Care Coordination v Partners in Recovery

Care Coordination v Partners in Recovery VICSERV Seminar November 2012 nousgroup.com.au 1

Contents 1. Care Coordination v Partners in Recovery 2. Care Coordination insights 3. How partnerships work nousgroup.com.au 2

Contents 1. Care Coordination v Partners in Recovery 2. Care Coordination insights 3. How partnerships work nousgroup.com.au 3

CC and PIR came about because of a lack of coordinated and integrated care available for people with severe and persistent mental illness. Care Coordination for people with severe mental illness and multiple needs (delivered through selected PDRSS) Care Coordination was part of a 2009-10 State Budget reform package Care Coordination aimed to address priority pressures, risks and opportunities associated with high risk/high need adult clients (16-64 years) of the specialist public mental health service system Care Coordination provides the practical support to access and remain engaged with the range of mental health and general health and social support services they need PIR aims to improve the system response to, and outcomes for, people with severe and persistent mental illness who have complex needs (delivered through Medicare Local regions) PIRs is part of the 2011/12 Federal Budget which has provided $549.8 million from 2011/12 to 2015/16 PIR will get the services and supports from multiple sectors to work in a more collaborative, coordinated, and integrated way The scale of PIRs dwarfs CC but they are the very similar programs Source: Department of Health and Department of Health and Ageing nousgroup.com.au 4

CC and PIR tackle the same problem. Below is the background to CC but the same could be read to PIRs.just on a national scale. Many people with severe mental health illness and psychiatric disability have multiple and complex needssuch as co-existing substance misuse problems, co-occurring physical health problems and/or intellectual disability and Acquired Brain Injury. This client group require a response from a range of service sectors such as health, housing, homelessness, drug and alcohol treatment, family support and justice. It is estimated that one third of all clients of the clinical specialist mental health service system (approximately 20,000 clients) require dedicated assistance to access the these services, and would significantly benefit from the development of an integrated, comprehensive care plan that is able to be modified over time to reflect their changing needs. These clients have a high level of dysfunction across several life areas and a limited capacity for self management, making it very difficulty for them to navigate the complexities of multiple service systems, particularly when they are unwell. The need for sustained support recognises the episodic and enduring nature of serious mental illness. In the absence of coordinated tailored packages of support, these individuals are at high risk of falling between the cracks of highly siloed service systems. This can lead to negative client outcomes such as repeated crises and hospitalisation, entrenched isolation and poverty, recurring homelessness, long term unemployment, poor physical health and frequent interactions with the police with a higher risk of incarceration. Source: Department of Health nousgroup.com.au 5

There is overlap between Care Coordinators, Support Facilitators and.clinical Case Managers. Differential role of care coordinators, case managers and support facilitators Care Coordinators Clinical Case Managers Support Facilitators Service system coordination -Operates more like service coordination or service hub -works with, and guides, the service team process and tasks while building collaboration with all parties involved with the client Long-term focus -Takes a long-term planning focus. Supports the care team, coordinates the broader community-level service plan, provides guidance around service delivery and may help to coordinate crisis intervention activity No direct engagement Care Coordination does not include the provision of psychosocial supports and the Care Coordinator does not engage in direct day to day work with the client. Client engagement is through assessment or review of the care plan and focus on how the client perceives the services to be working. Typically only meets the client with one of their direct support workers, Case Manager or in a case conferencing environment Source: The Nous Group and Department of Health and Ageing Clinical service guidance -Works with and guides the service needs of the client specific to that agency, and does provide direct clinical support to the client Direct engagement -Does have a component of service coordination and hence there is some overlap with Care Coordination Long-term focus -Similar to Care Coordination, takes a long-term planning focus, but also works with the client, providing direct support and involvement, develops an agency specific or treatment plan and is directly involved in crisis interventions Overlap with planning. Leave clinical care plans to clinicians. Take a load off clinicians nousgroup.com.au 6 Deliver the benefits of system collaboration Support facilitation with a coordination focus; Manage referrals, assess client needs Develop, monitor and regularly review PIR Action Plans Work with existing case managers (not replacing them) Build service pathways, networks of services and supports needed Be a point of contact for PIR clients, their families and carers.

