer journey from engagement to exit. 4. Quality services are provided. 5. The services are accessible to the target population and in particular specific populations such as Aboriginal people and people from culturally and linguistically diverse backgrounds. 6. Partnerships between government and non-government community mental health services, consumers and carers optimise outcomes. 7. The program enhances partnerships with the community to build capacity and optimise outcomes. 8. The program s governance arrangements and structures are effective and efficient enhancing desired outcomes. 9. The program is reaching the right people through the allocation process. 1.5 EVALUATION DESIGN AND METHODOLOGY The evaluation was conducted in four broad stages namely: 1. Developing a project plan and an evaluation framework - which identified the service program logic, data set and appropriate information gathering tools that would be required to support both process and impact evaluation. Appropriate ethics approval to undertake the evaluation was obtained from the SA Department of Health Human Research Ethics Committee as part of this stage. 2. Conducting the consultation process - with NGO service provider, government community mental health services, the SA Mental Health Carer Support Advisory Group and consumers via the Ridgeway Recovery Environment Enhancement (REE) tool survey. 11

19 3. Quantitative consumer outcome data analysis collection and analysis of available consumer outcome data. 4. Reporting - interim and final reports. A number of qualitative and quantitative processes have been utilised to evaluate the program. These include: an analysis of Consumer Activity Reporting System (CARS) program data in respect to consumer demography, access to the program, and program activity an analysis of government community mental health outcome data and inpatient admission data to review potential impact of the program an analysis of consumer perspectives obtained from the REE tool survey administration of the partnership analysis survey tool developed by VicHealth designed to test various aspects of the partnership attendance at allocation committee members in all metropolitan areas and two country regions (Murray Bridge and Port Pirie) by attending meetings as an observer and having group discussions about the program where time permitted (i.e. Eastern, Murray Bridge And Port Pirie) analysis of feedback from government MHS, NGO provider and carer stakeholder consultations. 1.6 REPORT STRUCTURE This report is structured as follows: Table 1.1: Report structure Chapter two Chapter three Chapter four Chapter five Chapter six Chapter seven Presents an evaluation of key aspects of the service model. Examines stakeholder perspectives on the partnership. Provides an analysis of governance arrangements for the IPRSS program. Analyses the impact of the program on consumer outcomes. Reviews consumer perspectives on the program. Outlines the overall conclusion to the evaluation. 12

20 2 THE CONSUMER JOURNEY Chapter two presents an evaluation of key aspects of the service model from the perspective of the consumer journey. 2.1 KEY ELEMENTS OF SERVICE MODEL The IPRSS program service model as promulgated by is presented in appendix A. The key elements to the service model include: adopting a recovery orientation approach the service partnership between NGO providers and government MHS governance arrangements a regional allocation meeting convened by the government MHS and attended by NGO providers to assess and allocate potential consumers developing individual support plans (ISPs) where goals are set with consumers involving the consumer, carer where appropriate, NGO providers and the government MHS regular three monthly ISP reviews with the consumer, the NGO provider, the government mental health worker and the carer where appropriate exiting consumers. A high level overview of the service model is presented in figure 2.1. Figure 2.1: IPRSS program service model overview The program logic developed as part of the evaluation framework is presented in appendix B. The service partnership, governance and consumer outcomes are considered in chapters three, four and five respectively. 13

21 2.2 PROGRAM ACTIVITY Figure 2.2 presents the number of consumers by provider who received an IPRSS service for the period April 2009 and August 2010 (the period for which data was made available). A total of 936 consumers received an IPRSS service. Figure 2.2: Number of consumers by provider April 09 to August 2010 Note (1): Each consumer is counted once. Provider Figure 2.3 presents the total consumer service hours recorded on the Consumer Activity Reporting System (CARS) by provider, for the period April 2009 to August The total hours recorded were 169,363 compared to 172,380 funded hours, a variation of 1.8% which we consider to be minor in the context of the evaluation. Figure 2.3: Total consumer hours by each provider April 2009 to August 2010 Provider Note (1): Hours include direct and indirect client hours. Figure 2.4 presents the regional distribution of all IPRSS program consumers. The figure shows that that 51% of consumers were serviced by NGO providers operating in the central and northern regions, which correlates with the 52% of funds being allocated to NGO providers in those regions. 14

22 Figure 2.4: Regional distribution of consumers 2.3 CONSUMER CHARACTERISTICS Figure 2.5 presents the age profile of all IPRSS program consumers. The majority of consumers fall within the 20 to 49 year age bracket (73%). There were 21 consumers less than 20 years of age which reflects the fact that the program is not focused on younger consumers. Figure 2.5: Age profile 15

23 Figure 2.6 presents the gender distribution of consumers on the program and table 2.1 presents the distribution by provider. For adult services males comprise the greater share of consumers (59%) and for older people services females comprise 74% of consumers, the higher percentage being attributed to higher male mortality rates. Figure 2.6: Overall gender distribution Table 2.1: Gender by provider Provider Gender Male Female Total Adult Providers (n=525) 59.0% 41.0% 100.0% Older Person Providers (n=78) 25.6% 74.4% 100.0% Overall (n=603) 54.7% 45.3% 100.0% The following is a general description of IPRSS consumers (excluding older people) as articulated by stakeholders. Consumers: have high and complex needs have been engaged with a government MHS over a long period of time are often at risk of becoming homeless are evenly distributed between male and female are at risk of relapse if they do not receive support more often than not they are living alone - in some cases aged parents have just moved into nursing homes or passed away and they often have no or limited skills in how to maintain their house. Table 2.2 compares IPRSS program consumer complexity as measured by the National Outcomes and Casemix Collection (NOCC) scores to the national average. The table shows that the complexity of IPRSS consumers is significantly greater than the average national ambulatory mental health consumer for both adults and older people. Table 2.2: IPRSS consumer complexity Assessment Type National Mean 1 IPRSS Mean Score Before First Contact Percentage Difference HoNOS Adult % HoNOS % K10 Adult % 16

24 K10 Older Person % LSP16 Adult % LSP16 Older Person % Note (1): Source NOCC web decision support tool Ambulatory Occasion review 2008/ NEEDS IDENTIFICATION, REFERRAL AND ALLOCATION Figure 2.7 presents the number of referrals to the IPRSS program per month. The figure shows that once established, new referrals to the program each month are relatively stable, although there was a large increase to 44 referrals in March Figure 2.7: Referrals per month NEED AND APPLICATION FOR RESOURCES The program guidelines require that the potential need for an IPRSS service is identified by the government MHS worker and confirmed by a government MHS senior clinician. An application for resources is completed and submitted to the relevant allocation committee. The government MHS worker involves the consumer in the application and gains consumer consent to proceed. 17

25 REFERRAL AND ALL OC ATION The regional allocation committee comprised of relevant NGO providers and government MHS considers the application and if approved, a referral is made. Regional allocation committee meetings are resource intensive given the number and time of people attending. Based on our observation of the regional allocation committees, application for resources are completed and presented for potentially relevant consumers. Ideally the relevant government MHS worker should present the IPRSS referral as this provides for a deeper and more meaningful discussion about the consumer than if the referral is presented by a third party although it is understood that this is not always practical. PRIORITY SETTING Different committees have different approaches to priority setting e.g. the west uses a first on the waiting list, first in the program approach whereas southern categorises consumers into one of three priority categories as well as taking time on the waiting list into account. ACCEPTANCE Once a consumer is referred and accepted onto the IPRSS waiting list, it can be some months before they actually commence on the program. It is not clear how changed consumer circumstances are taken into account when a vacancy in the program arises. At each meeting, NGO providers give a verbal update about their capacity to take new entries and whatever is stated is generally accepted. Some government MHS expressed concern that very little information in relation to consumer hours was provided to allocation meetings, and that this resulted in a lack of knowledge of who is receiving what level of service, and what may be their priority compared to another consumer on the waiting list. OTHER PROGRAMS Some allocation committee meetings cover a number of different programs (e.g. CSS/PHaMs/housing) and this helps link the consumer to the most appropriate service and ensures adequate support is provided. This appears to work well. A more strategic discussion of the role of the allocation committee is in section

26 Key Findings Allocation committee meetings and associated processes help to ensure the program is reaching the right consumers. Allocation committee meetings are resource intensive but provide a valuable role based on the current program structure. They are a key element of the service partnership. There is a need to establish an agreed priority ranking process for entry into the program state-wide as currently each region has a different approach. Allocation committees that cover multiple programs facilitate a streamlined service approach for the consumer. There can be significant waiting lists and it is not clear how consumers who have been on the list for some time are reprioritised when a vacancy arises. The provision of an NGO provider regional monthly report to allocation committee meetings, incorporating current consumers and hours allocated per consumer, would further strengthen the service partnership and help to prioritise need. 2.5 INDIVIDUAL SUPPORT PLANS AND REVIEWS DEVELOPMENT OF ISPS Individual Support Plans (ISPs) are generally developed with each consumer on entry into the program (or within the first few weeks) and then reviewed every three months, and in some cases updated as required. Input from government mental health workers occurs on a regular basis, although they are not able to get to all meetings. Communication is maintained as, in that situation, meetings take place without the key worker and relevant information is subsequently forwarded to them. The ISP is developed in collaboration with the consumers (and carers or significant others where agreed by the consumer although in many cases carers are not involved). Each area of the ISP is discussed with the consumer, with most service providers utilising the Camberwell Assessment of Need as a prompt if needed. The focus is on identifying consumers strengths and setting goals to improve their lives. It was identified as important for there to be a good understanding of where a consumer was at on their journey, as was having male, female and ethnic workers to suit individual consumer preferences. ISPs are signed by the consumer and both the consumer and government MHS receive a copy. 19

27 One suggestion was the concept of having one service/care plan across government MHS and IPRSS NGO providers. This would help to improve communication and provide clarity for providers and consumers alike. Currently there may be some duplication and the two care plans can be seen in contrast with each other and may cause conflict between the teams. Government MHS generally thought an electronically shared care plan was a good concept that they would support, however there were some concerns around privacy and technical logistical issues. The IPRSS operational protocols identify the need to develop with the consumer a Mental Health Care Plan (primary function of the government MHS) and the ISP (primary role of the NGO provider). It also articulates the process for developing these plans and their relationship to each other. In discussion with the both government and non-government providers it would seem this is not always well understood and/or there are barriers to implementing a shared plan utilising the current operational protocols. One factor impacting on the timeliness of ISP completion is the time from referral to first contact. This is also a proxy measure of capacity and efficiency. Table 2.3 presents the average days from referral to first contact by provider and by region. The average time from referral to first conact was 16.9 days, the shortest was 0.4 days and the longest 45.6 days. This represents a significant variartion which needs further exploration. There are also variations between providers and other data held by the DH that may account for some difference, however there needs to be greater clarity around recording and definitions. There are no benchmarks established for the program in this area. When setting benchmarks, the time from the need being identifed to the time support begins to be provided is the key. Any benchmark or indicator established would need to take into account the steps and responsibilities across this pathway. Organisation Table 2.3: Average days from referral to first contact Central Northern Adelaide (n=181) Country (n=162) Southern Adelaide (n=102) Overall (n=445) Provider 1 NA 2 NA Provider NA NA 10.1 Provider Provider Provider NA 37.7 Provider NA Provider NA 13.7 Overall (n=445) Note (1): Data sourced from CARS Note (2): NA = not applicable ie there are no consumers from the given provider in the given region The ISP and subsequent reviews are the key drivers of determining the intensity and duration of the service provision to a consumer. Figures 2.8 and table 2.4 present the average hours of service per consumer per month both by provider. The average hours of service per consumer per month is 18.7 hours. The pattern of hours per month was relatively consistent for the April 2009 to August 2010 period. There are significant variations between providers. While it is reasonable that there are variations between consumers, the level of variation demonstrated by figure 2.8 in our view should be a priority for further investigation. 20

28 Figure 2.8: Average service hours per consumer per month Provider Note (1): The total number of current consumers in a given month is calculated by counting the number of consumers who received a service that month. Thus, even if the database indicates that a consumer has not been discharged, the consumer is only considered to be a current consumer if he/she received a service in the given month. Note (2): The evaluation did not examine the accuracy or method for recording hours by consumer which is the key indicator used for funding. This issue was examined as part of KPMG audit early in the program based on the first three months of data. It is planned to undertake another audit and we support this. The terms of reference should be reviewed as some of the issues they considered have been explored by this evaluation. Table 2.4 presents the mean, median, minimum and maximum values for hours per consumer per month. Using the median there are still significant variations between providers. Table 2.4: Hours per consumer Organisation Mean Median Minimum Maximum Provider Provider Provider Provider Provider Provider Provider Overall (n=9037) Figure 2.9 presents an estimate of the average length of stay (ALOS) in the IPRSS program by provider. Overall the ALOS is 333 days (11 months). For reasons outlined in the table footnotes this is an underestimate. Six of the providers ALOS fall within the range 325 days to 370 days (or 10.5 months to 12 months). 21

29 Figure 2.9: Average length of stay by provider Provider Note (1): For a given consumer, the length of stay has been calculated as the number of days from the date of first contact to the discharge date. In calculating this we have applied a number of assumptions, the two most important being: if first contact occurred prior to 1 April 2009, the date of first contact was taken to be 1 April 2009, as this was date the IPRSS program commenced all patients in program on 31 August 2010 were assumed to be discharged on that date as we have no discharge information after that date. As a result the estimated average length of stay will be an underestimate of the true average length of stay. An alternative estimate can be obtained by calculating the average length of stay of all discharged consumers. Based on the data received the average length of stay of discharged consumers is days. However, this value is a significant underestimate. Note (2): Additional assumptions include: No consumer can re-enter the program before being discharged. No consumer can re-enter the program within three months of a previous date of first contact. For a given consumer, where a date (eg discharge date) has been entered differently in different records, the date is taken to be the earliest recorded date. The estimated length of stay includes one endpoint. For example, if first contact occurred on 1 April 2009 and the consumer was discharged on 2 April 2009, the length of stay is calculated as 1 day. There are two alternatives to this method of calculation. If both endpoints are included, the resulting number would represent the total number of days the consumer was in the program. In the example above, this would be two days (1 April 2009 and 2 April 2009). If neither endpoint is included, the result would represent the number of full days in the program (zero days in the example above). These assumptions have been made throughout the analysis presented in this report. ISPs set consumer goals across a range of domains. Table 2.5 presents the percentage of consumers with goals relating to each specified domain for the month of August Table 2.5: Goal profile - August 2010 Goal Type Percentage of Consumers (n=580) 1 Supporting and Promoting Self-Management/Health and Wellbeing 93.3% Developing Living Skills and Capacity to take Responsibility 76.9% Community Engagement 76.9% Family and Social Relationships 41.9% Legal 18.6% Housing 2 0.0% Note (1): Consumers are able to have goals in more than one domain. Note (2): Housing is zero percent as this domain was only recently added to the list of domains. 22

30 2.5.2 ISP REVIEWS Regular three monthly reviews with the consumer, the NGO provider, the government mental health worker and the carer where appropriate, are a key element of the program. The aim is to have a formal setting to discuss progress, look at what has been learnt and to readjust goals to improve the quality of life further if required. Stakeholders believe that the three month review process is a positive part of the IPRSS program and providers believe that the reviews are generally a positive experience for many consumers. Some service providers, both government and NGOs, felt three monthly reviews may be too frequent as not enough change had occurred in that period. They thought the review timeframe should be extended with the proviso that a review be conducted in the interim if the need arises. Less frequent mandated reviews would reduce demand on government mental health workers and may align more closely with consumer need. However this is inconsistent with the Mental Health National Outcomes and Casemix Collection (NOCC) three monthly review process and is not recommended. NGO providers reported that regular reviews were occurring although not always at the three month mark. However the CARS data does not reflect this. Table 2.6 presents the number of reviews recorded in the CARS data base compared to what would have been expected if reviews had taken place three monthly. The table shows overall only 6.5% of reviews that should have taken place have actually occurred and this was relatively consistent across all NGO providers. The wide variation between stakeholder feedback and the data indicates that the information is not correctly recorded in database. Table 2.6: Number of ISP reviews recorded on CARS compared to expected Organisation Total Reviews Recorded Total Reviews Expected Percentage Provider % Provider % Provider % Provider % Provider % Provider % Provider % Overall % While the majority of service providers reported that government mental health workers participate in a minimum of 90% of the ISPs reviews, this was not consistent across NGO providers or region. Several NGO providers stated they were having ongoing issues with government mental health workers attending. In at least one region less than 50% of reviews had a government mental health worker attending, although this varied substantially over time. This results in NGO providers becoming frustrated due to a lack of feedback from the government worker in the ISP review process. The difficulty is in coordinating the review meeting and finding a time which is suitable for the government mental health worker and the consumer. This can be due to competing demands and priorities within the government MHS. In these circumstances NGO providers conduct reviews without the government mental health worker being present. The requirement for NGO providers to have a government mental health worker present at the review and conducting the review in a timely manner can be a balancing act. Some service providers have managed to overcome these barriers. For example, one service provider explained that 23

31 initially there were some difficulties in getting government mental health workers on board for the three monthly reviews. Now 99% of the time the government MHS worker is present. We have worked really hard at this, going and speaking to government mental health workers and emphasising the importance of collaboration CARERS PERSPECTIVE Carers felt that service providers could be more proactive in involving carers. Carers believe they know consumer needs and what motivates them. They also felt that goals need to be appropriate, relevant and followed through. Carers also identified that they want feedback on consumer progress through the review process. Too often NGO providers accept the word of the consumer at face value no does not always mean no. Carers who had direct experience with different NGO providers noted significant variation in worker approach and performance, which they considered was primarily a training issue. Carer feedback was consistent with the consumer perspective, in that while meaningful activities were important to recovery and being identified, carers and consumers felt they were not always being assisted to become involved in such activities. Key Findings In the majority of instances the development and review of ISPs works well. There are instances when the IPRSS program does not effectively engage with consumers to achieve program outcomes through effective goal setting, the provision of meaningful activities and/or effective community connection. The average time from referral to first conact was 16.9 days. Variations between providers and other data held by the DH are likley to reflect recording and definitional issues. There are no benchmarks established for the program in the area. When setting benchmarks, from the consumer perspective it is the time from the need being identifed to support being provided that is the key. Any benchmark or indicator established would need to take this into account the steps and responsibilities across this pathway. In a number of situations it is possible that the Mental Health Care Plan and the Individual Support Plan are not compatible potentially causing conflict between the non-government and government service provider. The average hours of service per consumer per month is 18.6 hours (median 15 hours). There are significant variations between providers (based on mean or median). While it is reasonable that there are variations between consumers, the level of variation in average service hours per consumer per month bewteen NGO providers requires further investigation. Overall the ALOS in the IPRSS program is 333 days (11 months). There are some significant variations between NGO providers for which there are no obvious explanations. This requires further investigation. ISPs set consumer goals across a range of domains. Supporting and promoting selfmanagement/health and wellbeing is the most frequent goal domain with 93% of consumers having a goal in this area. Government mental worker s attendance at ISP reviews is variable in some cases. There has been increased workload for government mental health workers because of the requirement to attend ISP reviews. There is a need for improved co-ordination of reviews and better articulation of roles and responsibilities in operational protocols. Service providers should be more proactive in involving carers in the ISP process. The CARS data base does not accurately reflect the number of reviews undertaken. 24

32 2.6 EXITING THE PROGRAM DISCHARGES In accordance with the operational protocols exiting the program is to be a planned process involving the consumer, the government mental health worker and the NGO provider. A consumer will exit the program when the: consumer has achieved the planned goals consumer no longer agrees to participate in the program partners agree that services offered by the IPRSS program are no longer the most appropriate and the consumer is transitioned into other more suitable options. Generally exit planning occurs in line with the above. There are no specific exit criteria or guidelines in relation to when IPRSS ceases to be the most suitable program. Professional judgement, exercised on a case by case basis is the key determinate. For consumers and carers a seamless transition between services and a clear service pathway is critical. Figure 2.10 presents the number of discharges per month. The figure shows that the number of discharges per month has generally increased in 2010 compared to It is not clear what factors are impacting on this trend and it should be monitored through the Program Managerment Committee. Figure 2.10: Discharges per month 25

33 Two issues were identified that, while not systemic problems, are worthy of discussion. There have been cases where a consumer is no longer receiving government mental health services and the NGO provider has not been informed/consulted, resulting in difficulties in effectively transitioning the consumer out of IPRSS. NGO providers also indicated that there are some cases where a consumer no longer needs a clinical mental health service but may need limited support for a period of time to continue the transition to other services, which in turn will help to maintain their psychosocial recovery. Several NGO providers have suggested that they would like there to be a maintenance phase where they have responsibility to continue to transition the consumer to other services and maintain recovery after they have been discharged from the government mental health system. They believe that a maintenance phase would assist with relapse prevention. Anecdotal evidence suggests that some NGO providers may be accommodating a maintenance phase. While NGO providers were generally supportive of the idea of a maintenance phase, government MHS do not share this view. It was noted that occasionally a government mental health worker transfers a consumer to the duty worker list when they no longer need active government mental health worker involvement, but they still need some IPRSS related support. Some government MHS would agree that while communication around the closing out of a consumer may need improving on some occasions, if they close a consumer from the MHS program, then they would no longer need additional psychosocial support READMISSION An indicator of whether consumers are discharged at an appropriate point is the number of readmissions. Over the 17 months for which CARS data was provided, we identified 11 cases where a consumer was discharged from the program and then re-admitted at a later date. In 10 of those cases, the time from discharge to readmission was between 4.5 and 8.9 months. In the other case, the time was 1.3 months. Across all 11 readmissions, the average time from discharge to readmission was 6.3 months. This low level of readmissions suggests consumers are being discharged appropriately. Key Findings For consumers and carers a seamless transition between services and a clear service pathway is critical. The service partnership requires that there is timely communication around exiting consumers from the program which occurs in most, but not all, instances. The empirical data suggests that consumers are being discharged appropriately i.e. only 11 readmissions and average time from discharge to readmission was 6.3 months. There may be a need for a consumer to receive time limited support while exiting the program, when they are no longer an active consumer the government mental health service. Developing more specific discharge criteria or guidelines would strengthen the exit process. 26

