the integrated services project (isp): an inclusive model of intensive, transitional support for...

The Integrated Services Project (ISP): An inclusive model of intensive, transitional support for individuals with complex needs

Don Ferguson and James LimSydney, Australia

21 October 2009

Overview of presentation

Introduction How the ISP was developed The structure of ISP What we have learned Q & A

Before we start

We acknowledge your expertise

We are here to share our experience

What we have to say or suggest here may not be applicable to your circumstances, but

We hope to provide you with some ideas to support your thinking in this challenging area of human service delivery.

Introduction

Illustration : Aboriginal Dreaming

Australia

Queensland

NSW 6.8M

Northern Territory

South Aust.

Western Australia

Vic

Tas

Aust. Capital Territory

Victoria Tasmania

Total population = 22M

NSW

800,640 sq km

10.4% of continent

Sydney

7.6M sq/km

Human Service & Justice Agencies- NSW Government

Department of

Human Services

HEALTH Community

Services

HOUSING Juvenile

Justice

Aboriginal

Affairs

Dept of Corrective

Services

Police

DISABILITY(ISP Lead)

Justice & Attorney General’s Department

How the ISP was developed

First Steps

Timeline of model development

1999

Taskforce established

2001

Literature review commissioned

2003

Survey of Human service agencies

2005, April

NSW Government approves trial

2005, September

First participants accepted

2004, November

Project Director appointed

Model development continued…

Literature review confirmed local experience:

Rigid service inclusion/exclusion criteria Lack of capacity and incentives to be flexible in meeting

individual needs Lack of identified lead agency with responsibility for case

management and coordination of multiple services Lack of knowledge across services – confusion about roles

and responsibilities, and how to access services Lack of effective communication between service providers

(crisis-driven responses; rigid boundaries) Lack of access to specialist multidisciplinary expertise and

tailored treatment options (eg drug and alcohol) Lack of accommodation options

Model development continued…

Whole of government endorsement of ISP Pilot funding of $26M over 3-years provided by

state Treasury commencing July 2005 -2009 Catchment area determined as Greater Sydney Minimum age of entry determined as 18 years New legislation not considered necessary All NSW Government human service and justice

agencies drawn in to support project development and identification of individuals of highest need

Project Catchment

GREATER SYDNEY Key facts

Population: 3,637,500

Average age of residents is 35 years

Area Coverage: 6376sq/km

Target Group

Adults with high risk challenging behaviour, with one or more of the following diagnoses:

mental health disorder intellectual disability acquired brain injury/impairment substance abuse

who are blocking an acute mental health unit or

respite service, homeless, or in gaol and experiencing significant barriers to accessing services and securing

coordinated multi- agency support, where local support options have been exhausted.

The ISP Approach

The ISP aims to: Improve a person’s housing stability, behaviour

and social networks Improve coordination and capacity of local

supports Reduce cost and impact of behaviour on self,

others and services Contribute to evidence base on supporting people

with challenging behaviour

The ISP Approach continued

This is achieved through:

The direct and immediate provision of time limited housing and support, as required,

while

working in partnership with each individual and their support networks to understand, plan and establish a more sustainable range of support from across their community and the specialist services system.

The Structure of ISP

Sculptures by the Sea – Bondi NSW 08

Organisational context

The ISP is hosted by the Department of Human Services’ Ageing, Disability and Home Care Agency.

Located within directorate responsible for agency and whole of government development in support to people with an intellectual disability and a mental health issue, those with complex needs and challenging behaviour and those in, or at risk of, contact with the criminal justice system.

Also provides specialist state wide intellectual disability services via a tertiary behaviour intervention service and an accommodation and support services program for people with

intellectual disability exiting the criminal justice system.

Whilst ISP not focussed on people with an intellectual disability, the close alignment with the work of the directorate provides a clear avenue for influencing the wider service system.

Project Governance StructureHuman Services

CEO’s

Chief Executive ADHC

Project Director

Support Team

Area/ Regional CEOs

Local Agencies

Management Committee

Reference Groups

Senior Officer Groups

Accom

Project Organisational Chart

Assessment Unit262 Victoria Rd

Rydalm ere - S ep t 05 *N u rs ing s ta ff

Residentia l UnitNurse manager

G lebeA p ril 2 0 07

KentlynD e c 2 0 06

Narw eeS ep t 2 006

4Cavey StM arrickville

Ja n 20 06

In Hom e SupportNetw ork

Netw ork M anagerN e tw ork m an a g er

S yd ne y S ou th W e st

HornsbyA u gu st 20 08

Rouse HillD e ce m be r 20 07

Parram attaA u gu st 20 07

12 a & b Charlotte StRooty HillF eb 20 06

In Hom e SupportNetw ork

Netw ork M anagerS yd n ey N o rth W e st

M anager Supported Living

Specialist Support Team4 C lin ica l C o nsu lta n ts

2 S p e cia lis t P sych o lo g is ts4 C ase S up p ort W orke rs

M anager Support Services Project M anagem ent2 S e n io r P ro je c t O ff ic e rs