Care Coordination aimed to free up clinical services to focus on providing clinical treatment and treatment planning, review and medical monitoring of high need clients. Case management delivered by specialist clinical mental health service (as defined in the Framework for Service Delivery ) was intended to provide holistic care, assisting the clients in all life domains, such as support to develop daily living skills and access social support services. In practice, clinical mental health services do not have capacity (or in some instances knowledge of referral pathways) to effectively perform this function for all clients, mainly due to increased complexity and sustained demand pressures. As a result, case management is variable and ad hoc. It is also acknowledged that clinicians skills would be more efficiently and effectively used to deliver clinical treatment and interventions. Theintroduction of a dedicated non clinical care coordinators function would (subject to adequate investment over time) allow the redevelopment of treatment and support is coordinated for clients with severe and enduring mental illness. Source: Department of Health nousgroup.com.au 7

Contents 1. Care Coordination v Partners in Recovery 2. Care Coordination insights 3. How partnerships work nousgroup.com.au 8

Care Coordination seeks to support targeted clients with multiple needs to access and remain engaged with the range of health, community and social support services. efficiency effectiveness appropriateness INPUTS ACTIVITIES OUTPUTS OUTCOMES NEED/PURPOSE AMHS registered clients aged 16-64 who have a severe, enduring mental illness and psychiatric disability and: multiple, unmet service needs a history of accessing a range of services in an ad hoc and often chaotic way. Note: Clients who are currently receiving SECU diversion and substitution or IHBOS are not eligible for this response $2M per annum 20 new positions Indicative worker to client ratio - 1:15 Selected PDRS service providers Assessment, development, coordination and review of personalised Integrated Care Plan System advocacy Case Conferencing Links to wide range of clinical, psychosocial, rehab, physical health and social services. Brokerage services Source: Nous Group and Department of Health 20 Care Coordinators delivering up to 300 Integrated Care plans at any one time Brokerage funding ($500 per client) Standardised intake and assessment framework SYSTEM OUTCOMES Improved service coordination and strengthened accountability at the local level Increased capacity for specialist (clinical and PDRSS) mental health services to manage service demand Reduced repeated contacts with other service systems i.e. hospital, corrections, homelessness, and emergency contacts (police and ambulance) System outcomes Health, social and economic client outcomes Improve treatment and care of multiple need/high need clients Reduce system pressures CLIENT OUTCOMES Health Improved self-management of illness, medication and treatment compliance, relapse prevention and symptom stability Improved physical health and engagement with GP services Decreased psychiatric crisis, suicide, self-harm and other Sustained engagement with health, drug and alcohol, primary mental health and medical services as appropriate Improved client and carer experience of care, improved client and carer input into treatment care planning Social: Sustained stable housing Increased social and community engagement/connectedness Improved social relationships, including with significant others Economic: Engagement in educational and vocational training, and employment nousgroup.com.au 9

Nous has evaluated Care Coordination since inception. The Nous evaluation has two components: 1. The formative evaluation component this examines issues related to implementation. The key question is: Is the initiative being implemented as planned?. This covers: overall governance client intake, referral and discharge service models staffing arrangements key Enablers/Challenges local delivery arrangements involvement in care. Data source Document review Service provider survey Service provider interviews Comment Provider models of care. The content covered in the survey covers: intake, referral and discharge criteria and processes engagement model local delivery arrangements enablers and challenges. Interviews cover: changes in roles, staffing, etc. since the last interview client and carer experience and involvement system impacts. 2. The summative evaluation component this assesses whether the intended client and system outcomes have been achieved. The key question is: Has the initiative produced the planned client and system outcomes? Case studies Service provider supplementary data CMI-ODS Provider provided case studies Service providers submit data for each client about housing type, employment type, and interactions with other services Service providers submit BASIS32 scores for clients when these are not recorded in the CMI-ODS Use of beds and ambulatory services by each client BASIS32, HONOS and LSP scores for each client Source: Nous Group and Department of Health nousgroup.com.au 10