34 2.7 RECOVERY ORIENTATION RECOVERY All NGO providers demonstrated an understanding of recovery orientation, generally describing it as a person centred approach where an individualised, often holistic approach is adopted. One well articulated description from a service provider on their practical interpretation of the aims of the recovery orientation approach was as follows: assisting consumers to maintain good mental health through an ongoing process of enhancing and developing consumers strengths, future hopes and goals developing goals in partnership with consumers, government mental health workers and relevant others assisting consumers to achieve their goals, by breaking them down into smaller steps, providing support, helping them build skills and resilience in this process and pace the process in line with consumers needs encouraging consumers through setbacks, giving them the right to have a bad day reviewing and adjusting the goals on a regular basis. Some of the more common ways in which service providers are implementing and communicating the recovery orientation of the program include: being a key focus of information sheets and documents about the program training staff both at orientation and on an ongoing basis including by recognised national/international experts working with a consumer consultant to train staff in recovery orientation and the practical implications for workers, i.e. putting it into practice discussing recovery orientation in family and carers reference group meetings developing peer worker programs, which brings a lived experience into programs by involving workers in induction and training and providing consultations to staff building an understanding of the approach into regular staff reviews, supervision and team meetings. Language in brochures and communications with staff and consumers is considered to be important for engendering a recovery orientation. In the IPRSS program for older persons the use of the term recovery requires some qualification. For example, service providers are particularly mindful of language used as the term recovery for older people is something consumers often associate with recovering from a physical illness such as a broken arm. 27

35 Further, the service providers for older people identified that many consumers would not identify as having a mental illness and that they see their illness as being situation based. In terms of a recovery approach, care needs to be (and is) taken in the way that the philosophy and ideals are meaningfully translated to elderly consumers CONSUMER INVOLVEMENT In line with the recovery orientation framework, the IPRSS program is principally meant to be a consumer driven program. All NGO providers encourage consumer participation through a combination of feedback, forums, committees and peer support workers. NGO providers engage consumers in the IPRSS program management in a variety of ways including: consumer participation/satisfaction projects independent advice to determine how to successfully engage consumers hiring a consumer participation officer to work with the service providers (in one case to implement recommendations from consumer participation project) consumer forums although there have been difficulties getting consumers to participate consumer advisory groups consumer newsletters consumer satisfaction surveys use of peer workers ISP development and review CARER INVOLVEMENT With the informed consent of the consumer, carers are to be engaged at consumer level and broader advocacy. According to NGO service providers only a small percentage of IPRSS consumers have a carer or significant other that they wish to involve in the ISP process. Many consumers are single, widowed or divorced. While some consumers have very close, caring families others are totally disenfranchised from their families. All of the service providers report that if they know that a carer is involved then they try and include them. However the consumer has the ultimate decision in their care and the extent of the involvement of the carer. Carers do not necessarily agree with this proposition. As outlined in section carers felt that service providers could be more proactive in involving carers. A common difficulty NGO providers cited around the involvement of carers is a clash between what the family want and what the consumer wants. Carers consider they should at least be consulted and often they are heavily involved but this may not be acknowledged to service providers by the consumer. NGO service providers do encourage carer involvement in a variety of ways including: involving the carer in key decisions involving the carer in the development of the ISP (with consent of consumer) inviting carers to ISP reviews (with consent of consumer) establishing a working group to review operational practices against the Carers Act involving carers in the induction process, e.g. providing information regarding the feedback, comments and complaints regarding organisational procedure. 28

36 2.7.4 SERVICE APPROACHES NGOs are using a variety of service approaches. For example one NGO provider has adopted the collaborative recovery model 2 (CRM) across all programs in its organisation. Another is considering adopting the Flinders chronic disease management approach. This can cause confusion for government mental health workers. Key Findings Overall NGO providers have demonstrated an understanding of a recovery orientation and have incorporated it into their organisational culture. Care needs to be (and is) taken in the way that the philosophy and ideals are meaningfully translated to elderly consumers. NGO providers are active in involving consumers at the service level. NGO providers are constantly working on ways to include consumers in program management. Service providers try and accommodate and encourage the involvement of carers to some degree. However as most consumers indicate that they do not have carer involvement, NGO providers are not as active as they could be in promoting carer involvement. More information and analysis is required to assess the impact that different service approaches may have on service delivery. 2.8 ACCESSIBILITY This section examines to what extent services are accessible to potential consumers with Aboriginal or culturally and linguistically diverse (CALD) backgrounds ABORIGINAL CONSUMERS Figure 2.11 presents the number of consumers recorded as Aboriginal and Torres Strait Islander (ATSI) on the CARS database. Five percent of consumers declared themselves as being of ATSI descent. Figure 2.11: ATSI consumers 2 The CRMis a practice model developed over a number of years at the University of Wollongong that incorporates evidence of practices that have previously assisted people living with enduring mental illness. Influences include positive psychology, psychosocial rehabilitation principles, motivational interviewing and the stages of change model. The CRM is consistent with the values of the recovery movement. 29

37 Table 2.7 presents the ATSI status by region. The table shows that the number of consumers declaring themselves as being of ATSI descent is 5.3% and is relatively constant between regions, although the number of unknowns recorded in country is high (27%). Region Central Northern Adelaide (n=395) Neither Aboriginal nor TSI Table 2.7: ATSI status by region Indigenous Status Aboriginal or Torres Strait Unknown Islander Total ATSI Total Population % 5.6% 3.8% 100.0% 1.3% Country (n=59) 67.8% 5.1% 27.1% 100.0% Southern Adelaide (n=149) 87.9% 4.7% 7.4% 100.0% 0.8% Overall (n=603) 87.7% 5.3% 7.0% 100.0% Note (1): Data sourced from CNAHS and AHS Health Improvement Plans. Table 2.7 shows that the number of ATSI consumers in the program is higher than would be expected based on the overall percentage of the population that is Aboriginal. However based on the National Health Survey, Aboriginal and Torres Strait Islander people were two and a half times as likely as non-indigenous people to have experienced high/very high levels of psychological distress. It is not clear whether the IPRSS program is the most suitable model for ATSI people experiencing psychological distress and what should be an appropriate number of ATSI consumers and what a reasonable share of ATSI consumers would be. The DH would need to determine what would be considered a reasonable share. Interestingly most NGO providers felt that the ATSI population was under represented in their consumer base as they are not consumers of government MHS and are thus not referred. NGO providers have tried to overcome this gap in a variety of ways including: developing and implementing a reconciliation action plan cultural respect training a diversity project to ensure good representation training in aboriginal health first aid training an aboriginal worker in mental health work who now provides training to other staff hiring an aboriginal health worker as a support worker or peer support worker to work with ATSI consumers hiring a cultural consultant - the consultant can assist in accessing and communicating with aboriginal communities having an Aboriginal health worker on the allocation committee. The last two examples were both quite successful in improving ATSI access to the IPRSS program. Government and NGO service providers recognise the importance of innovative and culturally specific practices to maximise engagement with ATSI consumers. In the Riverland region, the Aboriginal Health Worker brings potential consumers to the allocation committee meeting who can then be accepted onto the program without formally being a consumer of the government MHS. This appears to be an innovative solution. 30

38 2.8.2 CALD Figure 2.12 presents the percentage of consumers recorded in the CARS database as having a non- Australian background. Overall 13% of consumers identified as having a CALD background. Figure 2.12: CALD consumers Table 2.8 presents the percentage of CALD consumers by region as per the CBIS database and it shows the percentage of CALD consumers is relatively consistent across regions. Table 2.8: CALD consumers by region Ethnicity Region Non- Indigenous Australian Aboriginal or Torres Strait Islander 1 Africa Asia Europe (not including UK) Middle East North or South America Oceania (not including Australia) UK Unknown Australian (including indigenous Australians) Non- Australian Total Central Northern Adelaide (n=395) Country (n=59) Southern Adelaide (n=149) Overall (n=603) 74.7% 3.3% 0.3% 0.8% 7.1% 0.8% 0.3% 2.0% 3.5% 7.3% 78.0% 14.7% 100% 59.3% 3.4% 0.0% 3.4% 0.0% 1.7% 0.0% 3.4% 5.1% 23.7 % 62.7% 13.6% 100% 78.5% 2.0% 0.0% 0.7% 4.0% 1.3% 0.7% 1.3% 2.0% 9.4% 80.5% 10.1% 100% 74.1% 3.0% 0.2% 1.0% 5.6% 1.0% 0.3% 2.0% 3.3% 9.5% 77.1% 13.4% 100% Note (1): The percentage of indigenous Australians differs from that indicated in CARS data base. NGO providers reported that they could not impact on the number of CALD consumers in the program as referrals are driven by government MHS. Key Findings The number of consumers declaring themselves as being of ATSI descent is 5.3% and is relatively constant between regions, although the number of unknowns recorded in country is high (27%). Overall 13% of consumers identified as having a CALD background relatively consistent across regions. Aboriginals and CALD groups access the program to the extent that they are referred by government MHS. All partners should continue to explore innovative solutions to ensure Aboriginal and Torres Strait Islanders have access to the program. 31

39 2.9 CARS DATA QUALITY The evaluation did not examine the accuracy or method for recording hours by consumer which is the key indicator used for funding. This issue was examined as part of KPMG audit early in the program based on the first three months of data. It is planned to undertake another audit and we support this. There were also a range of other minor data issues which did not have any impact on the data presented in this chapter, however they should be addressed. These issues are further discussed in appendix H. 32

40 3 THE PARTNERSHIP A key element of the IPRSS program is the partnership between NGO providers and government MHS. This chapter examines stakeholder perspectives on the partnership. All stakeholders who were interviewed were asked for their perspective on how the partnership is working including strengths, weaknesses, areas for improvement, any barriers to an effective partnership and potential strategies for improving the partnership. A partnership survey was also administered. The following sections present the findings of these consultations and an analysis of the partnership survey. 3.1 IPRSS PARTNERSHIP SURVEY INTRODUCTION To test the strength of the partnership we surveyed the IPRSS program management committee (PMC) and allocation committee members. The PMC is comprised of senior managers/representatives from the Department of Health (DH), government MHS and NGO providers and carer and consumer representatives. The allocation committee is comprised of regional operational managers. Accordingly the survey comprises the view of program leaders and managers. The survey was based on the VicHealth Partnership Analysis Tool agreed as part of the evaluation framework. The total score for a given response is obtained by adding the 35 scores for each question/statement together, resulting in an overall score of between 0 and 140. Each response can then be categorised into one of three groups according to Table 3.1 below. Table 3.1: Categorisation of total scores Check List Score Interpretation 0-49 The whole idea of partnership should be rigorously reviewed The partnership is moving in the right direction but it will need more attention if it is going to be really successful A partnership based on genuine collaboration has been established. The challenge is to maintain its impetus and build on the current success HOI received 26 survey responses, a response rate of approximately 60%. Twenty three responses were from allocation committee members and three were from program management committee members. Fourteen (54%) respondents were from government and twelve (46%) from non-government organisations. 3.2 KEY FINDINGS Figure 3.1 presents the distribution of the overall scores in terms of the categories outlined in Table

41 Figure 3.1 Overall strength of partnership Approximately half the respondents (46%) felt a partnership based on genuine collaboration had been established with the challenge being to maintain its impetus and build on current success. The remaining 54% felt the partnership was moving in the right direction but will need more attention if it is going to be really successful. No one indicated that the whole idea of partnership should be rigorously reviewed. There was no material difference in the pattern of responses between government or non-government organisations. The survey findings were reflected in the consultations with NGO providers and government MHS. The majority of people who were interviewed agreed that the partnership had come a long way and was on the right track. Approximately half of the people who were interviewed felt that the partnership was working well and only required some ongoing maintenance, with the remainder of people believing that the partnership had made great steps towards being an equal partnership but there was still room for improvement. There were, however, a few individuals who had very negative experiences with the partnership and felt that the entire partnership should be rigorously reviewed. Overall there is a clear commitment to continuing and strengthening the collaboration in the medium term. Critical success factors identified by NGO providers who reported strong partnerships included: developing good working relationships at the senior and middle management level which then filters down to NGO support workers, government MHS providers and eventually the consumer developing open and honest relationships at every management level where each partner recognises and respects the role and responsibilities of the other and adopts the intent of the operational protocols recognising from the start that the teams are not always going to agree but the consumers interests must always be at the heart of all decisions/ discussions. Where these success factors do not exist it can lead to NGO providers feeling the contribution they make is undervalued. The majority of people who felt that the partnership still need some improvement, identified that many of the problems they were experiencing arose from different conceptual understanding of the recovery approach and the role of the support worker in the IPRSS program. Partnership success could be improved by greater clarity of vision, roles and responsibilities, clearly articulated boundaries, concepts of recovery and recovery practice. One practical opportunity for improvement around which most agreed was the need to review and update the operational protocols and conduct joint training sessions on the rehabilitation and recovery approach and further definition around the role of the NGO support worker, supplemented by action learning case 34

42 studies. This would assist in developing a shared understanding of, and commitment to respective roles and responsibilities. 3.3 DETAILED ANALYSIS The survey questions were divided into seven groups, each containing five statements addressing the respondents views on a particular aspect of the success of the partnership. The seven areas covered are: determining the need for the partnership choosing partners making sure partnerships work planning collaborative action implementing collaborative action minimising the barriers to partnerships reflecting on and continuing the partnership. The responses received were largely positive. For most statements, the majority of respondents either agreed or strongly agreed. However, there were a number of statements that received a less positive response and these are discussed below. For the statements receiving less positive responses, we have investigated and found no evidence of any systematic differences between the responses of government organisations and NGOs DETERMINING THE NEED FOR THE PARTNERSHIP Table 3.2 presents the responses to the statements addressing the need for the partnership. Statement There is a perceived need for the partnership in terms of areas of common interest and complementary capacity. Table 3.2: Determining the need for the partnership Disagree Percentage of Response Disagree Not sure Agree Agree Total 0.0% 0.0% 7.7% 42.3% 50.0% 100.0% There is a clear goal for the partnership. 0.0% 15.4% 3.8% 53.8% 26.9% 100.0% There is a shared understanding of and commitment to this goal among all potential partners. The partners are willing to share some of their ideas, resources influence and power to fulfil the goal. The perceived benefits of the partnership outweigh the perceived costs. 3.8% 34.6% 3.8% 46.2% 11.5% 100.0% 0.0% 15.4% 11.5% 57.7% 15.4% 100.0% 0.0% 11.5% 7.7% 38.5% 42.3% 100.0% In all five statements relating to the need for the partnership the majority of respondents either agreed or strongly agreed with the statement. The third statement in Table 3.2 relates to a shared understanding of and commitment to the partnership goal among potential partners. While the majority (58%, n=15) agreed or strongly agreed that there is a shared understanding and commitment to the goal, a significant proportion of respondents (35%, n=9) disagreed and a further 4% (n=1) strongly disagreed. These findings align with the themes which emerged from the stakeholder interviews. Of those people who completed the survey, 92% stated that they believed in the need for the partnership and 81% felt 35

43 there is a clear goal for the partnership. This was also reflected in the interviews, with a significant majority stating that they believed the IPRSS program was beneficial to consumers and a worthwhile program. However, the majority of people who felt that the partnership still need some improvement identified that many of the problems they were experiencing arose from different conceptual understanding of the recovery approach and the role of the NGO support worker in the IPRSS program. Misunderstanding around the particular tasks and role of the support worker and the professional boundary between support worker and consumer were the most commonly cited cause of misunderstandings and conflicts between the mental health teams and the service providers. In some cases there are disparate views around what constitutes recovery practice. There is not always a common understanding of what rehabilitation and recovery are, with the government MHS service providers and the NGO providers views differing significantly in some regions. Several people suggested that joint training sessions on the recovery approach and further definition around the role of the NGO support worker would help overcome these issues CHOOSING PARTNERS Table 3.3 presents the responses to the statements addressing the choice of partners. Table 3.3: Choosing partners Statement The partners share common ideologies, interest and approaches. The partners see their core business as partially interdependent. There is a history of good relations between the partners. The coalition brings added prestige to the partners individually as well as collectively. There is enough variety among members to have a comprehensive understanding of the issues being addressed. Disagree Percentage of Response Disagree Not sure Agree Agree Total 0.0% 26.9% 11.5% 46.2% 15.4% 100.0% 0.0% 11.5% 15.4% 57.7% 15.4% 100.0% 0.0% 30.8% 11.5% 38.5% 19.2% 100.0% 3.8% 3.8% 38.5% 42.3% 11.5% 100.0% 0.0% 7.7% 11.5% 61.5% 19.2% 100.0% In all five statements relating to choice of partners the majority of respondents either agreed or strongly agreed. In the cases of the first and third statements, while the majority (approximately 60%) agreed or strongly agreed that there was a good relationship between the partners a significant proportion of respondents (approximately 30%) disagreed. As discussed in section above, these results enhance the finding of the interviews on the need for further clarity around role definition and the goals of IPRSS and practical implications of the recovery orientation, in order to improve the partnership MAKING SURE PARTNERSH IPS WORK Table 3.4 presents the responses to the statements addressing making the partnership work. 36

44 Table 3.4: Making sure partnerships work Statement The managers in each organisation support the partnership. Partners have the necessary skills for collaborative action. There are strategies to enhance the skills of the partnership through increasing the membership or workforce development. The roles, responsibilities and expectations of partners are clearly defined and understood by all other partners. The administrative, communication and decisionmaking structure of the partnership is as simple as possible. Disagre e Disagre e Percentage of Response Not sure Agree Agree Total 0.0% 3.8% 23.1% 46.2% 26.9% 100.0% 0.0% 26.9% 19.2% 30.8% 23.1% 100.0% 3.8% 7.7% 38.5% 42.3% 7.7% 100.0% 0.0% 34.6% 26.9% 30.8% 7.7% 100.0% 0.0% 23.1% 15.4% 50.0% 11.5% 100.0% In four of the five statements relating to making sure partnerships work, the majority of respondents either agreed or strongly agreed. The exception is the fourth statement, relating to clear definition and understanding of the roles, responsibilities and expectations of partners where 35% (n=9) disagreed and 27% (n=7) were not sure. This again aligns with the other results of the survey as well as the findings from the interviews. It is also noteworthy, that 23% (n=6) of the respondents felt that the administrative, communication and decision-making structure of the partnership could be improved. This highlights the findings of the interviews, where many people mentioned that improving administrative, communication and decisionmaking structures of the partnership would relieve tension in regions where the partnership is not working as effectively as it could be (refer to chapter 4) PLANNING COLLABORATIV E ACTION Table 3.5 presents the responses to the statements in relation to planning collaborative action. Table 3.5: Planning collaborative action Statement All partners are involved in planning and setting priorities for collaborative action. Partners have the task of communicating and promoting the coalition in their own organisations. Some staff have roles that cross the traditional boundaries that exist between agencies in the partnership. The lines of communication, roles and expectations of partners are clear. There is a participatory decision-making system that is accountable, responsive and inclusive. Disagree Percentage of Response Disagree Not sure Agree Agree Total 0.0% 23.1% 11.5% 57.7% 7.7% 100.0% 0.0% 7.7% 11.5% 65.4% 15.4% 100.0% 0.0% 15.4% 42.3% 34.6% 7.7% 100.0% 0.0% 23.1% 26.9% 38.5% 11.5% 100.0% 0.0% 19.2% 15.4% 53.8% 11.5% 100.0% 37

45 In four of the five statements relating to planning collaborative action, the majority of respondents either agreed or strongly agreed. The exception was the third statement relating to some staff having roles that cross the traditional boundaries between agencies - 15% (n=4) disagreed and 42% (n=11) were not sure. Again this suggests that the issue of role clarification is a pertinent issue which needs addressing IMPLEMENTING COLLABOR ATIVE ACTION Table 3.6 presents the responses to the statements in relation to implementing collaborative action. Table 3.6: Implementing collaborative action Statement Processes that are common across agencies such as referral protocols, service standards, data collection and reporting mechanisms have been standardised. There is an investment in the partnership of time, personnel, materials or facilities. Collaborative action by staff and reciprocity between agencies is rewarded by management. The action is adding value (rather than duplicating services) for the community, consumers or the agencies involved in the partnership. There are regular opportunities for informal and voluntary contact between staff from the different agencies and other members of the partnerships. Disagree Percentage of Response Disagree Not sure Agree Agree Total 0.0% 26.9% 23.1% 38.5% 11.5% 100.0% 0.0% 15.4% 19.2% 53.8% 11.5% 100.0% 0.0% 19.2% 38.5% 38.5% 3.8% 100.0% 0.0% 7.7% 15.4% 61.5% 15.4% 100.0% 7.7% 11.5% 7.7% 61.5% 11.5% 100.0% In four of the five statements relating to planning collaborative action, the majority of respondents either agreed or strongly agreed. The first statement relates to the standardisation of common processes such as referral protocols and reporting processes. The distribution of responses to this statement was still positive, with 50% (n=13) agreeing or strongly agreeing and 27% (n=7) disagreeing and 23% (n=6) not being sure. The findings of our interviews are in line with these results where it was highlighted that many of the processes that are common across agencies such as referral protocols, service standards, data collection and reporting mechanisms have not been standardised e.g. models of care, individual service plan format and outcome measures. This reflects findings discussed earlier in this report. The third statement relates to the existence of rewards for collaborative action and reciprocity. The distribution of responses to this statement was similar to the first statement, with 42% (n=11) agreeing or strongly agreeing and 19% (n=5) disagreeing and 39% (n=10) not being sure. It is likely that a perceived lack of acknowledgment by management is common across agencies and this is an area that the PMC could seek to address MINIMISING THE BARRIE RS TO PARTNERSHIPS Table 3.7 presents the responses to the statements in relation to barriers to partnerships. 38