DirectorIntegrated Services Project

Summary of Service Pathway

Intake

Nomination of Clients

ProjectManagementCommittee

Outcome

AssessmentCase

Planning

Clinical plans

InitialAssessment

Individual Case Plan

Individual Caseplan

Accommodation

AccomSystems

Transition New Service

Action plan

TransitionPlan

Proposed Servicemodel

Exit to NewService

Service Coordination Service Coordination Training & Development

ISP : Service Pathway from Intake to Exit of Service

0 month 3 12 Timeline 15 18 months

Service Pathway: Stage 1 of 3

Support TeamAccommodation

• In situ eg Corrections, Mental Health

• ISP acomm unit

• Assessment

•Individual Case Plan

•Interagency Agreement

•Behaviour and Health Support

Local service supports

Co-Case management and support as agreed through case plan

Stage 1



• In situ e.g. Corrections, Mental Health

• ISP accom unit

• ISP accom unit

• Own home/ public housing

• Assessment

• Individual Case Plan

• Interagency Agreement

• Behaviour and Health Support

• Individual Case Plan Implementation

• Trial Support Strategies

• Reconnect/ Establish Support Network



Stage 1

Stage 2



• In situ eg Corrections, Mental Health

• ISP accom unit

•ISP accom unit

• Own home/ public housing

• Assessment

• Individual Case Plan

• Interagency Agreement

• Behaviour and Health Support

• Individual Case Plan Implementation

• Trial Support Strategies

• Reconnect/ Establish Supports

• Phase out and exit



Stage 1

Stage 2

Stage 3 •Supported accommodation

•Own home/ public housing

The role of substitute decision making

NSW chose to rely upon existing legislation and decision making bodies for supporting people through the ISP.

In particular: The Guardianship Tribunal The Mental Health Review Tribunal The NSW Public Trustee & Guardian

They provide a strong source of advocacy for individual participants accountability for the ISP a significant role in shaping the project through membership

of the ISP interagency reference group.

ISP Accommodation Models

Assessment unit House with self contained unit Twin house A small block of units Semi rural house with on-site vocational

training Drop in support and co tenancy Crisis accommodation

Some properties purchased and some leased, all modified to some degree to better meet individual needs

Integrated Services Project – Accommodation

Options

Accommodation Considerations

What has worked?

Diversity and immediacy of accommodation options

Staffing model used to support complex needs

Allocation of key workers, psychologist & other professionals for ongoing assessment and support during transitional placements.


What has worked?

Flexibility around support needs with focus on promoting choice within structure, development of life skills and vocational options

Planning towards the development of consistency, stable accommodation and identification of longer term needs

Cost effectiveness of pooling services and resources to support complex cases – these individuals are not our exceptions


What has been some of the challenges?

Assessment unit industrial issues too restrictive Too expensive became early unintended focus of program and all-

consuming

Community acceptance


Some more challenges

Timeframe restrictions and staggered release of funding due to pilot status of project, big impact on issues such as staff employment stability intake and placement planning

Transition to next phase or locating appropriate service providers for service continuation On the flip side: ISP allows us to put individual need ahead

of service access issues – service fit becomes our problem not the individual’s

Characteristics of participants 38 participants Mean 36 years, Median 34 17 Women, 21 Men, Indigenous n = 3 CALD n = 12 ESB n = 23

30

Housing prior to ISP (n=38)

31

Characteristics of Participants continued

Mental health disorder n = 33 (87%)

Intellectual impairment n = 26 (66%)

Alcohol and other drugs n = 22 (58%)

Acquired brain injury n = 15 (39%)

Physical disability n = 14 (37%)

Case Example 1 (NR)

NR had a tendency to gravitate back to high risk environments She was very vulnerable to abuse and exploitation by others

(i.e. persuaded to engage in offending behaviour – break and enter – used as the “fall guy”)

She had frequent contact with the criminal justice system Soliciting / Prostitution Verbal aggression and property damage Extreme emotional lability Lack of impulse control

Case Example 1(NR)

Assessment findings Poor short term memory and impulse control Negative impact of multiple placements No length of meaningful engagement with past providers Systems issues – coordination failure, police, courts, disabilities, mental

health

What we did Provided a stable place to live with skilled and supportive staff Introduced comprehensive behaviour support strategies Established roles and responsibilities of mental health and disability support

services Developed cross agency response plans to reduce contact with criminal

justice system Negotiated long term service provider and funding source Provided intensive training to service provider Handed over of responsibility of case plan and interagency collaboration Ultimately resulting in successful sustainable support model and exit of ISP

Case Example 1 (NR)

Key individual outcomes Police reported a significant reduction in crime rate in local govt area and

attribute much of this to one individual…

NR has continued to spend greater lengths of time in the community and less time in custody.

She has a higher engagement with her support services

and has commenced work at supported employment, providing her a wonderful new source of income.