All services have established governance structures to monitor the Care Coordination that include pathways for receipt of referrals and consideration of client eligibility. Source: Nous Group and Department of Health nousgroup.com.au 11

Care Coordination case loads vary and referral processes have been problematic. Client load is between 8 10. The plan was for 15. Average client number per Care Coordinator increased to 8.75 (from 8) Reasons not to take on more clients are: clients require more time due to their complexity insufficient referrals from providers. PIRs has a similar case load requirement Waitlists are not used Only one provider has a waitlist, they operate with a caseload of 10 Providers state that caseloads could increase if referral process improves Waitlist should be big in PIRs Eligibility is tightly managed Providers have kept with the Government criteria Some providers noted that eligible clients are not in the program because: clinical staff members reluctant as it may create more work for them Care Coordinators are challenged by the level of complexity of clients the benefit of Care Coordination is still under-appreciated. Managing eligibility will be a challenge in PIRs Source: Nous Group and Department of Health nousgroup.com.au 12

Care Coordination intake, referral and discharge processes have taken more than 18 months to mature. 18 months to mature Service delivery in terms of client intake, referral and discharge, and the promotion of the initiative to local AMHS have taken 18 months to mature. Components include: Area mental health staff understanding of the role of care coordination staff Clinical governance structures to support delivery of this initiative Referral protocols within each area mental health service Joint planning and decision making The area mental health service sharing client information with your agency Common tools with our area mental health service Joint service delivery protocols. Once an effective working relationship between a PDRSS and AMHS provider has been established then it seems to work well A range of set-up challenges exist Issues that sit behind this include: Poor history between providers AMHS don t refer to PDRSS Client complexity Staff turnover and lack of a system approach Overlap between Care Coordinators and Clinical Case Managers Source: Nous Group and Department of Health PIRs will demand even more from the service delivery model Manage the risks and escalate quickly, where necessary Systems thinking and managing personal relationships is key nousgroup.com.au 13

Housing providers are the most important provider of nonmental health services. Importance of other services in the provision of care for clients Relative ranking PIRs will be similar in profile & therefore tells you about who you need to connect with and the skills to do this with Source: Nous Group and Department of Health nousgroup.com.au 14

With Care Coordination, clients increasingly use private housing but their employment status doesn t seem to change. Housing type Proportion of clients (%) Proportion of clients (%) 100% 80% 60% 40% 7 6 4 3 2 14 8 4 3 29 1 2 1 2 3 8 7 9 3 34 17 21 19 42 100% 80% 60% 40% Employment status 160 138 88 62 51 PIRs will be similar in profile 20% 32 31 19 14 11 20% 0% 0-3 3-6 6-9 9-12 12-15 months since entry into initiative Supported residential Private housing Psychiatric inpatient / rehab Homeless 0% 0-3 3-6 6-9 9-12 12-15 months since entry into initiative Unemployed Paid Part Time Volunteer Paid Casual Crisis or transitional housing Private boarding rooms Data is presented as the percentage of clients occupying each housing or employment type in the time period since entry to the initiative. The number of clients for which data is available in each time period is presented above each column. Source: Supplementary evaluation data provided by agencies nousgroup.com.au 15

Establishing service support networks has taken more time than anticipated. 60-80% of time in the initial period is focused on network set up The complexity and high level of needs of the target group means that Care Coordinators have to spend a lot of time in the initial stages to establish a range of support networks for the client. In addition, the Care Coordinator has to establish many more relationships than other roles, including multiple contacts across all bed-based and communitybased clinical services, and across a wide range of external providers. This can be very time consuming particularly while the role itself is being established. PIRs will have the similar establishment challenges Once set-up, 10%-30% of time is spent on maintaining networks and referrals Most of that time is spent developing and maintaining relationships with healthcare providers with some time spent with housing providers. The allocation of time is closely reflected in the amount of client referrals and contacts with each of these service providers, particularly for GPs, allied health and housing PIRs will probably have a similar profile Source: Nous Group and Department of Health nousgroup.com.au 16