46 Table 3.7: Minimising the barriers to partnerships Statement Differences in organisational priorities, goals and tasks have been addressed. There is a core group of skilled and committed (in terms of the partnership) staff that has continued over the life of the partnership. There are formal structures for sharing information and resolving demarcation disputes. Disagre e Disagre e Percentage of Response Not sure Agree Agree Total 3.8% 38.5% 30.8% 26.9% 0.0% 100.0% 0.0% 11.5% 15.4% 57.7% 15.4% 100.0% 0.0% 11.5% 15.4% 57.7% 15.4% 100.0% There are informal ways of achieving this. 0.0% 3.8% 3.8% 76.9% 15.4% 100.0% There are strategies to ensure alternative views are expressed within the partnership. 0.0% 3.8% 19.2% 69.2% 7.7% 100.0% In four of the five statements relating to minimising barriers to partnership, the majority of respondents either agreed or strongly agreed. The exception is the first statement, relating to differences in organisational priorities, goals and tasks. The distribution of responses to this statement was approximately neutral, with 27% (n=7) agreeing and 42% (n=11) disagreeing or strongly disagreeing and 31% (n=8) not being sure. Once again, the response to this statement highlights the issues in the partnership around service model, role definition and partnership REFLECTING ON AND CONTINUING THE PARTNERSHIP Table 3.8 presents the responses to the statements in relation to reflecting on and continuing the partnership. Table 3.8: Reflecting on and continuing the partnership Statement There are processes for recognising and celebrating collective achievements and/or individual contributions. The partnership can demonstrate or document the outcomes of its collective work. There is a clear need and commitment to continuing the collaboration in the medium term. There are resources available from either internal or external sources to continue the partnership. There is a way of reviewing the range of partners and bringing in new members or removing some. Disagre e Disagre e Percentage of Response Not sure Agree Agree Total 3.8% 38.5% 34.6% 23.1% 0.0% 100.0% 0.0% 7.7% 34.6% 42.3% 15.4% 100.0% 0.0% 0.0% 7.7% 46.2% 46.2% 100.0% 0.0% 0.0% 38.5% 42.3% 19.2% 100.0% 0.0% 3.8% 53.8% 34.6% 7.7% 100.0% In three of the five statements relating to planning collaborative action, the majority of respondents either agreed or strongly agreed. The exceptions are the first and last statements. It is also noteworthy that not sure responses are quite high for this group of questions. 39

47 The first statement relates to recognition of collective or individual achievements. The distribution of responses to this statement was slightly negative, with 20% (n=4) agreeing or strongly agreeing and 35% (n=7) disagreeing, with 45% (n=9) being unsure. Importantly there is strong agreement that there is a clear need and commitment to continuing the collaboration in the medium term. The majority of service providers believe that there is a genuine vision to see NGOs involved in mental health service provision and that there is a lot of good will to make the partnership work. However, although many report that there is a sense of partnership, there are some issues in terms of clear levels of responsibility. A number of NGO providers have a sense that government MHS see themselves as the boss. This has been reported as happening at all levels in many of the regions, from the organisational level down to government MHS service providers, believing NGO support workers should only do as directed. This is interpreted by a number of NGO providers as being reflective of a lack of equity. For the partnership process to function well, responsibilities for decision making need to be clear between all parties and communicated respectfully between the providers. However, most of the service providers also note that it has been a challenging five years for the mental health services and this partnership is a journey and it is strengthening and will continue to improve. Several NGO providers have indicated that they would like to have more responsibility which could in turn improve the quality of the partnership. For example if a consumer identifies they would like a financial counsellor, the NGO support workers presently have to ask the government MHS worker if it is possible/ appropriate and get a referral, whereas support workers feel that they could appropriately decide on and arrange referrals themselves. This may result in time saved for the government MHS service providers and an increasing level of confidence in the partnership with the NGO provider. Critical success factors identified by NGO providers who reported strong partnerships are highlighted in section Suggestions from NGO providers and government MHS service providers to strengthen the partnership included: shared team training including action learning co-location blended teams sharing ISPs using the same outcome measures shared risk assessment panel to facilitate shared risk management between the two teams partnership training including an open forum allowing people to put their fears and concerns on the table. 3.4 BUILDING COMMUNITY RELATIONSHIPS/CAPACITY Partnerships/linkages/initiatives have been developed with the community that have helped to build community capacity and impacted on IPRSS service usage levels and potentially consumer outcomes. Examples include: Partnership with Melbourne University: shared research director for the next three years to organise and facilitate shared research in this field. Relationships Australia: one service provider developed a partnership with Relationships Australia to organise group activities around social skills to enable consumers to better engage and interact. It started around self esteem courses and now there is a tools for life group. 40

48 YMCA: one service provider has organised a recovery retreat with the YMCA in which IPRSS consumers can be included. RecLink: RecLink was established to assist people experiencing social and economic disadvantage to gain access sporting and recreational opportunities as a form of social therapy and thus makes an ideal partner for IPRSS service providers. Other new links which have been have been reported as being established with external organisations as a result of IPRSS include: Disability SA Housing SA MIFSA TAFE Families SA Centrelink Mens Shed in Renmark Rainbow Group in Berri Allied Health Local Employment Services. 41

49 4 GOVERNANCE Chapter four provides an analysis of governance arrangements for the IPRSS program. 4.1 KEY GOVERNANCE ELEMENTS The key elements for governance of the IPRSS program are set out in figure 4.1. Figure 4.1: IPRSS governance - key elements 4.2 PROGRAM MANAGEMENT COMMITTEE The Program Management Committee (PMC) operates at a strategic level and includes all relevant stakeholders. Its aim is to provide guidance, high level oversight and input into the program and monitoring of the program. Given its size smaller subcommittees as per figure 4.1 have been established to progress bodies of work. The PMC is a key element of the partnership. The program has been operating for two years and it is timely for the leadership to recommit to the shared vision required to sustain the success of the program. As part of this the operational protocols should be reviewed to ensure they reflect current practice and include any agreed enhancements that may arise from this evaluation or the PMC. As identified in section 3.2 partnership success could be improved and strengthened by providing greater clarity of vision, roles and responsibilities, clearly articulated boundaries, concepts of recovery and 42

50 recovery practice. The PMC would lead this process together with monitoring other agreed actions arising from this evaluation. 4.3 SERVICE AGREEMENTS Each NGO provider has a service agreement with the Department of Health. Performance of individual NGO service providers is primarily monitored through the use of CARS. A stronger structured approach to monitor the performance of individual service providers needs to be developed to build upon processes already undertaken by the Department of Health. Issues can be raised and acted upon on an ad hoc basis at the local level or in meetings arranged between a particular NGO provider and the regional government MHS. This is consistent with the Operational Protocols. HOI consider the program would benefit if an annual contract management meeting was conducted with each service provider. 4.4 FUNDING NGO providers are funded an initial amount based on a maximum number of hours of service at a set hourly rate. Funding is to be adjusted (calculated annually) based on the actual hours of service where the number of hours is less than maximum agreed. Where the number of hours exceeds the maximum there is no adjustment. To date no service provider has had any funding adjustment applied. The total amount funded since inception is $19,797,009 as set out in table 4.1. Table 4.1: IPRSS funding Year Funding 2008/09 2,109, /10 8,712, /11 8,974,270 Total 19,797,009 In order to implement the IPRSS service model, NGO service providers must take into account the changing level of services required by consumers. To do this effectively, providers must manage the fluctuation in hours of support for individual consumers. Understandably there is considerable focus on recording and monitoring hours. It is noted that the issue of recording of hours was raised in the KPMG report. 4.5 REGIONAL ALLOCATION COMMITTEES Regional allocation committee meetings are resource intensive but provide a valuable role based on the current program structure. They are a key element of the service partnership. The operation of regional allocation committees is discussed at section 2.4. Regional allocation meetings comprise operational management staff and the focus is on identifying and prioritising consumers (sometimes from multiple programs). Allocation committees are now regionally based, three in the metropolitan area and six in the country. Some stakeholders believe there is a need to have the capacity on some occasions to be able to discuss and manage key strategic issues at a regional level. Regional allocation committee meetings could be utilised to discuss regional strategic issues although more senior staff may need to attend (say quarterly) in order to reach resolution around particular issues. 43

51 4.6 QUALITY PSYCHOSOCIAL REHABILITATION SERVICE STANDARDS Psychosocial rehabilitation service standards have been developed by Quality Management Services (QMS) in consultation with NGO providers and the DH. NGO providers have been audited against those standards within a quality improvement framework. The QMS accreditation process is a very detailed and time consuming process and in some cases is in addition to other organisation wide accreditation processes. Table 4.2 provides a few examples of the selected key areas for development in the service provider action plans resulting from their quality review processes. Table 4.2: Quality review status Key areas for development from action plans Specific information relating to person centred focus, key elements of PRSS and stigma reduction to be added to J&Ps. Incorporate 10 healthcare tips into consumer induction material & other appropriate areas. Review MOUs with partner agencies. Include focus on stigma reduction into plans. Develop contact flow chart and promulgate. Ensure appropriate qualifications obtained and training calendar implemented. Strengthen documentation of ISPs. Strengthen training and induction processes in relation to CALD. Ongoing effort to improve consumer participation in the ISP process. Strengthen consumer engagement (e.g. feedback mechanisms) and follow up including carers. Developing a practice guideline about the recovery framework and include in policy & procedure manuals. Review accessibility of services to, and enhance networks with, CALD groups. Develop and implement a file review and audit process. Strengthening of OH&S processes and provision of relevant training. Develop a training data base. Recruitment and retention strategies for peer workers and specific population groups. Review promotional material. Develop and implement consumer privacy audit tool. Review the structure of policies, procedures and forms and ensure currency. Expand focus of cultural diversity policy. Redevelop code of professional practice. Strengthen knowledge management throughout organisation. 44

52 Key areas for development from action plans Ensure consumer is provided information about rights, responsibilities and complaints procedures at service entry and on an ongoing basis. Review consumer and staff safety policies. Develop consumer/carer policy in relation to involvement in decision making and reconvene focus groups. Continue to build networks within the local community and with partners. Ensure consumer information folders include information about rights, responsibilities, complaints procedures, privacy and confidentiality. Establish links with Carers SA and other carer organisations. Develop health promotion and community acceptance policy. 45

53 4.6.2 WORKFORCE D EVELOPMENT Workforce development is an important component in the provision of quality services. This is a new workforce area and five years ago there were limited services of this nature. Accordingly a workforce has had to be developed which is an ongoing process. At present there is a scarcity of people with experience in recovery work and formal education programs are also newly developed. Based on a head count of 139 NGO provider staff, the profile of qualifications held is presented in table 4.3. Overall 87.8% of staff have a relevant qualification with 41% having a Bachelor degree. Table 4.3: Qualification profile 1 Highest Qualification Percentage of Staff Members (n=139) No Qualification % Unrelated Qualification 0.7% Certificate 28.1% Diploma 18.7% Bachelor 41.0% Total 100.0% Note (1): Where a support worker has more than one qualification we have only counted the highest qualification. Note (2): Includes two consumer consultants. To develop skills and help recruit and retain staff, NGO providers have active ongoing professional development programs which offer multiple training and staff development opportunities (summarised in table 4.4 below). 46

54 Table 4.4: Summary of additional training opportunities offered Area Specific Training Offered Governance Critical Incidents Training OH & S and Legislative Skill Development (General) Skill Development (Specific Techniques) Specific Population (ATSI, Youths, Older Consumers, Sexual Orientation) Critical Incidents Debriefing Process Risk Assessment Professional Boundaries Training Managing Aggressive Behaviours Managing Aggressive Consumers & Conflicts Defensive Driving First Aid Fire Safety Stress Management Discrimination & Harassment Guardianship training Communication training (Myer Briggs) Management of Consumer Information Legal Issues Rehabilitation and Recovery Level 1 & 2 Sexual Abuse Domestic Violence in the Workplace Mental Health First Aid Hearing voices training Nutrition and Physical Health training Physical Assistance Certificate III Motivational Interviewing Narrative therapy CBT Collaborative Therapy Aboriginal Health Aboriginal Mental Health Building Relationships with ATSI Communities Cultural training Indigenous and CALD Consumers Recognising and Responding to Complaints Values clarification training Program Evaluation Tools OH & S Hazard Training Child Safe Environments Infection Prevention & Control Manual Handling Food Safety Duty of Care/Duty to Report/Dignity of Risk Personality Disorders Mental Health & Disabilities Comorbidity Training Mental Health & Drug and Alcohol Comorbidity Training Mental Illness and Depression Breaking Patterns of Depression Medication Theory & Handling Medication Competence Certificate III Eating Disorders Suicide Risk Assessment Assist Tool Camberwell training of needs and assessment Strengths based intervention Working with Adolescents in Mental Health Dementia Awareness Understanding Issues for Bisexual, Lesbian and Gay People 47

55 Each NGO provider also has their own induction process which can include a corporate organisational induction, a site induction and a program induction. Staff have mandatory training relating to their roles, responsibilities, goals setting and working from person centred and strength based perspectives. There was consensus among the service providers that it is also important that staff have life experiences to share, bring a mature outlook and a broad range of life skills including carer and consumer experiences and an aptitude for working in a team. The latter is seen as particularly important as the teams use each other as a sounding board, with regular team meetings and supervision and they provide support for each other in a highly demanding role. There are examples where joint training with government MHS has been undertaken e.g. case studies, but this is not widespread and it is considered that there may be more opportunities in this area. The DH has been mindful of ensuring a non-government workforce with the capacity to deliver the objectives of the IPRSS program. Within the current service agreement all IPRSS NGO providers must employ staff with a minimum Certificate IV (Mental Health) qualification. A broad overarching goal of the DH is continued workforce education and increasing the profile of the support worker role as a career pathway. The IPRSS program will benefit from this WORKFORCE SUPERVISORY AND SUPPORT STRUCTURES Government MHS and NGO providers agree that the role of the support worker is a challenging one and it is imperative that there are excellent supervisory and support structures in place to ensure the provision of quality services. All of the service providers have team leaders who provide support, supervision, review, facilitate ongoing development, and monitor and discuss any pertinent issues. Service providers have a variety of informal and formal clinical/practice supervision processes. The following is a list of the workforce supervisory and support structures which are being utilised by NGO providers: consumer reports - which are filled out after every visit and sent to the government MHS worker once a month - the coordinator also has to sign off on them and reads them all once a week case consultation services with a consultant psychiatrist - staff prepare a case study where they are finding difficulties and the psychiatrist provides advice senior practice leader - supports workers on the ground by providing a coaching role monthly coaching sessions around the implementation of the model of care including discussions on how to implement the model in the community setting - in conjunction with the University of Wollongong as part of an NHMRC funded research project - the project involves transfer of skills from training into practice and whether coaching assists in this process monthly clinical supervision meeting fortnightly supervision visits from the team leader one on one supervision weekly team/support meetings - includes brainstorming and troubleshooting issues with consumers. Support workers value these meetings as they can share stories, hear about progress and support each other - also periodically used as a training session consumer support board - a daily system used to make sure that all of the support which is required for consumers on that day will be met external services provide any trauma support required. Examples were provided where government MHS raised performance issues and these were addressed satisfactorily by NGO providers. 48

56 In one NGO provider, support workers are not allocated to individual consumers, rather they work as a team of support workers, which allows them more flexibility with contact hours and maximises capacity. This management approach would need further exploration to determine whether there is any difference in consumer outcomes as a result (which is beyond the scope of this evaluation). 4.7 KEY FINDINGS Key Findings The governance structure has served the program well since its inception Regional allocation committee meetings are resource intensive but provide a valuable the role based on the current program structure. They are a key element of the service partnership. The program has been operating for two years and it is timely for the leadership to recommit to the shared vision required to sustain the success of the program There is no structured approach to monitor the performance of individual service providers or regions. HOI consider the program would benefit if an annual contract management meeting was conducted with each service provider. Regional allocation committee meetings could be utilised more strategically to further strengthen the partnership e.g. to discuss regional strategic issues and assist the PMC to implement strategic directions at the local level, although more senior staff may need to attend (say quarterly) in order to reach resolution around particular issues. There is a strong demonstrated commitment to quality in the program. Consideration should be given to endorsing an approach where only one recognised quality process need be adopted. Overall 87.8% of staff have a relevant qualification with 41% having a Bachelor degree. There is an active staff development program offered by NGO providers. Opportunities for joint training initiatives with government mental health providers should be explored. Promotion of the non-government support worker role as a career opportunity is an important strategy to improve service outcomes. NGO provider supervisory and support structures are satisfactory. 49

57 5 CONSUMER OUTCOMES This chapter analyses whether consumer outcomes were optimised. 5.1 INTRODUCTION An introduction to outcome measurement and a brief description of the specific outcomes measures utilised by government MHS and NGO providers are outlined at appendix D. During the development of the evaluation framework the following were identified as being potentially suitable for measuring the impact of the program on consumer outcomes: HONOS HONOS 65+ Life Skills Profile (LSP) 16 Kessler 10 (K10) IPRSS NGO provider internal outcome data impact on inpatient admissions where the primary diagnosis related to mental health impact on community mental health activity The focus of this chapter is the impact of the program on government NOCC outcomes measures as a result of their participation in the IPRSS program. NGO providers collect a range of outcome data however this has not been considered as part of the scope of this evaluation. Appendix D provides information on the status of NGO provider outcome data collection. When analysing the impact of the IPRSS program on selected outcome measures, it is not possible to make definitive conclusions as there are multiple factors that impact on a consumer s outcomes including: the unique physiological course of their illness; the external environment; the unique personal circumstances of each person; the fact that there were similar services being provided prior to the introduction of IPRSS program (i.e. known as strategy six services); and the range and quality of other services that the consumer maybe receiving. Having said this, any analysis is informative and should help inform program development. 5.2 APPROACH TO ANALYSIS This section outlines our approach to the analysis. Relevant CBIS data relating to IPRSS consumers was provided from April 2007 (two years prior to the commencement of IPRSS) up to 7 February Consumer National Outcomes and Case-mix Collection (NOCC) outcome measures the first score available immediately prior to a consumer s first contact with IPRSS was compared to the latest score available for that consumer, regardless of whether the person was still in the IPRSS program. Note that if no score is recorded for a given consumer either pre or post first IPRSS contact, the consumer is not included in the analysis. This ensures that we are comparing the same 50

58 group of consumers pre and post first contact. The strength of this approach is that it allowed us to maximise the use of available data and obtain the latest picture as well as increasing the sample to a reasonable level. The weakness is that consumers are being compared at different points in time since their first contact with IPRSS. In our view the strengths of the approach far outweigh the weaknesses. We have only utilised consumer scores where all items have been completed pre and post, to ensure scores are directly comparable. We have used mean scores where applicable due the small scales i.e. the median score will not be significantly different. Service impact for each consumer the number of community mental health services and acute admissions from April 2007 until the date of their first IPRSS contact was calculated. This was then used to calculate the average number of services/admissions on a per consumer per annum basis. This calculation yields an average that can be appropriately compared to the equivalent average post first contact. This was then compared to the number of services/admissions on a per annum basis calculated subsequent to a consumer s commencement with IPRSS. The strength of this approach is that it maximises the use of available data and presents the latest and most informative picture. The weakness is that different time periods are being used for each consumer pre and post although these are then adjusted to ensure what is presented is directly comparable. For example if the analysis was to only cover the period after a consumer had been discharged from IPRSS the number of consumers would be far too small to draw any meaningful conclusions. If the analysis was only to cover the period the person was in IPRSS, the question would be why, as the impact once they have been discharged from IPRSS is still highly relevant. In our view the strengths of our approach far outweigh the weaknesses. 5.3 IMPACT ON NOCC ASSESSMENT SCORES OVERALL SUMMARY Table 5.1 presents for the National Outcomes and Casemix Collection (NOCC) the mean total score for the consumers for the first score available immediately prior to a consumer s first contact with IPRSS and the latest available mean score where both scores were available. The table also provides the national mean score for comparative purposes. It is important to note that the percent change in score does not necessarily relate to equivalent percentage changes in relevant behaviours. Table 5.1: Change in NOCC assessment scores pre and post IPRSS commencement Assessment Type Number of Matched Consumers Nationa l Mean 1 Mean Score Before First Contact Mean Score After First Contact Mean Change in Score Percentage Change HoNOS Adult % HoNOS % K10 Adult % K10 Older Person % LSP16 Adult % LSP16 Older Person % Note (1): Source NOCC web decision support tool Ambulatory Occasion review 2008/09. Table 5.1 shows that there have been significant decreases in mean scores across all indicators. In particular the: HoNOS adult score has decreased by 14.3% to 12.3 HoNOS 65+ for older persons score has decreased by 11% to 11.4 K10 adult score has decreased by 8.7% to

59 K10 older persons score has decreased by 12.2% to 19.4 (note very small sample) LSP 16 adult score has decreased by 9.1% to 15.5 LSP 16 older persons score has decreased by 19.4% to 9. The table also shows that the complexity of IPRSS consumers is significantly greater than the average ambulatory mental health consumer for both adults and older people. A more detailed analysis of these changes is presented in the following sections. 5.4 IMPACT ON NOCC SCORES HONOS This sub section presents the changes in HoNOS scores for adults and older people on a per item basis. ADULT HONOS Table 5.2 presents the change in per item and subscale HoNOS score pre and post IPRSS commencement. Table 5.2: Change in per item and subscale HoNOS score pre and post IPRSS commencement 1,2,3 Item (n=379) Mean Before First Contact Mean After First Contact Change in Score Percentage Change Overactive, aggressive, disruptive, or agitated behaviour % Non-accidental self-injury % Problem drinking or drug taking % Behaviour % Cognitive problems % Physical illness or disability problems % Impairment % Problems associated with hallucinations and delusions % Problems with depressed mood % Other mental and behavioural problems % Symptoms % Problems with relationships % Problems with activities of daily living % Problems with living conditions % Problems with occupation and activities % Social % Total % Note (1): Of the 379 consumer pre IPRSS assessments used in this analysis, 81% were review assessments, 3% were admission assessments, 10% discharge assessments and 7% were other assessments. Of the post IPRSS commencement assessments used, 83% were review assessments, 1% were admission assessments, 12% discharge assessments and 3% were other assessments. Note (2): Scores of 2 or less are deemed not to be clinically significant. As scores presented are means, at an individual consumer level some scores will be clinically significant and some will not. The data presented should be considered illustrative. Note (3): Table compares the mean total score for the consumers for the first score available immediately prior to a consumer s first contact with IPRSS and the latest available mean score for the same group of consumers presented in table 5.1. Table 5.2 shows that all item scores reduced to varying degrees except for physical illness or disability. 52