Case Example 1 (NR)

Summary NR is a 29 year old female of Lebanese descent. She has a diagnosis of

Moderate Intellectual Disability, Borderline Personality Disorder and a Possible underlying mood disorder.

Oppositional behaviour and absconding from home at a young age. Living on ‘the streets’ by age 13yrs.

Frequent incarceration in Juvenile Justice detention centres and adult correctional facilities for theft related charges.

History of placement breakdown and disability services unable to provide adequate service model to meet client needs, new placement

Released on bail and charges dismissed over 50 times successive release from custody on grounds of unfitness to plea.

Disengaged from family.

Examples of the diversity of participants

Young women with no comprehension of English, native language undetermined, living in a short stay hostel with uncontrolled psychosis and no known supports or family

Homeless elderly male with repeated contact with police, aggression, AOD, previous self inflicted gun shot wound head injury, multiple untreated health conditions stuck on post surgical hospital ward.

Young women with a moderate intellectual impairment and personality disorder, long history of short periods in custody for low level offences and no stable community support

Young Indigenous male, mild cognitive impairment, IV drug use, HIV positive, living in unsustainable HIV related dementia service

Elderly male, 20+ years in custody for murder, previous diagnosis of anti social personality disorder, suffered brain trauma in custody with continued mental and physical deterioration

Indigenous participants

Over represented in criminal justice and welfare systems.

Recognition of past poor practices and tainted history

Focus on establishing trust Must change our thinking our

language and our engagement with individuals, families and community

ISP seeks support of Community Elders and

works in partnership with Indigenous services

Strives to establish culturally appropriate supports and individual outcomes.

National Sorry Day 26 May

What have we learned: Bridging our service gaps

Sydney Harbour Bridge

Concepts of service fit and behavior:Description of all participants on entry to ISP

High level behaviour

Poor service fit

Concepts of service fit and behaviorWhat we found

Group 3: 22.5%

High level behaviourgood service fit

Group 4: 12.5%

High level behaviourpoor service fit

Group 1: 40%

Lower level behaviourgood service fit

Group 2: 25%

Lower level behaviourpoor service fit

In other wordsNo claim to be a silver bullet

Project evaluation: Some results to date

ISP has had a positive impact on individuals and services Behaviours, risk, health, quality of life and “service fit” 18 individuals have successfully moved through and

exited the Project to long term service options with clear agreements in place for an additional 12 participants

Flexible needs based approach has enabled trials of innovative service models

No appropriate service fit for 8 individuals A small number of recurrent individual funding packages have

been approved for release each year Aim is to help resource extra-ordinary support arrangements for

such individuals and reduce likelihood being stuck in the ISP

Project evaluation: Some results to date

Service Costs Approximately $200,000 per annum per person compared with

$375,000 average cost pre-ISP

Behaviours Reduction in frequency and severity, especially for those who have

exited (36-42% decreases)

Service Use Decrease in hospital bed days from 47 to 2 days on average over 12

months period and reduced presentations to Emergency Departments from 24 to 4 presentations for 12 months

Decrease in number of days of imprisonment of 108 to 21 for 12 months

Elements of an effective service model

Timely identification of people and response to need High quality, clear and accountable case management Stable and flexible supported accommodation options Specialist multidisciplinary assessment, formulation

clinical, and behavioural interventions Individualised treatments such as D&A, anger

management, community participation and vocational programs

Interagency agreements and collaboration based on effective communication

In others words, from our experience, what the literature said was True!

We encountered barriers Integrated model of service delivery – “one stop shop” Work force management (recruitment, retention and support

initiatives) Funding implications and impact on work force management Extra ordinary complex client – implication of service moulding /

replication of ISP with other providers Strategic alliance within the Dept. – level of “guided autonomy”

and program sponsorship, as ISP was charting into “risk prone and unfamiliar territories in human services

Sound risk management practices Timelines and intake processes – start small …

Results continued

Systems Change and ISP influence

Effective mechanisms for resolving service support issues at local and senior levels Instrumental in developing of MOU between Mental Health and

Disability Services Participate in Mental Health Complex Needs Standing Committee

System requires greater flexibility in funding and program boundaries Working to supplement and expand existing programs Supporting development of revised intake criteria to close the gaps

Skilled workforce and open minded decision making Promoting new mindsets and culture of inclusion through staff

training and sharing the learnings with key decision makers

Tree of Change and Influence

ISP

InnovativePractice

PolicyDevelopment

Mental health and ID MOU

OSP

WorkforceManagement

Strategic Policy and

Planning

FutureDirections

HumanServices

ClinicalReferenceGroup

InteragencyGroup

ISP

CriminalJusticeResource

Behaviourpolicies

Drug & Alcohol Task

Group

New Servicemodels

Building Capacity in

human services

Quality Riskmanagement

Model of Accom Units

Research andDevelopment

Costeffectiveness

Community Perception &

Acceptance

Tree of Change

Quality of life

Q & A session

Questions

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