Most of that time is spent with healthcare, housing and social participation providers. Number of clients 180 160 140 Health services Homelessness/ housing services Employment/education/ participation services 120 100 80 D&A services 60 40 20 0 Number of contacts/referrals None 1 to 6 7 or more Data is presented as the number of clients that have the indicated number of contacts/referrals. Only clients for which more than 6 months have elapsed since entry into the initiative are included in the sample. Source: Supplementary evaluation data provided by agencies Source: Nous Group and Department of Health nousgroup.com.au 17

Care Coordination clients carers are increasingly involved in client care. Carer engagement in IHBOS Other Type of engagement PIRs is an opportunity to do something different with carers Recipients of information and referral for carer s support needs Round 3 Governance structures Round 2 Decisions relating to client's care/support Coordination of care Service planning and development Source: Nous Group and Department of Health 0 2 4 6 8 10 12 14 16 Number of responses nousgroup.com.au 18

Carers have expressed views on specific challenges, and providers have suggested improvements. Carers have expressed views on specific challenges Actively increase carer involvement Strengthen links to family support services Conduct carer forums Deliver information sessions Providers have suggested improvements Understanding the mental and community health systems Finding contact points within the service system Carer fatigue due to inadequate support available Disjointed and inconsistent service delivery Managing the behaviour of the person they care for Again PIRs is an opportunity to do something different with carers Source: Nous Group and Department of Health nousgroup.com.au 19

Clients involvement is mixed and they want assistance with service access issues. Providers use different recovery models Most Care Coordination providers refer to their use of the Collaborative Recovery Model and the Recovery Star Models as important aspects of client engagement. Clients are involved in recovery planning 40-60% of the time Clients and carers are routinely invited to attend case conference/care team meetings (though attendance is infrequent). Some providers have their case conferencing meetings with the client present others don t Most providers meet with clients on a monthly or longer basis Most Care Coordinators meet with the client to set up and review their goals, go through the care plan with them, and invite them to case conferences, often based on the client s self-determination and wishes. Clients tend to raise service access issues rather than support issues Common issues raised by clients (which are similar to those raised by carers) include: Housing Finances Employment Availability of clinical AMHS Family relationships. Source: Nous Group and Department of Health PIR clients will want assistance on service access rather than mental health support nousgroup.com.au 20

Regardless of the recovery method, Care Coordination clients have provided care with no adverse impact on client outcome measures. Outcome measures results for Care Coordination clients Score Score 4 3 2 1 0 48 40 32 24 16 8 0 pre (18) (24) (25) -12-12 to-9 to -9 --6 to -6 - -3-3 to 0 +3 to 33 +6 to 66 +9 to 9 +12 9 to Time from entry (months) -9 6 3 0 12 pre BASIS 32 (20) LSP post post -12-9 to -9-6 -6 to -3-3 to 0 to +3 33 to +6 66 to +9 9 9 +12 to to -9-6 Time -3 from 0 entry (months) 12 Score Precent maximum score 48 40 32 24 16 0 80 60 40 20 0-12 -9-9 to -6-6 to -3-3 to 0 +3 to 33 +6 to 66 +9 to 9 +12 9 to Time from entry (months) to -9-6 -3 0 12 Entry Exit pre HONOS BASIS 32 HONOS LSP BASIS32, HONOS and LSP scores presented in ~ 3 month intervals before and after entry into Care Coordination. Relative BASIS32, HONOS and LSP at entry and exit to and from Care Coordination. nousgroup.com.au 21 post Entry and exit scores The data presents the BASIS32, HONOS and LSP scores of clients in ~3 month periods prior to and post entry to the initiative. Data is presented as the mean ±standard error (number of clients). An improvement in mental health is represented by a decrease in the score. Sources: CMI-ODS, Supplementary evaluation data provided by agencies (25) (96) (99) (100) (100) (110) (80) (88) (59) (38) (23) (20) 8 (112) (127) (133) (143) (123) (12) (75) (15) (102) (95) (68) (53) (10) (0) Each PIR arrangement will require a common recovery method/ language