60 At a subscale level, all component scores reduced with Behaviour (12.3%), Symptoms (14.8%) and Social (18.3%) considered to be significant reductions. Nationally the social scale is more sensitive to change and that is consistent with the data presented above. HONOS 65+ Table 5.3 presents the change in per item and sub-scale HoNOS 65+ score pre and post IPRSS commencement. Table 5.3: Change in per item and subscale HONOS 65+score pre and post IPRSS commencement Item (n=45) Average Before First Contact Average After First Contact Change in Score Percentage Change Overactive, aggressive, disruptive, or agitated behaviour % Non-accidental self-injury % Problem drinking or drug taking % Behaviour % Cognitive problems % Physical illness or disability problems % Impairment % Problems associated with hallucinations and delusions % Problems with depressed mood % Other mental and behavioural problems % Symptoms % Problems with relationships % Problems with activities of daily living % Problems with living conditions % Problems with occupation and activities % Social % Total % Note (1): Of the 45 consumer pre IPRSS assessments used in this analysis, 89% were review assessments, 2% were admission assessments, 4% discharge assessments and 4% were other assessments. Of the post IPRSS commencement assessments used, 71% were review assessments, 0% were admission assessments, 27% discharge assessments and 2% were other assessments. Note (2): Scores of 2 or less are deemed not to be clinically significant. As scores presented are means, at an individual consumer level some scores will be clinically significant and some will not. The data presented should be considered illustrative. Note (3): Table compares the mean total score for the consumers for the first score available immediately prior to a consumer s first contact with IPRSS and the latest available mean score for the same group of consumers presented in table 5.1. Table 5.3 shows that all item scores reduced to varying degrees except for physical illness or disability and problems with activities of daily living which increased. At a subscale level, all component scores reduced with Behaviour (30%), Symptoms (16%) and Social (12%) considered to be significant reductions. Impairments increased insignificantly IMPACT ON LSP-16 This sub section presents the changes in LSP-16 scores for adults and older people on a per item and subscale basis. ADULTS Table 5.4 presents the change in per item and sub-scale LSP-16 score pre and post IPRSS commencement for adults. 53

61 Table 5.4: Change in adult per item and sub scale LSP-16 score a pre and post IPRSS commencement Item (n=295) Average Before First Contact Average After First Contact Change in Score Percentage Change Conversation % Withdraw from social contact % Warmth towards others % Well groomed % Clean clothes % Care of physical health % Violent towards others % Makes and maintains friendships % Adequate diet % Takes medications % Willing to take Psych medications % Cooperates with health services % Problems living with others % Offensive behaviour % Irresponsible behaviour % Work capability % Sub scales Withdrawal % Self care % Compliance % Anti-social % Total % Note (1): Of the 295 consumer pre IPRSS assessments used in this analysis, 87% were review assessments, 3% were admission assessments, 8% discharge assessments and 2% were other assessments. Of the post IPRSS commencement assessments used, 88% were review assessments, 4% were admission assessments, 7% discharge assessments and 1% were other assessments. Table 5.4 shows that all item scores reduced by greater than 5% except Work Capability (4.1% reduction) and Physical Health (3.9% reduction). At a subscale level, all component scores reduced by more than 5% which is considered to be significant, with the Anti-social subscale reducing by 12.0%. OLDER PEOPLE Table 5.5 presents the change in per item score and sub-scale LSP 16 score pre and post IPRSS commencement for older people. 54

62 Table 5.5: Change in older people per item LSP-16 score pre and post IPRSS commencement Item (n=30) Average Before First Contact Average After First Contact Change in Score Percentage Change Conversation % Withdraw from social contact % Warmth towards others % Well groomed % Clean clothes % Care of physical health % Violent towards others % Makes and maintains friendships % Adequate diet % Takes medications % Willing to take Psych medications % Cooperates with health services % Problems living with others % Offensive behaviour % Irresponsible behaviour % Work capability % Sub-scales Withdrawal % Self care % Compliance % Anti-social % Total % Note (1): Of the 30 consumer pre IPRSS assessments used in this analysis, 90% were review assessments, 3% were admission assessments, 3% discharge assessments and 3% were other assessments. Of the post IPRSS commencement assessments used, 80% were review assessments and 20% were discharge assessments. Table 5.5 shows that 12 of the 16 item scores reduced with some very large variations. At a subscale level, all components reduced with the Anti-social subscale reducing by 50.0% IMPACT ON K10 This section presents the changes in K-10 scores for adults and older people on a per item basis. ADULTS Table 5.6 presents the change in per item K10 score pre and post IPRSS commencement for adults. 55

63 Table 5.6: Change in adult per item K 10 score pre and post IPRSS commencement Average Before Average After First Change in Percentage Item (n=126) First Contact Contact Score Change Tired % Nervous % Nervous that nothing could calm % Hopeless % Restless % Restless could not sit still % Depressed % Everything an effort % Nothing could cheer up % Worthless % Total % Note (1): Of the 126 consumer pre IPRSS assessments used in this analysis, 87% were review assessments, 2% were admission assessments, 7% discharge assessments and 4% were other assessments. Of the post IPRSS commencement assessments used, 91% were review assessments, 2% were admission assessments, 7% discharge assessments and 0% were other assessments. Table 5.6 shows that all item scores reduced by more the 5% except Nervous that nothing could calm item which reduced by 1.9%. OLDER PEOPLE Table 5.7 presents the change in per item K10 score pre and post IPRSS commencement for older people. Table 5.7: Change in older people per item K 10 score pre and post IPRSS commencement Average Before Average After First Change in Percentage Item (n=10) First Contact Contact Score Change Tired % Nervous % Nervous that nothing could calm % Hopeless % Restless % Restless could not sit still % Depressed % Everything an effort % Nothing could cheer up % Worthless % Total % Note (1): Of the 10 consumer pre IPRSS assessments used in this analysis, 90% were review assessments, 0% were admission assessments, 0% discharge assessments and 10% were other assessments. Of the post IPRSS commencement assessments used, 80% were review assessments, 0% were admission assessments, 20% discharge assessments and 0% were other assessments. Table 5.7 shows that all item scores reduced, mostly by more the 5% except Depressed which increased 9.1%. 56

64 Key Findings The IPRSS program has had a positive impact on consumer outcomes. There have been significant decreases in mean scores across all NOCC indicators. In particular: the HoNOS adult score has improved by 14.3% and HoNOS 65+ for older persons score has decreased by 11%; the LSP 16 score has improved by 9% for adults and 19% for older people; and the K10 score has improved by 9% for adults and 12% for older people. 5.5 IMPACT ON INPATIENT ADMISSIONS This section presents an analysis of the impact on hospital admissions pre and post entry to the IPRSS program. Section 5.1 outlines our approach to this analysis. Table 5.8 presents the change in the average rate of acute mental health admissions and length of stay (LOS) pre and post IPRSS commencement per consumer. The table shows that has been a substantial reduction in the average rate of admission per consumer and the average LOS, 39% and 16% respectively. Table 5.8: Change in acute mental health admissions and LOS pre and post IPRSS commencement per consumer Before First Contact After First Contact Change Percentage Change Mean Admissions per Year per Consumer % Mean LOS (days) per Consumer % Note (1): Acute mental health admission defined as principal diagnosis was mental health related (i.e. F code). Note (2): Overall number of acute mental health admissions in the periods analysed were 1605 pre first contact and 553 post first contact. Table 5.9 presents the change in the average rate of non-mental health acute admissions and length of stay pre and post IPRSS commencement per consumer. The table shows an increase of 20% in rate of nonmental health admissions and a substantial reduction in the average LOS of 60%. This should be seen a positive in that consumers are receiving increased attention to their physical health needs and when they are in hospital, they are more capable of being discharged home earlier than was the case previously. Table 5.9: Change in non mental health total admissions and LOS pre and post IPRSS commencement per consumer Mean Admissions per Year per Consumer Before First Contact Mean Admissions per Year per Consumer After First Contact Change in Admissions Percentage Change Mean Admissions per Year per Consumer Mean LOS (days) per Consumer % % Note (1): Non mental health admission defined as principal diagnosis not being mental health related (i.e. non F code). Note (2): Overall number of acute non mental health admissions in the periods analysed were 608 pre first contact and 414 post first contact. As shown in tables 5.10 and 5.11, the combined reduction in the rate of both mental health and nonmental health related admissions was 23% and for LOS the combined reduction was 35%. 57

65 Table 5.10: Change in total admissions pre and post IPRSS commencement per consumer Admission Type Mean Admissions per Year per Consumer Before First Contact Mean Admissions per Year per Consumer After First Contact Change in Admissions Percentage Change Mental Health Admissions % Non Mental Health % Admissions All Admissions % Table 5.11: Change in LOS for all admissions pre and post IPRSS commencement per consumer Admission Type Mean LOS Before First Contact (days) Mean LOS After First Contact (days) Change in Mean LOS Percentage Change Mental Health Admissions % Non-Mental Health Admissions % All Admissions % Key Findings The IPRSS program has had a very positive impact on the rate on mental health hospital admissions and associated LOS. The rate of mental health admissions have reduced by 39% and LOS has reduced by 16%. The IPRSS program has had a positive impact on the rate on non-mental hospital admissions and associated LOS in that consumers are receiving increased attention to their physical health needs (increase in rate of admissions of 20%) and when they are in hospital, they are more capable of being discharged home earlier than was the case previously (LOS reduced by 60%). 5.6 IMPACT ON GOVERNMENT COMMUNITY MENTAL HEALTH SERVICES This section presents the impact on contacts recorded by government mental health service workers in the Community Based Information System (CBIS). As presented in table 5.12 average number of contacts has increased by 22% which is not unexpected as the IPRSS program does generate workload for government mental health service workers. It is possible that some of the increase is attributable to improved recording of contacts. Table 5.12: Change in government community health service contacts pre and post IPRSS Mean Services per Consumer per Year Prior to First Contact Mean Services per Consumer per Year After First Contact Change in Services Percentage Change % Note (1): The individual type of contacts that comprise this total is at appendix B. 58

66 Key Findings It is likely that the IPRSS program is increasing the work load of government mental health workers. 5.7 CONSUMER CASE STUDIES Eight consumer case studies provided by NGO providers are presented below. These consumers entered the IPRSS program with a wide range of mental illnesses, comorbidities and significant issues in the areas of housing, employment, education, family relationships, social connectedness, financial strain, drug and alcohol problems, and other issues. Table 5.13 summarises the improved outcomes across these domains for the eight consumers. Table 5.13: Areas of improvement from IPRSS consumer case studies Case study Health (physical & mental) Social Connectedness Family Relationships Employment Education Exercise & Nutrition Housing Domestic & self care skills Counselling D & A Counselling Increased Independence An analysis of consumer outcomes reflect that NGO providers are taking a holistic approach when goal setting. They are identifying issues across a wide range of domains and working with consumers to address them. Increased independence, improved health (both physical and mental) management, social connectedness, family relationships and improved domestic and self-care skills were the common areas being addressed. The more detailed case studies are presented in appendix E. 59

67 6 CONSUMER PERSPECTIVES This chapter presents a high level overview of the results of the Ridgeway Recovery Environment Enhancement (REE) tool survey and an overview of consumer surveys that were collected by NGO providers. Note that as agreed with the DH no consumer survey or consultations were undertaken by HOI as part of this evaluation. A more detailed presentation of the data and analysis is at appendices F and G. Carer perspectives on the program are reflected in relevant sections of this report. 6.1 INTRODUCTION TO REE SURVEY HOI received 21 responses to this survey from the DH, while CARS data suggests there are more than 900 consumers who have received services on the IPRSS program. The 21 respondents may not form a representative sample of all IPRSS consumers and the results of this survey must be treated with caution. For most questions there were 19 or 20 responses. Throughout this chapter and appendix F, the percentages are based on only those who responded. A substantial majority of respondents were aged 36 or over and 52% were aged 56 or over. Half of the respondents were non-indigenous Australians, 38% were from overseas (all European) and 13% were indigenous Australians. None of the respondents were either working or studying, although the majority were participating in other meaningful activities and 10% were looking into work or study options. Thirty three percent of respondents were from a minority group, 10% were gay, lesbian or bisexual and 10% had problems with substance abuse as well as mental health. Also noteworthy is that 76% of respondents have been receiving mental health services for over ten years. One third of individuals were actively involved in the process of recovery, however 90% of respondents were unaware of the IPRSS program, which highlights that people on the program are often not aware of the name of the program. 6.2 FEEDBACK ON ELEMENTS OF RECOVERY ENHANCEMENT PROGRAMS For many of the questions in the survey, there is a wide range of both agreement and disagreement, and there is no clear consensus of opinion. For this reason, much of the discussion refers to the majority of responses and relative proportions of respondents agreeing and disagreeing. Table 6.1 overleaf sets out a high level overview of the survey results by key element of recovery enhancement programs identified by Ridgeway: the percentage of respondents who believe that particular element is important, the percentage of respondents who believe that the element is being met, an overall summary rating on that element (with a negative rating (X) based on whether overall an average 30% of respondents or more rated the questions relating to that element as disagree/strongly disagree). 60

68 It appears that a significant number of respondents feel that the program does not help address a range of elements that are important to them and that there are a number of potential areas for improvements to the program. Feedback indicates that while consumers are very positive about the program they feel there are instances when the IPRSS program does not effectively engage with consumers to achieve program outcomes. Areas that were raised as being problematic include: Goal Setting: consumer goals can be unrealistic and there is a perception that consumers could be more actively assisted to achieve goals Meaningful Activities: there is a pathway gap for consumers to be: o o provided with real choices and opportunities engage in relevant interests and activities Community Connection: that is supporting consumers to build or rebuild positive relationships with family members or friendships with people outside the mental health system and further analysis, discussion and training with staff around these issue needs to occur. 61

69 Table 6.1: Overview of consumer feedback Element of Recovery Percentage agreeing/stro ngly agreeing that element is important Percentage agreeing/stro ngly agreeing that element is being met Percentage disagreeing /strongly disagreeing that element is being met Overall 1 Comment P E R S O N A L I D E N T I T Y, MEANI N G I N L I F E A N D H O P E Having a positive sense of personal identity beyond any psychiatric disorder 90% 65% 23% There are some participants who feel that the program is not helping them to achieve a positive sense of personal identity to the level that they would like. Sense of meaning in life 85% 49% 29% There are a proportion of participants who feel that the program has not helped them achieve a sense of meaning in life to the degree that they would like. Spirituality 65% 22% 54% X The majority of respondents believe that the program does not place a great enough emphasis on spirituality. Hope 90% 46% 37% X Of particular note is that 58% of respondents either disagree or strongly disagree that staff tell them most people do recover from psychiatric problems over time. Sense of control and feeling empowered 90% 65% 18% Challenging stigma and discrimination 79% 42% 30% X 42% of respondents believe the program does not help to overcome internalised stigma H E A L T H A N D S E L F - M A N A G E M E N T Up to date knowledge about psychiatric disorders and the most effective treatments. 74% 44% 39% X 53% disagree or strongly disagree that the program provides them with up to date information about effective treatments Self-manage symptoms and avoid 95% 50% 29% 62

70 Element of Recovery Percentage agreeing/stro ngly agreeing that element is important Percentage agreeing/stro ngly agreeing that element is being met Percentage disagreeing /strongly disagreeing that element is being met Overall 1 Comment relapse Improving my general health and wellness Being active consumers and directing their own recovery 95% 62% 30% X 50% disagree or strongly disagree that the program offers wellness programming such as nutrition, movement and relaxation 80% 67% 20% 40% disagree or strongly disagree that staff assist them to explore options and set their own personal goals Mutual self-help and peer support 80% 52% 35% X Generally respondents feel that the program promotes self-help and peer support, although there is a mixture of opinions as to whether or not the program actively links participants to self-help resources. R E S P E C T F O R R I G H T S Rights respected and upheld 95% 46% 42% X 60% either feel there is no clear grievance policy if their rights are violated A C T I V I T I E S A N D R E L A T I O N S H I P S Meaningful activities. 100% 53% 35% X 53% feel that it does not actually assist participants to become involved in such activities. Being involved, and a part of, the larger community 79% 47% 38% X 47% of respondents feel that staff do not help participants to find and use community resources. Positive relationships 90% 39% 46% X 50% of respondents feel that staff Intimacy and sexuality. 37% 18% 55% X Respondents feel that the program is not adequately addressing intimacy & sexuality issues although this element is not as important as other areas B U I L D I N G O N S T R E N G T H S Identifying and building on personal strengths 95% 53% 29% Generally, respondents feel that the program helps participants to identify and build on their personal strengths, although there are mixed opinions of whether 63

71 Element of Recovery Percentage agreeing/stro ngly agreeing that element is important Percentage agreeing/stro ngly agreeing that element is being met Percentage disagreeing /strongly disagreeing that element is being met Overall 1 Comment or not staff help participants to explore their dreams, values and goals. Developing new skills 65% 40% 42% X Opinions of whether or not the program helps participants to develop new skills are divided. M E E T I N G N E E D S Basic needs met 95% 57.8% 25% Taking on and succeeding in normal social roles Taking on new challenges and moving out one s comfort zone. 95% 33% 39% X 50% of respondents feel that staff would not assist them to return to study and be a successful student. 58% 57% 33% X Respondents generally feel that staff encourage and support participants in challenging themselves and trying new things. However 40% of respondents disagree or strongly disagree that staff encourage them to stretch themselves and grow. Availability of assistance during crisis. 95% 61% 20% Helpers who really care 95% 62% 20% Positive role model 80% 41% 37% X There are mixed feelings as to how well the program utilises positive role models. In particular, 55% of respondents disagree that staff help participants learn from others who have successfully recovered. O T H E R Ethnic and cultural background respected (n=7) 86% 48% 15% Help with alcohol and drugs (n=2) 100% 83% 0% 64

72 Element of Recovery Percentage agreeing/stro ngly agreeing that element is important Percentage agreeing/stro ngly agreeing that element is being met Percentage disagreeing /strongly disagreeing that element is being met Overall 1 Comment Healing trauma, including sexual abuse and/or physical abuse (n= 11) Having support for my sexual orientation (n=2) 91% 30% 42% X Respondents generally feel the program does not have adequate resources to help them heal from abuse or trauma and that staff do not effectively deal abuse and trauma. 50% 50% 0% - Both respondents feel that staff are not homophobic but also feel that staff are neither particularly effective nor ineffective in dealing with issues of sexual preference. Support as a parent (n=15) 67% 16% 47% X Note (1): negative rating (x) based on whether overall an average 30% of respondents or more rated the questions relating to that element as disagree/strongly disagree. Conversely a positive rating () is where the negative response is less than 30%, blank is inconclusive. These figures are arbitrary and this approach is adopted for presentation purposes. 65

73 6.3 ACHIEVEMENT OF RECOVERY MARKERS Table A.42 at appendix E highlights that the majority of respondents had achieved 16 of the 25 recovery markers. Of particular note is that 81% of respondents have one or more trusted people they can turn to for help, 71% have a living situation that is safe and feels like home, but only 9% see themselves beginning to work within the next six months. We have reviewed the literature and not been able to find any comparable benchmarks for the whole population. In addition there is no way of attributing these findings specifically to IPRSS related services. 6.4 ORGANISATIONAL CLIMATE Table A.41 at appendix E shows that overall respondents generally feel positive or neutral toward many aspects of the program. Aspects that were more positive were the promotion of learning and the caring, compassionate and welcoming nature of the staff. However 52% feel that the program does not have sufficient resources to meet people s needs and 40% believe the program does not provide real choices, desirable options and opportunities for participants. 6.5 CONSUMER SATISFACTION SURVEYS Three service providers provided HOI with the results of consumer satisfaction surveys they had undertaken and the results are presented in appendix G for information. While feedback across many aspects of the their services were positive or very positive, in one case 35% of respondents indicated they were confused about what support workers could support them with, and while 65% agreed or strongly agreed that support workers helped consumers explore options to do things differently 21% were neutral and 13% disagreed. The following identifies which aspects of the services consumers appreciated the most about the services they are receiving: having someone to talk to and someone who listens to them help given to do errands, e.g. doctors and shopping the friendship with the service provider help with tasks that are difficult to manage enjoyed getting out of house, e.g. going for drives or getting coffee increased social connectedness: someone to take the consumer out to socialise someone to help translate or increase understanding with english is not the consumers first language increasing independence linking me the community, e.g. church, family and friends linking with education outdoor activities which support relaxation, e.g. walking., fishing help getting drug and alcohol counselling treated as a human, not just as someone with a mental illness staff are very encouraging 66

74 how the goals are set out in manageable stages help with managing mental health. The following suggestions were made about how services could be improved: overcome language barriers additional hours more driving greater focus on employment and employment activities improved communication with workers: workers are sometimes disorganised, not easily contactable only gives the consumer short notices more outings simple paperwork reduce support worker turnover group activities provide more information about the services, including the hours which are allocated and hours flexibility improve partnerships between support workers and key workers. 67

75 7 CONCLUSION This section provides a high level conclusion against the key aims of the evaluation drawn from the body of the report. EVALUATION A IM ONE: ASSESS WHET HER THE IPRSS PROGRAM WA S IMPLEMEN TED A S PLANNED Overall the IPRSS program was implemented as planned. RECOVERY APPROACH Overall NGO providers have demonstrated an understanding of a recovery orientation and have incorporated it into their organisational culture. NEEDS IDENTIFICATION, REFERRAL AND AL LOCAT I ON AND ACCESS Allocation committee meetings and associated processes help to ensure the program is reaching the right consumers. The complexity of IPRSS consumers is significantly greater than the average ambulatory mental health consumer for both adults (53%) and older people (33%). Regional allocation committees vary in the priority setting process for consumers entering the IPRSS program. There is limited discussion on the capacity of NGO providers to accept referrals, and the provision, for example, of an NGO provider regional monthly report to allocation committee meetings, incorporating current consumers and hours allocated per consumer, would further strengthen the service partnership and help to prioritise need. Aboriginal and Torres Straight Islanders (ATSI) currently comprise 5.3% of IPRSS consumers and this is relatively constant between regions, although the number of unknowns recorded in country is high (27%). Overall 13% of consumers identified as having a CALD background, relatively consistent across regions. It is not clear whether the IPRSS program is the most suitable model for ATSI people experiencing psychological distress and there is no benchmark for the percentage of ATSI IPRSS consumers. INDIVIDUA L SUPPORT PLAN (ISP) PROCESS In the majority of instances the development and review of ISPs works well. Consumers actively participate in the ISP process i.e. goal planning, implementation and reviews and the consumer perspective is sought at service development, evaluation and management levels. Government mental worker s attendance at reviews is variable in some cases and there has been an increased workload for government mental health workers because of the requirement to attend ISP reviews. There is a need for improved co-ordination of reviews and better articulation of roles and responsibilities in operational protocols and there should be a more concerted effort to involve carers in the ISP process where appropriate. There are instances when the IPRSS program does not effectively engage with consumers to achieve program outcomes through effective goal setting, the provision of meaningful activities and/or effective community connection. 68

76 EXITING The empirical data indicates that in consumers are being discharged appropriately. Qualitative feedback indicated there may be a need for some adult consumers to receive time limited support while exiting the program when they are no longer an active consumer of the government MHS. Developing more specific exit guidelines would assist in strengthening the exit process and enhancing the consumer journey. QUALITY There is a strong demonstrated commitment to quality in the program. Consideration should be given to endorsing an approach where only one recognised quality process need be adopted. W ORKFORCE Staff are appropriately skilled and trained to provide a recovery oriented approach to services. Overall 87.8% of staff have a relevant qualification with 41% having a Bachelor degree. There is an active staff development program offered by NGO providers and supervisory and support structures are satisfactory. GOV ERNANCE Governance structures have served the program well since its inception. The program has been operating for two years and it is timely for the leadership to recommit to the shared vision required to sustain the success of the program There is no structured approach to monitor the performance of individual service providers or regions. HOI consider the program would benefit if an annual contract management meeting was conducted with each service provider. Regional allocation committee meetings could be utilised more strategically to assist the PMC in implementing strategic requirements at the local level and also to further strengthen the partnership. PARTNERSHIP Approximately half of the manager level stakeholders (46%) felt a partnership based on genuine collaboration had been established with the challenge being to maintain its impetus and build on current success. The remaining 54% felt the partnership was moving in the right direction but will need more attention if it is going to be really successful. No one indicated that the whole idea of partnership should be rigorously reviewed. Partnership success could be improved by greater clarity of vision, roles and responsibilities, clearly articulated boundaries, concepts of recovery and recovery practice. One practical opportunity for improvement around which most agreed was the need to review and update the operational protocols and conduct joint training sessions on the recovery approach and further definition around the role of the NGO support worker, supplemented by action learning case studies. This would assist in developing a shared understanding of, and commitment to respective roles and responsibilities. EVALUATION AIM T WO: DET ERMIN E WHETHER CO NSUMER OUTCOMES WERE OPTIMISED The IPRSS program has had a positive impact on consumer outcomes. There have been significant decreases in mean scores across all NOCC indicators. In particular: the HoNOS adult score has improved by 14.3% and HoNOS 65+ for older persons score has improved by 11%; the LSP 16 has improved by 9% for adults and 19% for older people; and the K10 has improved by 9% for adults and 12% for older people. 69

77 An analysis of consumer outcomes from the case studies and feedback from consultations reflect that NGO providers are taking a holistic approach when goal setting. They are identifying issues across a wide range of domains and working with consumers to address them. Increased independence, improved health (both physical and mental) management, social connectedness, family relationships and improved domestic and self-care skills are common areas being addressed. Having said that, carer and consumer feedback indicates that while they are positive about the program, there are instances when the IPRSS program does not effectively engage with consumers to achieve program outcomes. Areas that were consistently raised as being problematic include: Goal Setting: consumer goals can be unrealistic and there is a perception that consumers could be more actively assisted to achieve goals Meaningful Activities: there is a pathway gap for consumers to be: o o provided with real choices and opportunities engage in relevant interests and activities Community Connection: that is supporting consumers to build or rebuild positive relationships with family members or friendships with people outside the mental health system. A process needs to be more clearly identified within the operational protocols for collecting and reviewing information pertaining to consumers exiting the IPRSS program. The IPRSS program has had a very positive impact on the rate on mental health related hospital admissions and associated average length of stay (ALOS). The rate of mental health admissions have reduced by 39% and ALOS has reduced by 16%. The IPRSS program has had a positive impact on the rate on non-mental health related hospital admissions and associated ALOS in that consumers are more aware of their physical health needs and attending to them (increase in rate of admission of 20%), and when they are in hospital, they are more capable of being discharged home earlier than was the case previously (LOS reduced by 60%). EVALUATION AIM THR EE AND FOUR: IMPROVE IPRSS PROGRAM ARRANGEMENT S AND PERFORMANCE, INFOR M FUTURE SERVICE PLANNING, DELIVERY AND FUN DING AND MAKE RECOMMEN DATIONS The full report identifies a range of opportunities to strengthen the program governance and partnership as well as service delivery. Clear recommendations are presented in the executive summary. 70

78 A ABBREVIATIONS Abbreviations used in this paper are presented in the table below for ease of reference. Term ALOS ASSIST ATSI BASIS 32 CARS CALD CAMHS CAN CANE CBIS CBT CRM CSS DH GAF HoNOS IPRSS ISP J&P LWB MHS Definition Average length of stay Alcohol, Smoking and Substance Involvement Screening Test Aboriginal or Torres Strait Islander Behaviour and Symptom Identification Scale Consumer activity reporting system Culturally and Linguistically Diverse Child and Adolescent Mental Health Services Camberwell Assessment of Need Camberwell Assessment of Need for the Elderly Community Based Information System Cognitive Behaviour Therapy Collaborative Recovery Model Community Support Scheme Department of Health Global Assessment of Functioning Health of the Nation Outcomes Scales Individual Psychosocial Rehabilitation Support Service Individual Service Plan Job and person specification Life Without Barriers Mental Health Service(s) I

79 Term MIFSA MOU NGO NHMRC NOCC OH&S PHaMs PMC PRSSS QIC QICSA QMS QOL REE SRF STORI TAFE WHOQOL WHOQOL BREF Definition Mental Illness Fellowship of South Australia Memorandum of Understanding Non-Government Organisation National Health and Medical Research Council National Outcomes and Case-mix Collection Occupational Health and Safety Personal Helpers and Mentors Program Management Committee Psychosocial Rehabilitation Support Services Standards Quality Improvement Council Quality Improvement & Community Services Accreditation Quality Management Services Quality of Life Recovery Enhancing Environment Supported Residential Facility Stages of Recovery Instrument Training and Further Education World Health Organisation Quality of Life tool World Health Organisation Quality of Life tool Brief version II

80 A APPENDIX A SERVICE MODEL The following is the Service Model for Individual Psychosocial and Rehabilitation Support Services developed by the Department of Health in INTRODUCTION Psychosocial rehabilitation is the provision of evidence based interventions that will assist the recovery process of those individuals who have the capacity and willingness to do so. Psychosocial rehabilitation support services are provided by non government community mental health services to those people with psychiatric disability as a result of serious mental illness. The delivery of psychosocial rehabilitation requires a partnership approach across the government and non government sectors to support a recovery oriented system. There is an international trend emerging around the integration of social and clinical care in mental health. 3 This document describes the model of service delivery known as Individual Psychosocial Rehabilitation and Support Services to be provided by non government organisations in partnership with the South Australian public mental health system. A majority of mental health consumers (79%) have an identified need for non clinical support services in addition to the clinical support services that they receive. 4 This description of the model will provide a consistent and authoritative reference for all providers of individual psychosocial rehabilitation support services. It is also intended to provide guidance for the Department of Health in considering program resources, evaluation and accountability arrangements. 2. SERVICE CONTEXT The centre piece of the mental health reform agenda is the stepped model of care which includes: Support in the Community 24 hour Supported Accommodation Community Recovery Centres Intermediate Care Adult Acute Inpatient Beds; and Secure Rehabilitation The Social Inclusion Board in its report, Stepping Up: A Social Inclusion Plan for Mental Health Reform made two recommendations relating to the non government sector: South Australia should continue to build capacity in the non government sector to deliver psychosocial rehabilitation and support services. The development should be framed within a partnership approach that builds on a system that will have community mental health at its centre. South Australia should reassess its current investment in NGO services based on the evidence from the evaluation that is due for completion in early A new and more rigorous contracting process is warranted that builds on the concepts of the stepped system. Rehabilitation and support services 3 Stepping Up: A Social Inclusion Action Plan for Mental Health Reform : South Australian Social Inclusion Board 4 Profile of Community Mental Health Consumers, Report 1: Social Inclusion Strategy and Research: Research and Analysis Unit (March 2007) III

81 should be focused on helping people to step down from formal care to maintaining ordinary associations in society that support a meaningful life. 3. PHILOSOPHY A recovery approach is fundamental to the delivery of individual psychosocial rehabilitation support services. This approach is nationally and internationally recognised, having been developed by the international and national mental health consumer movements. Recovery is both a process and an outcome and is unique to the individual. It does not imply cure but refers to the ways in which a person with mental illness can adjust to living a personally meaningful life in the presence or absence of symptoms. Recovery is a personal experience dependent on a complex interplay of factors: Internal factors such as whether the person has hope for the future, meaning and purpose in his/her life, is treated with dignity and respect and feels empowered External factors such as whether the person has adequate income and housing; social relationships and supports; meaningful activity and employment and whether he or she experiences prejudice or exclusion Distinguishing characteristics of a recovery approach include: A holistic view that focuses on the person, not just the symptoms Considers the person in the context of their family, significant others and community Supports the person to achieve full citizenship with all its rights and responsibilities Recognises that recovery from severe mental illness is achievable Acknowledges the uniqueness of each person s journey Acknowledges the person as the driver of their own recovery Builds hope and supports the person to take control of his/her life Recognises that recovery is a complex and non linear process Acknowledges people s strengths and capacity to learn, grow and change Is non stigmatising and non discriminatory Values and supports natural and informal systems of support Connects the person to a broad range of services and opportunities that meet the person s needs including promotion and early intervention services Requires a comprehensive coordinated community based approach based upon partnership Ensures adequate, flexible and responsive services appropriate to a person s changing needs 4. PRINCIPLES People with a mental illness or disability resulting from that illness require appropriate community based support that assists them to manage the everyday impacts of their illness and maximise their capacity to live stable and productive lives. The following principles underpin the delivery of services. Consumers are respected as citizens and their participation in, and contribution to the life of the community is supported and promoted Consumers are provided with choices and opportunities to develop and maintain skills and to participate in the activities that enable him or her to achieve valued roles in the community Consumers will have timely access to services on the basis of relative need and available resources Each consumer receives a service(s) which is designed to meet, in the least restrictive way, his or her individual needs and personal recovery goals Consumers will be assisted to access mainstream services, similar to other members of the community As far as possible there will be a clear separation between housing and support services Each consumer has the opportunity to participate as fully as possible in making decisions about the events and activities of his or her daily life including in relation to the services he or she receives IV

82 Each consumer s right to privacy, dignity and confidentiality in all aspects of his or her life is recognised and respected The individual needs and aspirations of consumers are recognised and respected by service providers Service providers will work in partnership with consumers, carers and each other to maximise a consumer s recovery Consumers have access to high standards of care and are free to raise and have resolved any complaint or dispute he or she might have regarding the services they receive 5. SERVICE DESCRIPTION Non government organisations provide a range of community mental health services of which individual psychosocial rehabilitation is one service type. Support in the community is a critical element of the Stepped Model of care. Individual psychosocial rehabilitation and support services are provided to individuals living in their own homes, whether the home is public or private housing, a family or shared home, a boarding house or supported residential facility. An important component of individual psychosocial rehabilitation is community capacity building and therefore services are provided within consumer s homes and in the community. This service type includes: Services delivered to assist the consumer engage in meaningful daytime activity and employment Services delivering combined housing and support programs (e.g. Supported Accommodation Demonstration Projects) provided the service is not facility based Services delivered in community settings intended to promote community engagement, social connectedness Independent living skills support and training to enable day to day living in the community Transition from facility based services to home and community living 6. OBJECTIVES Individual psychosocial rehabilitation and support services provide structured, goal focused and individually tailored rehabilitation and support services at a level of intensity and duration appropriate to the consumer s needs. The aims of the service are to: Assist people to self manage their own recovery and build on their interests, aspirations and strengths to live full and active lives Develop skills to improve competence and confidence in community living Improve health and well being Improve independence and resilience Prevent relapse and limit the severity of any crisis Engage the consumer with desired community and social activities Reduce social and physical dislocation by assisting people to sustain suitable housing and to develop improved social relationships Increase opportunities to participate in the workforce Reduce demand on acute and emergency services The emphasis on these objectives will vary between programs and funding rounds. 7. CONSUMER PARTICIPATION Consumer participation includes consumers participating in their own care and treatment as well as providing consumers with an opportunity to contribute to the systemic operations of the service. The former is promoted by the development of Individual Support Plans (ISP s) while the latter requires the involvement of peer support workers and consumer consultants in service development and evaluation. V

83 8. CARER PARTICIPATION Many family members and other carers have an ongoing role and are important partners in supporting people to live in the community. Where appropriate and where the participant agrees, the carer should be involved in the development of the Individual Support Plan. Services should also involve carers in service development, evaluation and management activities. 9. PARTNERSHIP MODEL Individual psychosocial rehabilitation and support services are delivered as a partnership between mental health services and the non government sector. In order to reflect this partnership processes and guidelines will be developed in consultation with the non government partners. However, given that mental health services are responsible for the identification, allocation and monitoring of consumers to particular programs, mental health services will assume responsibility for the management of regional and subregional processes required to ensure a successful partnership in relation to service delivery. Adult mental health services will work cooperatively with the Child Adolescent Mental Health Service (CAMHS) and with the State-wide Adolescent Assertive Mobile Outreach Service (AAMOS) to ensure that consumers in this younger age cohort are allocated packages as appropriate. The following practice principles will be adopted by public mental health services and the non government sector: A collaborative planning process resulting in a recovery oriented support plan Using appropriate tools such as self reporting documents, standardised outcome measures, quantitative tools and assessment of need measures Ensuring a self reporting tool is offered as an option for consumers to utilise Valuing the right of the consumer to negotiate their own plan Sharing knowledge as appropriate with the consent of the individual Sharing information in the context of duty of care Acknowledging risk within a dignity of risk framework Collecting data to inform evaluation, research and service development Working towards formal partnership agreements where appropriate 9.1 ROLE OF MENTAL HEALTH SERVICES Mental health services will work collaboratively with non government organisations providing individual psychosocial rehabilitation support services and will: Convene and chair all allocation committees (or manage regional processes) relating to individual psychosocial rehabilitation support services Provide comprehensive information at the point of referral: referral form, care plan, risk assessment, current NOCC scores (HONOS, HONOSCA, FIHS LSP, SDQ and K10) and consent form Ensure the needs of children of parents with mental illness are taken into account in the development of the ISP and development of supports Participate in the assessment of the consumers psychosocial rehabilitation support needs Participate in the development of the Individual Support Plan (ISP) ensuring that the consumers mental health care plan is aligned with the goals and supports agreed in the ISP Participate in the review of the ISP ensuring that the consumers care plan and ISP are integrated and agreed Participate in the process of discharge planning from the non government organisation and in ensuring that an appropriate transition plan is in place to ensure effective discharge from individual psychosocial rehabilitation support services VI

84 Ensure that there is a mental health contact person for the duration of the delivery of individual psychosocial rehabilitation support services 9.2 ROLE OF T HE NON GOVERNMENT COMMU NITY MENTAL HEALTH SERVICES All participants of individual psychosocial rehabilitation support services should be allocated a psychosocial rehabilitation worker on entry into the service. The non government community mental health service is responsible for allocating a staff member as the psychosocial rehabilitation worker and in ensuring that this person is the primary contact for the mental health services partnership. The non government community mental health agency is responsible for the provision of psychosocial rehabilitation and will achieve this by: Collaborating with the consumer in the development of the Individual Support Plan (ISP) that reflects the psychosocial rehabilitation support needs across the life domains Coordinating implementation of the ISP Developing with the informed consent of the consumer, a cooperative relationship with any carers involved, family members or significant others Ensuring that the consumer receives the services and support necessary to regain the skills and confidence required in activities of daily living, for the development and maintenance of social relationships and where appropriate assisting people to independently care for their children. Facilitating access to and participation in a range of community support programs and activities, including those provided by mainstream organisations. These include programs and activities relating to accommodation, education and training, income security, employment, recreation and leisure. On the request of the consumer, acting as an advocate for the consumer especially in dealing with discriminatory attitudes and behaviour and in facilitating access to services. Working in partnership with the consumers government MHS worker Delivering services according to relevant legislation and within the constraints of any orders that may be in place. Facilitating access to and developing a co-operative relationship with the consumers private psychiatrist or General Practitioner. 10. MODEL OF SERVICE DELIVERY 10.1 SERVICE LOCATION The major focus of individual psychosocial rehabilitation and support services is the development and delivery of structured social and living skills programs in the person s own home, regardless of where the person lives and the nature of that accommodation. It therefore includes private and public housing, boarding houses, supported residential facilities, Aboriginal hostels, private hotels or caravan parks. Home is defined by the consumer who may live alone, with family or with others. Support will also be provided in community settings where one to one support is required to assist the consumer to access and to sustain involvement in educational, vocational, recreation, social and transport opportunities HOUR S OF OPERA TION Programs are expected to provide services 7 days per week and 52 weeks per year. The hours of operation should reflect the needs of the consumers and therefore some extended hours coverage is expected. Specific programs may be funded to provide extended hours, including 24 hour, 7 days per week in limited circumstances. VII

85 10.3 CONSUMER CHAR ACTERIST ICS Individual psychosocial rehabilitation and support services are targeted at adult men and women who have: Serious mental illness and functional disability Consumers with high and complex needs Require one to one support to assist with self management of housing, finances, relationships, activities of daily living, social integration and parenting Require one to one support to assist in the management of their physical and mental health Are at risk of requiring acute care or relapsing without support Have complex health, lifestyle and behavioural needs Co-morbidity such as drug and alcohol issues, intellectual disability and acquired brain injury People who are homeless, at risk of becoming homeless or who are residing in unstable or unsuitable housing Individual psychosocial rehabilitation support services will also be targeted at people under 18 years of age who have the following characteristics: High and complex needs Are in transition to adult mental health services or are highly likely to require adult mental health services in the future Have developmental needs likely to require ongoing psychosocial rehabilitation support/disability support From time to time access may be further targeted to provide priority for people who: Present frequently to acute and emergency departments Are homeless or experience severely disrupted housing Are leaving acute or facility based care It is acknowledged that specific programs may be required for particular consumer groups such as Aboriginal people, people from culturally and linguistically diverse populations, and people having comorbid cognitive disability (intellectual disability or brain injury) ADMISSION CRITERIA Unless otherwise specified consumers in this group will be: Registered consumers of the public mental health system Have undergone an assessment by adult mental health services to establish eligibility for public mental health services and to establish which component of the mental health system is most appropriate to respond to the consumers mental health needs. Have undergone an assessment by the Child Adolescent Mental Health Service. Have a current care plan and risk assessment determining that individual psychosocial rehabilitation support services is the recommended service response to meet the identified needs. The recommendation will be based upon consideration of the assessment, care plan, risk assessment and the national outcome measures. Have an identified government MHS worker or contact person. VIII

86 10.5 REFERRAL SOURCES Referrals will generally be via public mental health services unless otherwise specified. Referral Information will consist of the following: Referral Form Current Care plan Risk Assessment Current NOCC scores HONOS/HONOSCA/LSP/FIHS/K10/SDQ Consent Form In recognition of the specific needs of particular populations, some designated programs will accept referrals from other sources e.g. General Practitioners, Aboriginal Community Controlled Organisations and organisations delivering services to culturally and linguistically diverse groups SER VICE ALLOCATION Individual psychosocial rehabilitation and support services are one component of the non government community mental health service system and therefore service allocation needs to ensure that resources are targeted appropriately. In order to reflect the partnership model and to ensure that resources are targeted appropriately the allocation process will: Ensure that allocation committees and processes consist of representation from the non government sector and mental health services Demonstrate an approach that is local, responsive and flexible Ensure referrals are dealt with in a timely manner and feedback occurs quickly to the referring worker Determine eligibility for services Determine priority of access Manage transfers and waiting lists as required Ensure that a formal process is established to deal with appeals Maintain concise and accurate records Ensure representation from other organisations as agreed by local partnership arrangements 10.7 SER VICE INT ENSITY AND DURATION Individual psychosocial rehabilitation support services are provided at a level appropriate to the consumers needs. It is acknowledged that people with mental illness have support needs which are fluctuating in nature and that the delivery of individual psychosocial rehabilitation needs to reflect the need for a fluctuating and responsive level of support. Program types will vary along the continuum of need and will include: Intensive individual psychosocial rehabilitation services for people leaving institutional care to live in the community with support Individual psychosocial rehabilitation services for people living in the community who require a range of support (intensive, moderate and low) to assist them to maintain community tenure Low level, short term and intermittent individual psychosocial rehabilitation support services Programs designed for a particular target group requiring a specialist focus IX