Recruitment of Care Coordinators is hard and getting the right competencies is critically important. The staff initially recruited had a high turnover rate as they did not have the required skillset (local provider knowledge and relationships, communication and negotiation skills) Providers have tended to appoint staff with: clinical qualifications (such as nursing and allied health) to these roles often with cross sector experience (especially drug and alcohol or housing) preferably with existing relationships with a wide range of local providers. A typical award levels allocated for Care Coordinators is SACS award SOC 2 year 1-3. Don t recruit clinicians. Recruit system navigators who understand what recovery means The required competencies include: Tertiary qualifications with experience in the sector of homelessness, mental health or D&A Intimate knowledge of the mental health service system and inter-relationships between sectors Capacity to develop and sustain partnerships with service providers Applied use of recovery models in social settings combined with a humanistic attitude Comprehensive assessment skills and ability to analyse and bring together a client's previous history Advanced communication and written skills High level of interpersonal skills including assertiveness, diplomacy, negotiation skills, active listening and the ability to address and resolve conflict Facilitation/leadership skills to chair meetings, lead teams, and negotiate with other services. Source: Nous Group and Department of Health nousgroup.com.au 22

Reduction of use of inpatient beds by Care Coordination clients. Estimated time of inpatient beds made available by the client group since entry into the initiative Care Coordination Time made available per client (days) 10 8 6 4 2 0 1 2 3 4 5 Bed days made available per client Time made available total (days) 1,500 1,000 500 0-500 85 103 118 Collection Period 135 152 1 2 3 4 5 Data presents the difference in use of each bed type based on each client s historical average use over the year prior to entry to the initiative. Client s that have left the initiative continue to contribute to the availability of service hours. The number of clients included in each Collection Period is presented above each column. Sources: CMI-ODS, (Note that data for Collection Periods 4 and 5 may be absent from the system), Supplementary evaluation data provided by agencies nousgroup.com.au 23 PARC CCU SECU Acute inpatient Sample size

Reduction in use of MST, CCT, and CAT. Estimated reduction of ambulatory services use by the Care Coordination client group since entry into the initiative. Time made available per client (hours) 15 10 5 0-5 -10 1 2 3 4 5 Service hours made available per client Time made available - total (hours) 2,000 1,000 0-1,000 85 103 118 1 2 3 4 5 Collection Period Data presents the difference in use of each service type based on each client s historical average use over the year prior toentry to the initiative. Client s that have left the initiative continue to contribute to the availability of service hours. The number of clients included in each Collection Period is presented above each column. Sources: CMI-ODS (Note that data for Collection Periods 4 and 5 may be absent from the system), Supplementary evaluation data provided by agencies nousgroup.com.au 24 135 152 MST CCT CAT Sample size

Contents 1. Care Coordination v Partners in Recovery 2. Care Coordination insights 3. How partnerships work nousgroup.com.au 25

The notion of partnership has gained increasing currency in policy debates in recent years. Partnerships have captured the minds of many politicians, policy analysts and practitioners with the partnership model touted as the best way forward to tackle social problems However, the notion of partnerships is not an uncontested idea. Judd (2000: 26) notes that partnerships far from bringing coordination to tackling social problems, partnership working is spinning off into a series of haphazard initiatives without a clear set of priorities. Hess and Adams (2001: 13) notes that rhetoric of partnerships has become a muddle of ideas in which potentially useful concept is in danger of becoming just another public policy reform fad A growing body of literature has attempted to bring greater clarity to the confusion surrounding partnerships Source: The Agora Think Tank (which included the Nous Group) nousgroup.com.au 26

Key characteristics of partnerships differentiate partnership from the contractual end of the collaborative continuum. A partnership implies a greater sense of mutuality beyond service agreements, referral or information sharing. A number of common characteristics emerge from these studies. These key elements include: Common vision and goals Organisations from two or more sectors Shared decision making and responsibility Shared risks and resources Address social issue Agreed outcome Long term Autonomy New structures and process Equality and trust. Collaboration vs competition Degree of intensity and commitment Low- involvement - engagement - empowerment No risk Protect individual boundaries Competition for funding & resources Independent Entities Meeting of agencies for information sharing Shared intake or referral tools Little joint planning Little change required Coordinated Effort RELATIONSHIPS Referral protocols and case management New structures and processes Commitment of effort Joint planning Pooled or shared resources Collaborative Delivery Improvements to service systems High- involvement - empowerment - engagement Shared vision Commitment to change Sustainable relationships Formal agreements (MoU) Interdependence / Integration Detailed planning Role clarity Financial and resource commitment External focus Integrated Partnership Agencies create new structures to address wider issues Source: The Agora Think Tank (which included the Nous Group) nousgroup.com.au 27

The most valued partnerships clearly delivered lasting solutions to the prime beneficiaries those experiencing disadvantage and their communities. Successful, sustainable partnerships create value for each party: For those experiencing disadvantage, the value comes from the opportunity to pursue more effective and more sustainable pathways out of disadvantage. In local communities, value can be created in the form of greater social cohesion and community capacity with the ability to prevent future disadvantage. For the not-for-profit sector, the value comes from the opportunity to better serve the disadvantaged by contributing to services that are innovative, better resourced and better meet the needs of those requiring them. For business, the value can come from an improved corporate reputation in its product and employment markets, better engagement of existing employees and the opportunity to directly improve economic returns. For the philanthropic sector, the value comes from a greater public return on its investment. For government, public value is created by solving problems in partnership and involvement of other sectors. Source: The Agora Think Tank (which included the Nous Group) nousgroup.com.au 28

Organisations from across all sectors have expressed an enthusiasm to partner, but can under-estimate the challenges. There are two major challenges: 1. It is easy to underestimate the scale and difficulty of the challenge. The target population generally experiences complex problems; working to address social disadvantage can be politically sensitive and partnership design and implementation is complex. 2. Partners are typically diverse. The value that each partner is seeking to create may be at odds with other and each partner will certainly bring a different culture, organisational values and appetite for assuming risk. Successful partnerships do not underestimate the challenge, and work hard to harness their diversity as a strength of, rather than a constraint to, their partnership. Source: The Agora Think Tank (which included the Nous Group) nousgroup.com.au 29

There is a lot of research on what makes a good partnership. This is our take Partnerships designed to address disadvantage share the common ingredients such as shared vision, trust, respect and honesty. These challenging partnerships have seven distinctive elements: Passionate leadership A connecting passionamong key individuals, complemented by strong support from organisational leaders. The leadership roles and responsibilities are agreed and clearly defined. Flexible can-do mindset-there is flexibility and willingness to work around unforeseen barriers and difficulties. The funding provided is flexible to accommodate solutions that are innovative and address a real need. Partners come seeking opportunity rather than to overcome a problem. The values of openness, trust, honesty and transparency are agreed, shared and lived. It is helpful where the partnership has grown from a pre-existing relationship where mutual trust and respect has already been established. Value creation focus-delivers value to each partner commensurate with their effort and risk, and avoids having low input partners. There are agreed and defined outcomes, milestones, strategies, structures, decision making frameworks and operating processes. The risks and the benefits are shared. All partners as members of the community participate in the design of the solution not just the delivery. Intelligent resource usage-draws on the distinctive capabilities, resources and business systems of partners. There are dedicated and appropriately skilled resources, individuals or organisations that provide facilitation/brokerage support to overcome some of the cultural barriers that can exist between sectors. There is equal contribution from partners/community members and all contribution is respected. Loaded for success designed for early wins and clear, reinforcing feedback on performance. Partnership investment -There is investment in the partnership andthe solution. This includes time, energy, funding and strengthening the relationships and connections between partners. There is willingness from all partners to engage in mutual learning. The learnings are available and easily accessible to others. Sustainability There is a persistence and commitmentthat develops beyond the original passionate few. The outcome is sustainable because sustainability has been incorporated into the design of the solution. The time frames are medium to long term. Source: The Agora Think Tank (which included the Nous Group) nousgroup.com.au 30

For more information on parternership. http://www.agorathinktank.org http://thepartneringinitiative.org nousgroup.com.au 31