87 11. INDIVIDUAL SUPPORT PLAN (ISP) All consumers of individual psychosocial rehabilitation and support services will have an ISP developed by the non government provider, in partnership with mental health services and including their input. The ISP will build upon the information provided by mental health services at the time of referral. Who should be involved in the development of the ISP? The consumer is central to the ISP. The assessment of a consumers rehabilitation and support needs will be undertaken collaboratively by the consumers non government psychosocial rehabilitation worker and the mental health services government MHS worker. This promotes consistency of practice and ensures that all parties are working together to achieve the same goals. It also assists the consumer to understand the roles and responsibilities of the non government worker and of the government MHS worker. The consumer should have his or her own copy of the ISP. With the consent of the consumer, family members or others involved in a care giving or support role should also be involved in the development of the ISP. What should be in the ISP? A comprehensive Individual Support Plan will address all life domains and contain: A description of the consumer s current situation Information regarding children, family and carers The consumers hopes and aspirations The consumer s goals and the supports required Detailed strategies for achieving the goals including timeframes and phases of intervention Information in relation to identified risk and strategies to address and manage the risk Clear documentation in relation to roles and responsibilities Indicators for assessing when and whether the goals have been achieved A timetable for review of the ISP Timetable for developing an ISP The period of time required to develop an ISP will vary depending upon the consumer s level of engagement. However, non government organisations will aim to have an ISP in place within two months of the service commencing. A less formal approach to developing an ISP may be necessary for those consumers who may find it difficult to engage with a service; for example people who have experienced significant transience or homelessness, or state that they do not want to be involved in the development of an ISP. Whether or not a formal ISP is developed, the process of engagement and exploration of a consumer s goals, aspirations and support needs is an integral part of involvement in a structured, goal focused individual psychosocial rehabilitation program. ISP Reviews The ISP will be monitored and formally reviewed at regular intervals by the non government psychosocial rehabilitation worker, the mental government MHS worker, consumer and other appropriate people. At a minimum, formal reviews will be scheduled three monthly but will occur more often as required and as agreed by the parties. Evidence of the informal and formal review process should be clearly documented by the non government provider. Discharge The ISP will have clear and documented information in relation to discharge planning. The process of discharge planning will have been discussed and agreed at ISP reviews and arrangements made for the consumer to transition out of the individual psychosocial rehabilitation support service. X

88 12. OTHER KEY PARTNERSHIPS The delivery of individual psychosocial rehabilitation services requires mental health services and the non government sector to work in partnership with a number of key stakeholders including housing, disability, drug and alcohol, aged care, child protection services and general practitioners MENTAL HEA LTH SERVICES Mental health services have the following formal partnership arrangements designed to assist in the provision of cooperative working relationships: Memorandum of Understanding between the Minister for Housing (Housing SA and the Office for Community Housing) and Minister for Mental Health and Substance Abuse (January 2007) Mental Health Memorandum of Understanding: Department of Health, SA Ambulance, Royal Flying Doctor Service and the South Australian Police (2006) In addition to the formal arrangements noted above mental health services have developed cooperative working relationships with a number of other stakeholders including Disability SA, Families SA, Drug and Alcohol Services, Divisions of General Practice, Aboriginal Health Organisations and local councils NON GOVERNMEN T ORGANISATIONS Non government community mental health services are essential players in an integrated and comprehensive area mental health service, as well as the mainstream community and primary care service system. Individual psychosocial rehabilitation support services are also expected to be responsive to the needs of their geographic area as well as the needs of individual participants. Non government organisations delivering services within the country will require particularly good links with primary care providers. Primary care networks will pay a critical role in promoting the needs of service users in the local area. Strong and established linkages are also required with a range of generic and specialist services available in the community to facilitate access to these services for consumers and to ensure coordinated service delivery. These services will include general practitioners, housing, disability, child protection services, education and training, recreation, labour market, Home and Community Care and local councils. Services should be encouraged to develop partnerships with Aboriginal community controlled health services to improve outcomes in the mental health and wellbeing of Aboriginal consumers. Services should be encouraged to develop partnerships with non government organisations providing services to people from culturally and linguistically diverse backgrounds to improve outcomes in the mental health and wellbeing of this consumer group. 13. STAFFING The provision of individual psychosocial rehabilitation support services to people with mental illness is a specialist area and therefore non government organisations providing services require a staffing profile to ensure that: Services can be provided 7 days per week for 52 weeks of the year with some extended coverage as required. The organisation has a management structure which ensures effective supervision and support for all employees. Services are delivered by suitably trained and qualified personnel. Expert staff are involved in both management and service delivery having a range of qualifications including tertiary and non tertiary qualifications. Certificate IV in Community Services is the minimum standard for employment (or working towards). Non government organisations are expected to employ peer workers. Peer workers may not have attained Certificate 1V in Community Services, however, NGO s will be required to develop a professional development plan with peer workers with this qualification attained within three years. I

89 Services should be encouraged to develop their capacity to respond to the mental health and well being of Aboriginal consumers by recruiting Aboriginal staff with the appropriate cultural expertise and community knowledge Services should be encouraged to develop their capacity to respond to the mental health and well being of consumers from culturally and linguistically diverse backgrounds by recruiting staff with appropriate cultural expertise and community knowledge. 14. DATA COLLECTION All providers of individual psychosocial rehabilitation support services are expected to provide data as per the standard consumer and activity report format for reporting by NGOs funded through service agreements in The data is used for: Monitoring service performance Service planning: the data provides detail about the level of service activity and consumer characteristics that assist in understanding consumer needs, monitoring changes in the consumer population and service delivery issues. When linked to other data sources such as population data and Consumer Based Information System (CBIS) service gaps and consumer needs can be better understood. Non government providers will also collect qualitative data from consumers to gain an improved understanding of their experiences of service provision and to engage in a continuous process of service improvement. 15. SERVICE STANDARDS All providers of individual psychosocial rehabilitation support services are expected to comply with the South Australian Psychosocial Rehabilitation Support Standards (PRSSS) and are encouraged to seek independent accreditation by a recognised external assessor. II

90 A APPENDIX B IPRSS PROGRAM LOGIC This program logic was developed for the evaluation framework. III

91 A APPENDIX C ADDITIONAL PROGRAM ACTIVITY TABLES This appendix presents two tables not included in the body of the report. Table: Average hours per consumer by service provider by month Month Provider 1 Provider 2 Provider 3 Provider 4 Provider 5 Provider 6 Provider 7 Overall April May June July August September October November December January February March April May June July August Overall IV

92 Service Type Table: Mean services per year by contact type Mean Services per Year Prior to First Contact Mean Services per Year After First Contact Change in Services Percentage Change Care and Treatment % Education/Information % Medication % Depot % Assessment / Screening % Risk Assessment - Adult/OP % NOCC Adult Measures % DNA - did not attend % Emergency Triage % Care and Treatment AoD % NOCC Older Persons Measures % Community Initiative % Assessment/Screening AoD % Education/Information AoD % MHA5 Risk Screen/Risk Formulation NA MHA2 Comprehensive Client Assessment % NOCC Child/Adolescent Measures % Risk Assessment - Child/Adolescent % MHA3 Mental State Examination NA Post discharge follow up NA MHA8 Prov Diagnosis & Treatment Plan NA Overall % V

93 A APPENDIX D BRIEF DESCRIPTION OF OUTCOME TOOLS IN USE This appendix provides details of the outcome tools used by government MHS and NGO providers as well as data availability in relation to NGO providers. GOVERNMENT MHS OUTCOME ME AS UREMENT - INTRODUCTION A key lesson from various outcome measurement studies and field trials in the mental health area is that the process of assessing consumer outcomes is as important as the choice of measures, and that no single outcome measure is 'ideal'. Consumers, policy makers and researchers agreed that it was preferable to focus on a group or 'suite' of measures, where each measure contributes to the overall picture while counterbalancing some limitations of individual measures. For example, whilst HoNOS is an excellent indicator of severity, its focus on the most severe symptoms in the past two weeks has led to criticism that it provides a limited and problem-orientated picture of a person s situation. However, this can be counterbalanced by the Life Skills Profile, which measures a consumer's typical functioning over the past 3 months. In combination, the two measures provide a more comprehensive picture, which can be further broadened where consumers agree to rate their own health status using a self-rating instrument such as BASIS-32. By comparing these ratings over time, the clinician can obtain an overall picture of progress. 5 HONOS HoNOS was developed by the Royal College of Psychiatrists in the UK as a tool to be used by clinicians in their routine work to measure consumer outcomes. It was designed specifically for use with people with a mental illness and is best considered as a general measure of severity of mental health disorder. The focus of HoNOS is on health status and severity of symptoms. It consists of 12 items that cover the sorts of problems that may be experienced by people with a significant mental illness with each item rated on a five-point scale (0 = no problem, 1-4 = minor to very severe problem). The domains covered include behaviour, impairment, symptoms and social. The clinician rates the consumer on each of the scales in terms of their assessment of the person s situation over the recent period, usually the previous two weeks. The clinician uses a range of relevant information to make their ratings, for example case notes, interviews with consumer and carers, team meetings etc. HoNOS is designed to easily fit into day-to-day work, does not require special interviews/procedures and takes an experienced clinician about 5 minutes to complete. LSP The Life Skills Profile, also known as the LSP, was developed by an Australian clinical research group to assess a consumer s abilities with respect to basic life skills. Its focus is on the consumer s general functioning and disability rather than their clinical symptoms that is, how the person functions in terms of social relationships, ability to do day-to-day tasks and so forth. When combined with the HoNOS, which requires ratings of the most serious problem encountered, the LSP contributes towards gaining a more comprehensive understanding of the consumer. LSP contains 16 items across four domains: withdrawal; antisocial behaviour; self-care; and compliance. As with HoNOS LSP takes about 5 minutes to complete once the clinician becomes familiar with the scales. 5 DHS Victoria2008, Suites of Outcome Measures for Mental Health Clinicians VI

94 NGO OUTCOME DATA Table: NGO Outcome data status Organisation Outcome Tools Data status for evaluation Centacare Helping Hand Life Without Barriers Mind Neami UCW Adelaide CAN (prior to reviews & as required). WHOQOL BREF (no set decision did commence to do six monthly). Social Inclusion web (not mandated aim to do every three months or as needed). CANE done at initial assessment. Waiting for direction. Use WHOQOL BREF - commenced at start of voluntary due to concern in relation to questions around sex lives and intimacy. WHOQOL BREF. Global assessment of functioning (GAF). Both done at entry, every six months and then on exit. The initial GAF is done within three months as it requires some knowledge of the consumer. WHOQOL BREF every 6 months. CAN at entry and then 6 12 monthly. CAN six monthly or earlier if needed. Basis 32 usually 12 monthly but some people find it useful to do it every 3 or 4 months. Assist drug and alcohol screening tool if applicable and a six month follow up assessment. Stages of Recovery Instrument (STORI) is under consideration. If adopt may drop Basis 32. Social inclusion web. CANE was administered initially but was found not to be useful. The Manchester short assessment of QOL was trialled but not continued. Outcome tool results kept in consumer file. No data available for evaluation. CANE data in consumer files. WHOQOL- Very few complete. No data available for evaluation. Currently reviewing and advising what outcome/qol data is available at the consumer level on entry & exit or latest available. WHOQOL and Camberwell data for the most recent 6 consumers to exit the program from the Northern region. Research done across Neami (refer to section 7.3.2). No local data available for this evaluation. Individual social inclusion data is available electronically (we have been provided with 10 consumer records but we have not been able to match consumer identifier. VII

95 Organisation Outcome Tools Data status for evaluation UCW Port Adelaide CAN. Life Skills Profile. Aggregate CAN data is presented in section To date UCW Adelaide has provided social web inclusion data from their data system for 10 consumers but we could not link this to CARS data and UCW Port Adelaide was able to provide aggregated CAN data and could provide CAN data for selected consumers. LWB was not able to provide data. Mind has provided WHOQOL BREV data for six consumers and could possibly provide some additional data. OVERVI EW OF NGO TOOLS USED This section summarises the intent of the major tools used or being considered by NGOs. SOC IAL INCLUSION WEB The social inclusion web identifies ten key domains in which consumers could have had interactions with people. The tool was developed in Scotland and aims to map a consumer s network. It maps relationships and the shifting of relationships. This enables monitoring if networks change over time and used in conjunction with other tools it may be possible to determine if an enlarged network correlates positively with mental health, self esteem and quality of life. The social inclusion web is both a monitoring and assessment tool. It helps people who use services to think about their lives and set plans for the future. 6 CAMBERWELL AS SESSMEN T OF NEED The Camberwell assessment of need for the elderly is mandated by the IPRSS service model guidelines. The tool is designed to assess areas of need and is usually administered as part of the ISP and review process. NGOs believe the tool is focused on what a consumer does not have rather than what strengths they have and that need can often increase as consumers can become more self aware due to being on the program. NGOs believe the tool can be particularly useful for the consumer as a prompt when they get stuck. UCW Port Adelaide Camberwell assessment of need data The figures below present aggregate CAN data provided by Port Adelaide. The data shows that unmet needs have reduced (both consumer and support workers assessments). Note that the data is not a like for like comparison and the number of assessments available after 12 months is relatively small. 6 The Inclusion Web Manual (2008). National Development Team VIII

96 Figure: UCW Port Adelaide CAN average score by milestone Jan Sept 2010 consumer self assessment Figure: UCW Port Adelaide CAN average score by milestone Jan Sept 2010 support worker assessment Neami Research Neami has been using the CAN, a consumer and staff rated needs assessment instrument, for over seven years. In a research project they reported on the question of whether the rate of resolution of unmet needs was associated with the consumer's length of stay in the service. Fifty-nine consumers had (a) started at Neami since outcome measures were introduced, (b) had subsequently left Neami, and (c) had more than one self-rated CAN assessment. The average lengths of stay of consumers whose subjective unmet needs reduced were significantly lower than those whose unmet needs were unchanged, which were in turn lower than the lengths of stay of those whose unmet needs increased. The corresponding associations with unmet needs as rated by government Mental health workers were not significant. IX

97 These results show that routine self-assessment of unmet needs by consumers can be used to demonstrate personal progress and service effectiveness. 7 ere very WHOQOL BREV In the development of the WHOQOL Quality of Life is defined as an individual s perception of his/her position in life in the context of the culture and value systems in which s/he lives, and in relation to his/her goals, expectations, standards and concerns. It is a broad-ranging concept, incorporating in a complex way the person s physical health, psychological state, level of independence, social relationships and their relationship to salient features of their environment. The WHOQOL instruments are designed specifically for population use and are not appropriate for use at an individual level. They are designed to be self administered. 8 GLOBA L ASSES SMENT FUN CTIONING SCALE (GAF) The GAF (used by Life Without Barriers) attempts to capture a snapshot of where consumers sit in the general population based on their level of functioning in all aspects of life and citizenship. This includes access to suitable accommodation, diet, self care, health, employment and social support. The GAF in particular has a focus on measuring deficits in functioning, severity of symptoms and the extent to which these impair functioning and therefore seems opposed to the strengths based model and recovery principles. The aim is to develop an evidence base that can demonstrate that services are relevant, effective and required by a particular consumer population with specific needs. 9 STAGES OF RECOVERY IN STRUMENT (STORI) The STORI (being considered for use by Neami) is designed to capture the following stages of recovery from the consumer s perspective: moratorium (a time of withdrawal characterised by a profound sense of loss and hopelessness) awareness (realisation that all is not lost, and that a fulfilling life is possible) preparation (taking stock of strengths and weaknesses regarding recovery, and starting to work on developing recovery skills) rebuilding (actively working towards a positive identity, setting meaningful goals and taking control of one s life) growth (living a full and meaningful life, characterised by selfmanagement of the illness, resilience and a positive sense of self). 10 BASIS 32 This instrument (used by Neami) is designed as a measure of the major symptoms and functioning difficulties experienced by people as a result of a mental illness. It is a self reported measure where respondents indicate the degree of difficulty they have had over the last two weeks in a range of dimensions including managing day to day life, relating to other people, clinical symptoms, physical symptoms, drug and alcohol usage and level of satisfaction with life. 7 T Trauer., T & Tobias, G. (2009) Be the Change You want workforce Ingenuity, Auckland Conference Proceedings 2008, The MHS Conference, Sydney Australia. 8 Guilelines for Administering the Word Health Organisation Quality of Life Instrument. Life Without Barriers 9 Guidelines to using Global Assessment Functioning Scale. Life Without Barriers 10 Review of Recovery Measures version. Australian Mental Health Outcomes and Classification Network. January X

98 A APPENDIX E CONSUMER CASE STUDIES This appendix presents the eight detailed consumer case studies provided by NGO providers. CASE STUDY 1 X a 34 year old male who had his first Psychotic episode 12 months prior to joining the IPRSS program in June X was in a long term relationship with a partner and had a new baby daughter who was diagnosed with a severe illness shortly after her birth. X lived with his partner, daughter and partners mother. In his initial meeting, X asked for assistance to find independent housing, skills to enable him to help with his daughter and also to find work. In order to help X attain these goals, a family parenting program was found and X was supported to attend it until he was comfortable to attend on his own. After assisting X in compiling a resume and several mock interviews process, X from his own initiative found an ad for a car washer at a local car yard, and was encouraged him to apply. He was successful and started 4 day a week employment. The team also advocated for him in finding private rental and supported him to investigate what his entitlements may be to assist him and his family to move independently of his partner s mother. When X was discharged from IPRSS, he was living in private rental with a large backyard where he had planted many vegetables and was building a dog house so he could get a dog for his partner, now wife s birthday. X is now working full time, helping to care for his daughter, undertaking courses offered by the Women s & Children s hospital and is enrolled at TAFE to commence mature age HSC. CASE STUDY 2 P is aged 32 and has a diagnosis of bipolar disorder. P was 18 when his girlfriend fell pregnant, during which time he was also a heavy marijuana and alcohol user. P and his partner relocated to be closer to family. His daughter was born, followed by a son two years later. For almost 10 years, P had experienced delusions, mood swings and psychotic episodes and continuing substance abuse despite repeated attempts at quitting. P s partner and children left him as they could not cope. Eventually, P was re-admitted to a psychiatric hospital and placed on different medications. Currently the IPRSS team are assisting and working with P with regards to finding long-term independent accommodation and to meet P s psycho-social needs. P has not had any hospital admissions over the last 3 years and keeps in contact with his psychiatrist every 6 months. Previously P lived with his mum, but at the moment he is staying independently in a caravan park. P also started seeing his children once a month and is hoping to increase this once he has his own accommodation. CASE STUDY 3 M is a male who has been part of the IPRSS program for 4 years (previously under Strategy 6), experiences fixed delusions and high anxiety and had previously been identified as being treatment resistant. M s appointments were structured to focus on social connection and supporting his interest with TAFE. M struggled with identifying appropriate behavior around others and as such was asked to discontinue attending a cooking class at MIFSA due to the females in the group feeling confronted by the attention he showed them. In 2008 M had an extended stay in a psychiatric clinic, and at this time he underwent ECT treatments. Upon leaving the hospital, he had a weekly routine and sees different people on the set days of the week. He also would visit his friends regularly. XI

99 M regularly attended sessions with a psychologist, with the end of sessions occurring mid 2010, once his fixed delusion reduced and his ability to self assure increased. M attended a YMCA Retreat and a Peer Worker course ran through MIFSA in He completed the course and since has worked with LWB Peer support worker to update his resume. He is also currently enrolled in and attending his certificate II in community service at TAFE. In Dec 2010 he was successful in achieving social supported housing. LWB CSW again increased their support at this time and he has taken 3 months to slowly move into his own accommodation. CASE STUDY 4 C is an indigenous woman with three children under the age ten and a past history of substance abuse. In the past C had worked part time as an enrolled nurse. C has had several recent major life stressors including a relationship breakdown resulting in her partner leaving the family home and progressive debt accrual, resulting in several psychotic episodes and subsequent hospitalisations. At the time of the referral to IPRSS, Families SA were concerned for the three children, particularly the oldest child who had seemingly taken on a caring role. She had been regularly absent from school in order to care for the two younger children, one of whom has chronic health issues. Understandably when the IPRSS team began working with C there were a number of stressors impacting upon C s mental health and wellbeing. Using a collaborative approach C and the IPRSS team addressed the stressors and the C became increasingly independent and self motivated. Some of the areas that C and IPRSS worker addressed included linking C and her partner into regular relationship and financial counseling sessions. The children have all been successfully enrolled in schools and kindergarten and the child with chronic health conditions is now linked to follow up hospital appointments. C has been linked to a Job Network and has applied for an Aboriginal scholarship at the end of this year to study for some higher nursing qualifications. C has also registered with a local Nursing Agency and is waiting for an intake course as she has not worked for the agency in last 12 months. Through addressing these issues, C s stressors have reduced significantly and C has regained confidence and motivation. CASE STUDY 5 B is an Italian male, who has a diagnosis of Bi-Polar Disorder and commenced with the predecessor of IPRSS in April of At this time the person was in a manic state, he wasn t taking his medication, was often out during the day and night ranging around town. He was at risk of losing his accommodation, he was rarely home for the IPRSS team visits and was not engaging with the program. At this point he was detained to a psychiatric hospital. Upon discharge a similar lifestyle resumed, including: not engaging with the program and not being home when the worker was scheduled to visit. Eventually he was discharged from the IPRSS program (Strategy 6) in December From that time, he was in and out of hospital. In October 2010, the IPRSS program recommenced with B. From the rereferral, the IPRSS team provided a more structured approach, visiting every day to monitor that he was correctly taking his medication, and to provide a foundation of interactive support. The IPRSS team recruited an Italian male support worker who the consumer has responded well to. Positive outcomes for B included: taking more care with his personal hygiene e.g. showering more often; his diet has improved; he has started a garden; he has joined an Italian social club and made friends with some of the other men. Currently the IPRSS team are looking at strategies to reduce the number of visits e.g. using Medalert to prompt medication. CASE STUDY 6 Z was referred to the IPRSS program with a risk of eviction from Housing SA due to holes in many walls and doors in the house and with the backyard in a substandard state and complaints from neighbours as a result. Z was not eating properly and presented to the IPRSS team very physically unwell and depressed. Z s personal hygiene was affecting her ability to get out in the community due to poor choices in clothing and her dishevelled appearance. XII

100 The IPRSS team worked closely with Z, building rapport over many months before she was able to allow any steps to be put in place for the house repairs. This in turn opened the communication for other small changes to occur. A year later Z s mental health has stabilized, she is compliant with taking her medication, she has reconnected and has ongoing weekly connection with family. Z sought mediation with her ex-husband and was successful with obtaining access of children once a fortnight with the support of her mother. She went on family holiday for the first time in many years with parents and her children. Z has sought psychologist services for therapy regarding her anxiety and depression and she is motivated to seek out activity groups and arrange transport to get there. She has addressed her weight concerns, lack of exercise, quit smoking and reduced her alcohol consumption, and taken up a walking regime and a healthier diet. CASE STUDY 7 After having experienced substantial abuse in her childhood, consumer J was diagnosed with severe depression, PTSD and borderline personality disorder at age sixteen. She often sought refuge in substances and found herself in many abusive relationships. Amid the chaos of her life, she had a son. By three years old, her son was mimicking the violence he had witnessed and J sought help from Child and Adolescent Mental Health. This led J to access mental health services for herself, resulting in hospitalisation. At this time J decided to relinquish the care of her son for a period. Since joining the IPRSS program, J now settled into independent accommodation with her son and has embarked on a journey towards helping other people dealing with mental illness. She has completed peer support training, child safe environment training and is currently working towards her Certificate IV in mental health. She is aiming to find employment in the mental health sector. CASE STUDY 8 Consumer Z was diagnosed with a schizotypal personality and on referral he was at risk of hospitalisation and homelessness. Z s home was sub-standard needing industrial cleaning. Z s hygiene was very poor along with multiple health issues e.g. chronic infections, severe oral decay. Z s only access to ablutions was at the local caravan park- where he showered weekly. Z has difficulties with relationships and social skills. He is regarded in his town with suspicions and is defensive as a result. Z had developed a gambling addiction in recent years that had left him in financial difficulties and at threat of losing his home. Z s home was cleaned industrially, and Z has managed to maintain an acceptable level of cleanliness and order. Z s personal hygiene has improved due to negotiations with caravan park for more access until hot water installed in his home. Z was also placed on health care plan with a GP with several issues resolved and ongoing dental care receiving a package from Medicare. The IPRSS team arranged to engage a financial counsellor, negotiated payments for utilities and arranged an application for hardship provision to be provided by a bank. Z has attended several local functions and is in general well received. He enjoys visiting local shopping areas, socializing and gambling no longer an issue. Z informed his IPRSS team that without the service he may not have survived. Z spoke of his continual improvement in his physical and mental wellbeing and how that in turn allows him to be more social. Z talked of enjoying his home, and willingness to maintain it, his happiness in respect of his new relationship, and his ability to resolve issues. Z believes the IPRSS team has given him a second chance at life. XIII

101 A APPENDIX F REE SURVEY ANALYSIS Appendix F presents a detailed analysis of the REE survey. DEMOGRAPHICS Table A.1 presents the age distribution of the 21 respondents to the REE survey. The age distribution is heavily skewed toward the older age groups, with 95% of respondents aged 36 or over and 52% aged 56 or over. Table A.1: Age distribution of respondents Age Number of Percentage of Respondents Respondents % % % % % % Total % Figure A.1 shows that more responses were received from females (67%) than males (33%). Figure A.1: Gender distribution of respondents Table A.2 presents the ethnicity of the 16 respondents who indicated their ethnicity. It shows that half of the respondents were non-indigenous Australians, 38% were from overseas and 13% were indigenous Australians. All non-australian respondents were European. XIV

102 Table A.2: Ethnicity of respondents Ethnic Background Number of Respondents Percentage of Respondents Non-Indigenous Australian % Indigenous Australian % Non-Australian % Total % Not Stated 5 Table A.3 presents the length of time respondents have been receiving mental health services. It reveals that the majority of respondents (76%) have been receiving mental health services for over ten years. Table A.3 Time receiving mental health services Time Receiving Mental Health Services Number of Respondents Percentage of Respondents Between 1 and 5 years % Between 5 and 10 years 2 9.5% More than 10 years % Total % Table A.4 presents the employment status of respondents. Note that respondents were able to select more than one response to this question. Table A. reveals that no respondents were either working or studying, although the majority (57%) were participating in other meaningful activities and 10% were looking into work or study options. Table A.4 Employment status Percentage Employment Status of Respondents (n=21) Working part-time (<35 hrs per week) 0.0% Working full-time (35 hrs or more per week) 0.0% Studying 0.0% Looking into work or study options 9.5% Participating in other meaningful activities 57.1% Table A.5 to table A.7 shows that 33% of respondents were from a minority group, 10% were gay, lesbian or bisexual and 10% had problems with substance abuse as well as mental health. XV

103 Table A.5: Are you a member of a minority group? Are you a member of a minority group? Number of Respondents Percentage of Respondents Yes % No % Total % Table A.6: Sexuality Are you lesbian, gay or bisexual? Number of Respondents Percentage of Respondents Yes 2 9.5% No % Total % Do you have both mental health problems and substance abuse problems? Table A.7: Substance abuse Number of Respondents Percentage of Respondents Yes 2 9.5% No % Total % Table A.8 presents the respondents assessments of their own stage in the recovery process. Responses were widely spread across the options. The most popular response was I am actively involved in the process of recovery from mental health problems (33%), followed by I do not see recovery as a goal for myself at this time (19%) and I have been thinking about recovery, but haven't decided to move on it yet (14%). Involvement in the Recovery Process Table A.8: Involvement in the recovery process Number of Respondents Percentage of Respondents I am actively involved in the process of recovery from mental health problems % I do not see recovery as a goal for myself at this time % I have been thinking about recovery, but haven't decided to move on it yet % I feel that I am fully recovered; I just have to maintain my gains % I do not understand what is meant by recovery from mental illness % I do not believe I have any need to recover from mental health 1 4.8% problems. I am committed to my recovery, and am making plans to take action very soon % Other 1 4.8% Total % Table A.9 shows that 90% of respondents were unaware of the IPRSS program. HOI has been advised that all 21 respondents were on the IPRSS program. People on the program are often not aware of the name of the program. XVI

104 Table A.9: Awareness of IPRSS program Are you aware of the IPRSS Program? Number of Respondents Percentage of Respondents Yes 2 9.5% No % Total % Table A.10 presents the services respondents are currently receiving. Note that respondents were able to select more than one response for this question. The services most commonly being received were outreach support services and individual support packages, both being received by 29% of respondents. Table A.10: Services received on current program Services Currently Received Number of Respondents Percentage of Respondents (n=21) Outreach Support Services % Individual Support Package % Supported Accommodation and Assistance 2 9.5% Residential Rehabilitation 2 9.5% Day Program 1 4.8% Employment and Training 1 4.8% PERSONA L IDENT ITY, MEANING IN LIF E AND HOPE Table A.11 presents the responses to a number of statements relating to having a positive sense of personal identity. Note that not all respondents provided a response to all statements. This is the case throughout the remainder of this chapter. Table A.11: Positive sense of personal identity Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having a positive sense of personal identity beyond any psychiatric disorder is important to my recovery. (n=19) Staff view me as more than a "case" or a diagnosis; they want to know me as a person. (n=20) The program offers individualised services to meet my unique needs. (n=20) Staff treat me as a whole person with a body, mind, emotions, important relationships and spirit. (n=20) 0.0% 0.0% 10.5% 52.6% 36.8% 100.0% % 15.0% 10.0% 55.0% 10.0% 100.0% % 5.0% 15.0% 65.0% 5.0% 100.0% % 20.0% 10.0% 50.0% 10.0% 100.0% 1 Average % for last three questions 10.0% 13.3% 11.7% 56.7% 8.3% Of the 19 respondents who provided a response to all statements, a large majority (90%) either agree or strongly agree that having a positive sense of personal identity beyond any psychiatric disorder is important to their recovery. XVII

105 The other three statements in A.11 relate to how well the IPRSS program enables participants to achieve a positive sense of personal identity. Generally, respondents indicated that the program was effective in this regard, with the majority of respondents either agreeing or strongly agreeing with each statement. It should be noted, however, that the percentage agreeing with the last three statements was somewhat less than the first statement. This indicates that there are some participants who feel that the program is not helping them to achieve a positive sense of personal identity to the level that they would like. Table A.12 presents the responses to a number of statements relating to having a sense of meaning in life. Table A.12: Sense of meaning in life Statement Having a sense of meaning in life is important to my recovery. (n=20) Staff help me make sense out of what is happening in my life. (n=19) Staff ask me what is meaningful to me. (n=17) This program encourages me to do things that give my life meaning. (n=20) Disagree Disagree Neutral Agree Agree Total Not Stated 0.0% 10.0% 5.0% 45.0% 40.0% 100.0% % 15.8% 31.6% 31.6% 5.3% 100.0% % 23.5% 23.5% 35.3% 5.9% 100.0% % 10.0% 10.0% 50.0% 20.0% 100.0% 1 Average % for last three questions 12.5% 16.4% 21.7% 39.0% 10.4% Table A.12 shows that 85% of respondents feel that having a sense of meaning in life is important to their recovery. However, responses to the other three statements were less positive, with 37%, 41% and 70% agreeing or strongly agreeing, respectively. This indicates suggests that there are a significant proportion of participants who feel that the program has not helped them achieve a sense of meaning in life to the degree that they would like. Table A.13 presents the responses to a number of statements relating to hope. Table A.13: Hope Statement Having hope is important to my recovery. (n=20) Staff believe I have a positive future. (n=19) Staff encourage me to feel hopeful again when I'm discouraged or have a setback. (n=19) Staff tell me most people do recover from psychiatric problems over time. (n=19) Disagree Disagree Neutral Agree Agree Total Not Stated 0.0% 5.0% 5.0% 55.0% 35.0% 100.0% 1 0.0% 21.1% 31.6% 31.6% 15.8% 100.0% % 21.1% 10.5% 42.1% 15.8% 100.0% % 47.4% 10.5% 31.6% 0.0% 100.0% 2 Average % for last three questions 7.0% 29.8% 17.5% 35.1% 10.5% Table A.13 shows that while 90% of respondents feel that hope is important to their recovery, the percentage of respondents who feel that the IPRSS program helps them to feel more hopeful is substantially less than 90%. Of particular note is that 58% of respondents either disagree or strongly disagree that staff tell them most people do recover from psychiatric problems over time. Table A.14 relates to having a sense of control over one s life. XVIII

106 Table A.14: Sense of control over my life Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having a sense of control over my life and feeling empowered is important to my recovery. (n=20) Staff encourage and support my sense of empowerment. (n=20) Staff assist me to gain or maintain control over important decisions in my life. (n=20) Staff do not try to maintain power and control over me. (n=20) 0.0% 0.0% 10.0% 60.0% 30.0% 100.0% 1 5.0% 15.0% 10.0% 60.0% 10.0% 100.0% % 10.0% 15.0% 55.0% 10.0% 100.0% 1 5.0% 10.0% 25.0% 50.0% 10.0% 100.0% 1 Average % for last three questions 6.7% 11.7% 16.7% 55.0% 10.0% Table A.14 shows that while the percentage of respondents who feel that the program helps them achieve a sense of control over their life is less than the percentage who feel a sense of control is important, the difference is smaller than in previous tables. Table A.15 relates to spirituality. Table A.15: Spirituality Statement Disagree Disagree Neutral Agree Agree Total Not Stated Spirituality is important to my recovery. (n=20) Staff ask me about my spiritual beliefs. (n=19) Staff help me connect with spiritual resources and groups if I so desire. (n=20) Staff encourage me to explore spiritual practices such as prayer or meditation that can support wellbeing. (n=20) 10.0% 15.0% 10.0% 35.0% 30.0% 100.0% % 52.6% 15.8% 21.1% 0.0% 100.0% % 40.0% 25.0% 25.0% 0.0% 100.0% % 40.0% 30.0% 20.0% 0.0% 100.0% 1 Average % for last three questions 10.2% 44.2% 23.6% 22.0% 0.0% Table A.15 reveals that the importance of spirituality to the recovery of IPRSS participants is less widespread than other factors, although despite this 65% of respondents feel that spirituality is important to their recovery. The majority of respondents believe that the program does not place a great enough emphasis on spirituality. Table A.16 relates to the importance of challenging stigma and discrimination. XIX

107 Table A.16: Challenging stigma and discrimination Statement Disagree Disagree Neutral Agree Agree Total Not Stated Challenging stigma and discrimination is important to my recovery. (n=19) This program helps me overcome internalised stigma (feeling badly about myself because of my psychiatric label). (n=19) This program raises my awareness of stigma and discrimination. (n=18) This program teaches me to be an effective self-advocate for my civil, human and personal rights. (n=20) 0.0% 10.5% 10.5% 36.8% 42.1% 100.0% 2 5.3% 36.8% 26.3% 26.3% 5.3% 100.0% 2 5.6% 22.2% 22.2% 44.4% 5.6% 100.0% 3 5.0% 15.0% 35.0% 35.0% 10.0% 100.0% 1 Average % for last three questions 5.3% 24.7% 27.8% 35.3% 6.9% Table A.16 shows that 79% of respondents agree or strongly agree that challenging stigma and discrimination is important to their recovery. There are a range of opinions regarding whether or not the program helps participants to overcome these issues, with some respondents agreeing and some disagreeing. HEALTH AND SELF MANAG EMENT Table A.17 relates to the importance of having up to date knowledge about psychiatric disorders and the most effective treatments. Table A.17: Up to date knowledge of psychiatric disorders Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having up to date knowledge about psychiatric disorders and the most effective treatments is important in my recovery. (n=19) Staff help to inform me about my mental health issues. (n=19) The program provides me with up to date information about effective treatments. (n=19) Staff give me enough information about my treatment options and their risks and benefits for me to give informed consent for treatment. (n=19) 0.0% 21.1% 5.3% 52.6% 21.1% 100.0% 2 5.3% 26.3% 21.1% 42.1% 5.3% 100.0% % 42.1% 15.8% 31.6% 0.0% 100.0% % 15.8% 15.8% 47.4% 5.3% 100.0% 2 Average % for last three questions 10.5% 28.1% 17.5% 40.4% 3.5% Table A.17 shows that 74% of respondents feel that up to date knowledge about psychiatric disorders is important to their recovery. There is mixture of opinion as to how well the program helped equip XX

108 participants with such knowledge. For example, 53% of respondents agree or strongly agree that staff give them adequate information about treatment options and their risks and benefits, and 53% disagree or strongly disagree that the program provides them with up to date information about effective treatments. Table A.18 relates to self-management of symptoms. Table A.18: Self-management of symptoms Statement Being able to self-manage symptoms and avoid relapse is important to my recovery. (n=20) This program helps me identify and monitor triggers/early signs of relapse. (n=19) This program helps me develop personalised coping skills so I can manage stress well. (n=19) This program teaches me ways to selfmonitor and self-control psychiatric symptoms. (n=20) Disagree Disagree Neutral Agree Agree Total Not Stated 0.0% 0.0% 5.0% 50.0% 45.0% 100.0% % 10.5% 15.8% 52.6% 10.5% 100.0% % 26.3% 15.8% 47.4% 0.0% 100.0% % 20.0% 30.0% 35.0% 5.0% 100.0% 1 Average % for last three questions 10.4% 18.9% 20.5% 45.0% 5.2% Table A.18 reveals that 95% of respondents agree or strongly agree that being able to self-manage their symptoms and avoid relapse is important to their recovery. While there is a mixture of opinion as to the extent to which the program helps participants to manage their own symptoms, the proportion of respondents who feel that the program helps them self-manage outweighs those who feel it does not. Table A.19 relates to the improvement of participants general health. Table A.19: General health Statement Improving my general health and wellness is important for my recovery. (n=20) Staff pay careful attention to my physical health. (n=20) This program encourages me to achieve a higher level of wellness. (n=20) This program offers wellness programming such as nutrition, movement and relaxation. (n=20) Disagree Disagree Neutral Agree Agree Total Not Stated 0.0% 0.0% 5.0% 40.0% 55.0% 100.0% 1 0.0% 20.0% 15.0% 45.0% 20.0% 100.0% 1 5.0% 15.0% 5.0% 55.0% 20.0% 100.0% 1 5.0% 45.0% 5.0% 40.0% 5.0% 100.0% 1 Average % for last three questions 3.3% 26.7% 8.3% 46.7% 15.0% Table A.19 reveals that 95% of respondents feel that improving their general health and wellness is important to their recovery. Generally, respondents agree that the program helps improve their general health and wellness, although 50% disagree or strongly disagree that the program offers wellness programming such as nutrition, movement and relaxation. Table A.20 relates to participants being active consumers and directing their own recovery. XXI

109 Table A.20: Directing own recovery Statement Being an active consumer and directing my own recovery is important to my recovery. (n=20) Staff assist me to explore options and set my own personal goals. (n=20) Staff treat me as a responsible partner in decision-making. (n=20) I direct my own recovery in this program. (n=20) Disagree Disagree Neutral Agree Agree Total Not Stated 0.0% 5.0% 15.0% 45.0% 35.0% 100.0% 1 5.0% 35.0% 5.0% 50.0% 5.0% 100.0% 1 5.0% 10.0% 30.0% 45.0% 10.0% 100.0% 1 0.0% 5.0% 5.0% 65.0% 25.0% 100.0% 1 Average % for last three questions 3.3% 16.7% 13.3% 53.3% 13.3% Table A.20 shows that 80% of respondents feel that being and active consumer and directing their own recovery is important. Generally, respondents feel that the program helps them to direct their own recovery, although it should be noted that 40% disagree or strongly disagree that staff assist them to explore options and set their own personal goals. Table A.21 relates to mutual self-help and peer support. Table A.21: Mutual self-help/peer support Statement Disagree Disagree Neutral Agree Agree Total Not Stated Mutual self-help/peer support is important to my recovery. (n=20) This program encourages consumers to help and support one another. (n=20) Self-help groups and peer support opportunities are available in this program. (n=20) This program actively links me to selfhelp groups and self-help resources in the community. (n=20) 0.0% 15.0% 5.0% 40.0% 40.0% 100.0% 1 5.0% 25.0% 5.0% 55.0% 10.0% 100.0% 1 0.0% 35.0% 15.0% 45.0% 5.0% 100.0% % 30.0% 20.0% 40.0% 0.0% 100.0% 1 Average % for last three questions 5.0% 30.0% 13.3% 46.7% 5.0% Table A.21 shows that 80% of respondents feel that mutual self-help and peer support is important to their recovery. Generally, respondents feel that the program promotes self-help and peer support, although there is a mixture of opinions as to whether or not the program actively links participants to self-help resources. RESP ECT FOR RIG HT S Table A.22 relates to the rights of participants being respected. XXII

110 Table A.22: Having rights respected and upheld Statement Having my rights respected and upheld is important to my recovery. (n=20) Disagree Disagree Neutral Agree Agree Total Not Stated 0.0% 5.0% 0.0% 60.0% 35.0% 100.0% 1 Staff inform me of my rights. (n=20) 10.0% 30.0% 5.0% 40.0% 15.0% 100.0% 1 There is a clear grievance policy if any of my rights are violated. (n=20) 10.0% 50.0% 5.0% 25.0% 10.0% 100.0% 1 Staff uphold my rights. (n=20) 5.0% 20.0% 20.0% 55.0% 0.0% 100.0% 1 Average % for last three questions 8.3% 33.3% 10.0% 40.0% 8.3% Table A.22 shows that 95% of respondents feel that it is important that their rights are respected and upheld. Generally, respondents feel that their rights are respected and upheld within the IPRSS program, although 60% either feel there is no clear grievance policy if their rights are violated. ACTIVIT IES AND RELA TI ONSHIP S Table A.23 relates to meaningful activities. Table A.23: Meaningful activities Statement Disagree Disagree Neutral Agree Agree Total Not Stated Being involved in meaningful activities is important to my recovery. (n=19) Staff encourage me to get involved in activities that are meaningful to me. (n=20) Program activities are meaningful. (n=19) The program assists me to become involved in meaningful activities (such as working, furthering my education, creativity, and volunteering). (n=19) 0.0% 0.0% 0.0% 63.2% 36.8% 100.0% 2 5.0% 20.0% 10.0% 50.0% 15.0% 100.0% % 15.8% 10.5% 47.4% 15.8% 100.0% % 42.1% 15.8% 31.6% 0.0% 100.0% 2 Average % for last three questions 8.7% 26.0% 12.1% 43.0% 10.3% Table A.23 shows that all participants providing a response to the first statement in this table feel that being involved in meaningful activities is important to their recovery. While respondents generally feel that the program promotes involvement in meaningful activities, 53% feel that it does not actually assist participants to become involved in such activities. Table A.24 relates to being a part of the larger community. XXIII

111 Table A.24: Being a part of the larger community Statement Disagree Disagree Neutral Agree Agree Total Not Stated Being involved, and a part of, the larger community is important to my recovery. (n=19) Staff help me find and use community resources. (n=19) Staff help me gain individualised supports so I can live, learn and work in the community. (n=20) I don't feel cut off from the community outside the program. (n=20) 0.0% 21.1% 0.0% 52.6% 26.3% 100.0% 2 0.0% 47.4% 15.8% 31.6% 5.3% 100.0% 2 0.0% 25.0% 20.0% 45.0% 10.0% 100.0% % 25.0% 10.0% 45.0% 5.0% 100.0% 1 Average % for last three questions 5.0% 32.5% 15.3% 40.5% 6.8% Table A.24 shows that 79% of respondents feel that being involved and a part of the larger community is important to their recovery. Generally, respondents don t feel cut off from the community and report that staff help them gain individualised support to live, learn and work in the community. However, 47% of respondents feel that staff do not help participants to find and use community resources. Table A.25 relates to positive relationships. Table A.25: Positive relationships Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having positive relationships is important to my recovery. (n=20) Staff assist me in having positive relationships with my peers. (n=20) Staff support me in building or rebuilding positive relationships with family members. (n=20) Staff assist me in forming friendships with people outside the mental health system. (n=19) 0.0% 5.0% 5.0% 50.0% 40.0% 100.0% 1 5.0% 30.0% 15.0% 40.0% 10.0% 100.0% % 40.0% 10.0% 35.0% 5.0% 100.0% 1 0.0% 52.6% 21.1% 26.3% 0.0% 100.0% 2 Average % for last three questions 5.0% 40.9% 15.4% 33.8% 5.0% Table A.25 shows that 90% of respondents feel that positive relationships are important to their recovery. Significantly, 50% of respondents feel that staff do not support them in building or rebuilding positive relationship with family members and 53% feel that staff do no assist them in forming friendships with people outside the mental health system. Table A.26 relates to intimacy and sexuality. XXIV

112 Table A.26: Intimacy and sexuality Statement Disagree Disagree Neutral Agree Agree Total Not Stated Intimacy and sexuality are important to my recovery. (n=19) This program supports me in forming and succeeding in intimate relationships. (n=19) This program adequately addresses my sexuality. (n=18) This program provides information on sexuality, such as safe sex and medication side effects & sexuality. (n=18) 10.5% 21.1% 31.6% 21.1% 15.8% 100.0% 2 5.3% 52.6% 26.3% 10.5% 5.3% 100.0% % 33.3% 33.3% 11.1% 5.6% 100.0% 3 5.6% 50.0% 22.2% 22.2% 0.0% 100.0% 3 Average % for last three questions 9.2% 45.3% 27.3% 14.6% 3.6% Table A.26 reveals that intimacy and sexuality is important to some participants but not to others. Generally, respondents feel that the program does not provide sufficient support for participants to develop intimate or sexual relationships. BUILDING ON STRENG THS Table A.27 relates to identifying and building on personal strengths. Table A.27: Identifying and building on personal strengths Statement Disagree Disagree Neutral Agree Agree Total Not Stated Identifying and building on my personal strengths is important to my recovery. (n=20) Staff recognise and focus on my positive attributes and talents. (n=19) Staff help me explore my dreams, values and goals. (n=19) Staff link me to opportunities and resources that build on and reflect my strengths. (n=19) 0.0% 0.0% 5.0% 65.0% 30.0% 100.0% 1 5.3% 15.8% 10.5% 57.9% 10.5% 100.0% % 31.6% 15.8% 31.6% 10.5% 100.0% 2 0.0% 26.3% 26.3% 36.8% 10.5% 100.0% 2 Average % for last three questions 5.3% 24.6% 17.5% 42.1% 10.5% Table A.27 shows that 95% of respondents feel that identifying and building on their personal strengths is important to their recovery. Generally, respondents feel that the program helps participants to identify and build on their personal strengths, although there are mixed opinions of whether or not staff help participants to explore their dreams, values and goals. Table A.28 relates to developing new skills. XXV

113 Table A.28 : Developing new skills Statement Disagree Disagree Neutral Agree Agree Total Not Stated Developing new skills is important to my recovery. (n=20) Staff help me assess how I am progressing in relation to my goals and identify skills I need to develop. (n=20) This program teaches me the skills I want and need. (n=20) This program connects me to places and people who help me build important skills. (n=20) 0.0% 30.0% 5.0% 40.0% 25.0% 100.0% 1 5.0% 35.0% 20.0% 40.0% 0.0% 100.0% 1 5.0% 40.0% 15.0% 40.0% 0.0% 100.0% 1 5.0% 35.0% 20.0% 35.0% 5.0% 100.0% 1 Average % for last three questions 5.0% 36.7% 18.3% 38.3% 1.7% Table A.28 shows that 65% of respondents feel that developing new skills is important to their recovery. However, opinions of whether or not the program helps participants to develop new skills are divided. MEETING N EEDS Table A.29 relates to participants having their basic needs met. Table A.29: Basic needs Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having my basic needs met is important to my recovery. (n=20) This program assists me to get a basic income and/or benefits. (n=19) This program helps me get decent, affordable housing and/or rent assistance. (n=18) This program helps me gain access to health care. (n=20) 0.0% 5.0% 0.0% 55.0% 40.0% 100.0% 1 5.3% 15.8% 21.1% 57.9% 0.0% 100.0% 2 5.6% 22.2% 16.7% 50.0% 5.6% 100.0% 3 5.0% 20.0% 15.0% 55.0% 5.0% 100.0% 1 Average % for last three questions 5.3% 19.3% 17.6% 54.3% 3.5% Table A.29 shows that 95% of respondents feel that having their basic needs met is important to their recovery. Generally, respondents feel that the program helps participants to fulfil their basic needs. Table A.30 relates to succeeding in normal social roles. XXVI

114 Table A.30: Succeeding in normal social roles Statement Disagree Disagree Neutral Agree Agree Total Not Stated Taking on and succeeding in normal social roles is important to my recovery. (n=20) Staff would help me get a meaningful job and succeed as an employee. (n=18) Staff would assist me to return to study and be a successful student. (n=18) Staff would help me get housing and be a successful tenant. (n=18) 0.0% 0.0% 5.0% 50.0% 45.0% 100.0% % 33.3% 22.2% 27.8% 5.6% 100.0% % 38.9% 33.3% 16.7% 0.0% 100.0% 3 0.0% 22.2% 27.8% 27.8% 22.2% 100.0% 3 Average % for last three questions 7.4% 31.5% 27.8% 24.1% 9.3% Table A.30 shows that 95% of respondents feel that taking on and succeeding in normal social roles is important to their recovery. Opinion of whether or not the program assists participants to achieve this is divided. Notably, 50% of respondents feel that staff would not assist them to return to study and be a successful study. Table A.31 relates to taking on new challenges and moving out one s comfort zone. Table A.31 : Taking on new challenges Statement Disagree Disagree Neutral Agree Agree Total Not Stated Taking on new challenges and moving out of my comfort zone is important to my recovery. (n=19) Staff encourage me to take on new challenges. (n=20) I feel supported when I try new things that seemed out of my reach before. (n=18) Staff encourage me to stretch myself and grow. (n=20) 0.0% 15.8% 26.3% 42.1% 15.8% 100.0% 2 0.0% 25.0% 10.0% 45.0% 20.0% 100.0% 1 5.6% 27.8% 11.1% 50.0% 5.6% 100.0% 3 5.0% 35.0% 10.0% 45.0% 5.0% 100.0% 1 Average % for last three questions 3.5% 29.3% 10.4% 46.7% 10.2% Table A.31 reveals that only 58% of respondents feel that taking on new challenges and moving out of one s comfort zone is important to their recovery. Despite this, however, respondents generally feel that staff encourage and support participants in challenging themselves and trying new things. Note, however, that while 50% of respondents agree or strongly agree that staff encourage them to stretch themselves and grow, there are also 40% who disagree or strongly disagree with this. Table A.32 relates to the availability of assistance during crisis. XXVII

115 Table A.32 : Assistance in crisis Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having assistance when I am in crisis is important to my recovery. (n=20) This program has help available immediately if I am in crisis. (n=20) Staff hang in with me through hard times. They help me see setbacks are a part of recovery. (n=19) This program has good options if I am in crisis, that help me avoid involuntary treatment and hospitalisation. (n=20) 0.0% 0.0% 5.0% 35.0% 60.0% 100.0% % 10.0% 20.0% 55.0% 5.0% 100.0% % 10.5% 10.5% 57.9% 10.5% 100.0% % 10.0% 25.0% 55.0% 0.0% 100.0% 1 Average % for last three questions 10.2% 10.2% 18.5% 56.0% 5.2% Table A.32 shows that 95% of respondents feel that the availability of assistance in crisis is important to their recovery. Respondents generally feel that such assistance is available through the IPRSS program and that staff hang in with them during difficult times. Table A.33 relates to having helpers who really care. Table A.33 : Helpers who really care Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having helpers who really care about me and my recovery is important to my recovery. (n=20) The staff here really listen to me. (n=20) Staff here spend enough quality time with me on activities that promote my recovery. (n=20) Staff encourage, motivate and support me to move toward recovery. (n=20) 0.0% 5.0% 0.0% 50.0% 45.0% 100.0% 1 5.0% 20.0% 20.0% 50.0% 5.0% 100.0% 1 5.0% 15.0% 25.0% 55.0% 0.0% 100.0% 1 5.0% 10.0% 10.0% 75.0% 0.0% 100.0% 1 Average % for last three questions 5.0% 15.0% 18.3% 60.0% 1.7% Table A.33 shows that 95% of respondents feel that having helpers who really care is important to their recovery. Respondents generally feel that staff listen to them, spend quality time with them and support them toward their recovery. Table A.34 relates to having positive role models. XXVIII

116 Table A.34: Positive role models Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having positive role models is important to my recovery. (n=20) This program employs people who are positive role models of recovery. (n=20) Staff help me learn from others who have successfully recovered (eg share consumer life stories, internet sites, speakers, mentors). (n=20) I have opportunities to become a provider or role model in the program if I so choose. (n=19) 5.0% 15.0% 0.0% 55.0% 25.0% 100.0% 1 5.0% 15.0% 25.0% 45.0% 10.0% 100.0% % 45.0% 15.0% 30.0% 0.0% 100.0% 1 5.3% 31.6% 26.3% 36.8% 0.0% 100.0% 2 Average % for last three questions 6.8% 30.5% 22.1% 37.3% 3.3% Table A.34 shows that 80% of respondents feel that having positive role models is important to their recovery. There are mixed feelings as to how well the program utilises positive role models. In particular, 55% of respondents disagree that staff help participants learn from others who have successfully recovered. MINORITY GROUPS Table A.35 presents a set of statements answered by only those who identified as being part of a minority group. There were seven responses to these statements. Table A.35: Minority group statements Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having my ethnic and cultural background respected is important to my recovery. (n=7) Staff here are respectful to me as a person of racial, ethnic or cultural minority. (n=7) This program understands and supports my cultural values, languages and customs. (n=7) Staff are aware of and sensitive to my cultural heritage and needs. (n=6) 0.0% 0.0% 14.3% 42.9% 42.9% 100.0% % 0.0% 14.3% 42.9% 28.6% 100.0% % 0.0% 28.6% 42.9% 14.3% 100.0% % 0.0% 66.7% 16.7% 0.0% 100.0% 15 Average % for last three questions 15.1% 0.0% 36.5% 34.1% 14.3% Table A.35 shows that 86% of those responding feel that having their ethnic and cultural background respected is important to their recovery. Respondents indicated that staff are respectful of XXIX

117 participants racial, ethnic and cultural backgrounds and that the program understands and supports their cultural values, languages and customs. SUBSTANCE AND OTHER A BUSE Table A.36 presents a set of statements answered by only those who identified as having problems with substance abuse. There were two responses to these statements. Due to the small number of responses. Table A.36 presents the raw number rather than percentages. Table A.36: Substance abuse statements Statement Having help with alcohol or drug problems is important to my recovery. This program has resources to help me with both alcohol and psychiatric problems. This program has resources to help me with both drug and mental health problems. This program links me to self-help groups that deal with dual diagnoses/substance abuse. Disagree Disagree Neutral Agree Agree Total Not Stated Table A.36 shows that the two respondents felt strongly that having help with alcohol or drug problems is important to their recovery. They felt that program has adequate resources to help them with substance abuse and mental health problems. Table A.37 relates to participants with a history of abuse and/or trauma. It shows that 52% of respondents identified as having experienced abuse and/or trauma. Do you have a history of abuse and/or trauma? Table A.37: Abuse/trauma Number of Respondents Percentage of Respondents Yes % No % Total % Table A.38 explores aspects of the program relevant to those with a history of abuse and/or trauma. XXX

118 Table A.38: Abuse/trauma statements Statement Disagree Disagree Neutral Agree Agree Total Not Stated Healing trauma, including sexual abuse and/or physical abuse is important to my recovery. (n=11) This program has resources to help me heal from abuse and/or trauma. (n=11) It feels safe to open up about abuse or trauma in this program. (n=11) Staff deal effectively with abuse and trauma. (n=11) 0.0% 9.1% 0.0% 27.3% 63.6% 100.0% % 27.3% 27.3% 0.0% 27.3% 100.0% % 27.3% 27.3% 18.2% 18.2% 100.0% % 27.3% 27.3% 18.2% 9.1% 100.0% 10 Average % for last three questions 15.2% 27.3% 27.3% 12.1% 18.2% Table A.38 shows that 91% of participants responding to these statements feel that healing trauma and abuse is important to their recovery. Respondents generally feel the program does not have adequate resources to help them heal from abuse or trauma and that staff do not effectively deal abuse and trauma. SEXUALITY Tale A.39 presents a set of statements answered by only those who identified as being lesbian, gay or bisexual. There were two responses to these statements. Due to the small number of responses, table A.39 presents the raw number rather than percentages. Table A.39: Sexuality statements Statement Having support for my sexual orientation is important to my recovery. Staff of this program are not homophobic (very negative about gay, lesbian or bisexual people). Staff of this program are respectful to me as a lesbian, gay or bisexual person. Staff deal effectively with issues of sexual preference. Disagree Disagree Neutral Agree Agree Total Not Stated Table A.39 reveals that one of the two respondents feels that having support for their sexual orientation is important to their recovery, while the other feels that it is neither important nor unimportant. Both respondents feel that staff are not homophobic but also feel that staff are neither particularly effective nor ineffective in dealing with issues of sexual preference. PARENTING Table A.40 relates to support for participants with children in their role as parents. XXXI

119 Table A.40: Parenting statements Statement Disagree Disagree Neutral Agree Agree Total Not Stated Having support as a parent is important to my recovery. (n=15) Staff support me in my role as a parent. (n=15) Staff assist me to become an effective parent. (n=14) Staff help me uphold my rights in custody disputes. (n=14) 0.0% 13.3% 20.0% 26.7% 40.0% 100.0% % 26.7% 46.7% 6.7% 6.7% 100.0% 6 7.1% 50.0% 28.6% 7.1% 7.1% 100.0% % 28.6% 35.7% 14.3% 7.1% 100.0% 7 Average % for last three questions 11.6% 35.1% 37.0% 9.4% 7.0% Table A.40 shows that 67% of respondents who are parents feel that having support in their role as a parent is important to their recovery. Respondents generally feel that the support available to parents in the program is inadequate. XXXII

120 PROGRAM ORGANISATIONA L CLIMATE Table A.41 explores some more general feelings of participants toward the program. Table A.41: Organisational climate Statement Disagree Disagree Neutral Agree Agree Total Not Stated The program promotes learning, striving and growth. (n=21) 4.8% 4.8% 23.8% 61.9% 4.8% 100.0% 0 The program is a hopeful environment that promotes positive expectations. (n=21) 4.8% 9.5% 23.8% 57.1% 4.8% 100.0% 0 The program is inspiring and encouraging. (n=21) 0.0% 23.8% 19.0% 52.4% 4.8% 100.0% 0 Staff of this program are caring and compassionate. (n=21) 4.8% 14.3% 14.3% 61.9% 4.8% 100.0% 0 The program has enough resources to meet peoples' needs. (n=21) 14.3% 38.1% 14.3% 28.6% 4.8% 100.0% 0 The program provides opportunities for meaningful participation and contribution. (n=21) 0.0% 23.8% 19.0% 52.4% 4.8% 100.0% 0 The program helps people feel valued, respected and powerful. (n=20) 0.0% 25.0% 35.0% 35.0% 5.0% 100.0% 1 The program helps people connected to others in positive ways. (n=21) 4.8% 14.3% 42.9% 33.3% 4.8% 100.0% 0 The program is safe and attractive. (n=21) 0.0% 9.5% 28.6% 61.9% 0.0% 100.0% 0 All levels of staff are welcoming. (n=20) 5.0% 15.0% 10.0% 60.0% 10.0% 100.0% 1 There are creative and interesting things going on in the program. (n=20) 5.0% 30.0% 20.0% 45.0% 0.0% 100.0% 1 The program provides real choices, desirable options and opportunities. (n=20) 0.0% 40.0% 25.0% 30.0% 5.0% 100.0% 1 The program asks for consumer feedback. (n=20) 5.0% 35.0% 5.0% 55.0% 0.0% 100.0% 1 The program makes changes based on consumer satisfaction. (n=19) 10.5% 21.1% 21.1% 42.1% 5.3% 100.0% 2 Table A.41 shows that overall respondents generally feel positive or neutral toward many aspects of the program. Aspects that were more positive were the promotion of learning and the caring, compassionate and welcoming nature of the staff. However 52% feel that the program does not have sufficient resources to meet people s needs and 40% believe the program does not provide real choices, desirable options and opportunities for participants. XXXIII

121 WHERE CONSUMER S A RE AT IN RELATION T O KEY R ECOVERY MARKERS Table A.42 relates to a number of markers on the way to recover for people suffering from mental illness. Table A.42: Recovery markers Recovery Marker Percentage of Respondents (n=21) I have one or more trusted people I can turn to for help. 81.0% I have a living situation that is safe and feels like home to me. 71.4% I have things I'm looking forward to in life. 61.9% I have reasons to get out of bed in the morning. 61.9% I control the important decisions in my life. 61.9% I have a sense of belonging. 61.9% I feel hopeful about my future. 61.9% I am involved in meaningful and productive activities. 57.1% My psychiatric symptoms are under control. 57.1% I have personal goals I'm working to achieve. 57.1% I have a decent quality of life. 57.1% I have one or more close mutual (give and take) relationships. 57.1% I feel alert and alive. 57.1% I have a positive sense of self esteem; I like and respect myself. 52.4% I am growing as a person. 52.4% I believe I can make positive changes in my life. 52.4% I have a positive spiritual life/connection to a higher power. 47.6% I'm using my personal strengths, skills or talents. 47.6% I have more good days than bad. 47.6% I contribute to my community. 47.6% I am learning new things that are important to me. 42.9% I am in good physical health. 42.9% I have enough income to meet my needs. 42.9% I have the ability to deal with stress. 42.9% I am not working, but I see myself beginning to work within the next six months. 9.5% Table A.42 suggests that most respondents have achieved the majority of these recovery markers, although the majority of the markers have been achieved by only a slight majority of respondents. Of particular note is 81% of respondents have one or more trusted people they can turn to for help, 71% have a living situation that is safe and feels like home, but only 9% see themselves beginning to work within the next six months. XXXIV

122 A APPENDIX G- NGO PROVIDER CONSUMER SATISFACTION SURVEYS Appendix G provides details of the NGO provider consumer satisfaction surveys that were provided to HOI as part of the documentation review. Three of the service providers undertook consumer satisfaction surveys, including: Mind Consumer Satisfaction Survey Centacare IPRSS Consumer Survey Results Helping Hand Health and Wellbeing Service Satisfaction Questionnaire. The Mind Consumer Satisfaction Survey consisted of telephone interviews with existing Mind consumers, utilising the survey developed by the Consumer Satisfaction Project team in The survey covered three main areas: general consumer satisfaction, consumer outcomes and partnership effectiveness. Forty percent of respondents are IPRSS consumers (27% from metro 13% from country areas). Centacare also undertook a consumer satisfaction survey into September Of the 32 IPRSS consumers who were contacted for a telephone interview, 14 consumers responded, 13 did not answer or respond to voic messages and 5 refused to participate. In September of 2010, helping Hand Aged Care Services also undertook a Health and Wellbeing Service Satisfaction questionnaire. There were 85 completed responses, however, it is unclear how many of these respondents who are IPRSS consumers. The table below provides a summary of the results of all three consumer satisfaction surveys. XXXV

123 Table: Consumer satisfaction survey results across service providers Domain Helping Hand Centacare Mind Overall satisfaction with service 52.7% satisfied 47.4% very satisfied Services support me in my recovery? My care plan was developed with my input? Staff Support 46% strongly agree 49% agree 5% neutral 22% strongly agree 53% agree 17% neutral 8% disagree 64% very satisfied 32% satisfied 2% neutral 2% dissatisfied Do the staff listen to you? Provide opportunities tot talk about thing which are important to you? 36.9% good listeners 63.2% excellent listeners 100% agree the staff are good listeners Responsiveness to needs 5.3% neutral 78% agree 73% very satisfied Are the staff helpful? Have the staff followed up any issues for you? 47.4% helpful 47.4% very helpful 21% disagree 25% satisfied 2% neutral Do you feel comfortable with your support worker? 85% agree they are comfortable 15% disagree they are not comfortable Are your individual requirements met by the services? 42.1% well met 57.9% very well met 85% agree that individual needs are met 8% disagree Overall quality of service? 47.4% good 52.6% excellent If you have multiple workers, do you find this beneficial? 35% agree it is beneficial 7% disagree 51% do not have multiple workers Has there been a time when you have been confused about what your support workers can support 35% agree they are confused 42% disagree - they are not XXXVI

124 Domain Helping Hand Centacare Mind you with? confused 14% unsure Does your support worker help you explore options to do things differently? Improve your individual outcomes? Are you acknowledged as a person with strengths and capabilities? How do you feel when changes are made to your support visits? Satisfaction with support worker and key worker partnership, overall? 78% agree 14% disagree 85% agree they are acknowledged 8% disagree 35% feel positive 35% feel negative 14% unsure 20% strongly agree 45% agree 21% neutral 13% disagree 29% very satisfied 41% satisfied 22% neutral 10% dissatisfied XXXVII

125 A APPENDIX H- CARS DATA QUALITY Appendix H outlines some of the data issues associated with analysing the CARS data base. There were five main issues in relation to the quality of the CARS data. Firstly, as discussed in section 2.5, the number of ISP reviews recorded was much smaller than would be expected if reviews were to occur approximately on a quarterly basis for each consumer. Secondly, the data provided contained many instances of conflicting dates of referral, first contact, review and discharge. For example, there were many instances where, for a given consumer, multiple referral dates were recorded on consecutive days. For example, a consumer may have been recorded as being referred on both the 1/5/2009 and 2/5/2009. The key difficulty caused by these anomalies was in determining whether a given referral date related to a new referral or a previously recorded referral. This made it difficult to determine the true number of referrals to the IPRSS program. Ultimately, in order to analyse the data provided, it was necessary to make a number of assumptions. The key assumption made was that no consumer can referred be to the IPRSS program if they are currently in the program (i.e. if they have previously been referred and have not yet been discharged). Thirdly, there were a small number of instances where multiple records were recorded for a given consumer for a given month. In these cases we took the first record and ignored any subsequent records. There were 77 records in the data provided, where the hours of services recorded for the given month was zero. These records have been excluded from our analysis. In particular, in calculating the average hours of services provided per consumer per month, it was necessary to first calculate the number of active consumers each month. In this calculation, a consumer was considered to be active in a given month if and only if they received a service that month. By this definition, if zero hours were recorded against a given consumer in a given month, the consumer was considered to be inactive in that month. Finally in the CARS data, approximately one quarter of consumers had differing dates of birth reported in different records. In most cases, the difference is only one or two days. In calculating the age of a given consumer, we have used the most frequently occurring date of birth for that consumer. XXXVIII