Care Coordination v Partners in Recovery VICSERV Seminar November 2012 1 nousgroup.com.au
Contents 1. Care Coordination v Partners in Recovery 2. Care Coordination insights 3. How partnerships work 2 nousgroup.com.au
Contents 1. Care Coordination v Partners in Recovery 2. Care Coordination insights 3. How partnerships work 3 nousgroup.com.au
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 PIR aims to improve the system response to, mental illness and multiple needs ( delivered and outcomes for, people with severe and through selected PDRSS ) persistent mental illness who have complex needs (delivered through Medicare Local regions) • Care Coordination was part of a 2009-10 State Budget reform package • PIRs is part of the 2011/12 Federal Budget • Care Coordination aimed to address priority which has provided $549.8 million from pressures, risks and opportunities 2011/12 to 2015/16 associated with high risk/high need adult • PIR will get the services and supports from clients (16-64 years) of the specialist public multiple sectors to work in a more mental health service system collaborative, coordinated, and integrated • Care Coordination provides the practical way support to access and remain engaged with The scale of PIRs the range of mental health and general dwarfs CC but they are health and social support services they need the very similar programs Source: Department of Health and Department of Health and Ageing 4 nousgroup.com.au
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 needs such 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 hig h 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 5 nousgroup.com.au
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 � Clinical service guidance - Works with � Deliver the benefits of system ‘service coordination’ or ‘service hub’ - works with, and and guides the service needs of the collaboration guides, the service team process and tasks while building client specific to that agency, and does � Support facilitation with a collaboration with all parties involved with the client provide direct clinical support to the coordination focus; client � Long-term focus - Takes a long-term planning focus. � Manage referrals, assess client Supports the care team, coordinates the broader � Direct engagement - Does have a needs community-level service plan, provides guidance around component of service coordination and � Develop, monitor and regularly service delivery and may help to coordinate crisis hence there is some overlap with Care review PIR Action Plans intervention activity Coordination � Work with existing case managers � No direct engagement – Care Coordination does not � Long-term focus - Similar to Care (not replacing them) include the provision of psychosocial supports and the Coordination, takes a long-term Care Coordinator does not engage in direct day to day planning focus, but also works with the � Build service pathways, networks work with the client. Client engagement is through client, providing direct support and of services and supports needed assessment or review of the care plan and focus on how involvement, develops an agency � Be a point of contact for PIR the client perceives the services to be working. Typically specific or treatment plan and is clients, their families and carers. only meets the client with one of their direct support directly involved in crisis interventions workers, Case Manager or in a case conferencing environment Overlap with planning. Leave clinical care Source: The Nous Group and Department of Health and Ageing plans to clinicians. Take a load off clinicians 6 nousgroup.com.au
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 . • The introduction 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 7 nousgroup.com.au
Contents 1. Care Coordination v Partners in Recovery 2. Care Coordination insights 3. How partnerships work 8 nousgroup.com.au
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. effectiveness appropriateness efficiency OUTPUTS NEED/PURPOSE INPUTS ACTIVITIES OUTCOMES SYSTEM OUTCOMES • Improved service coordination and strengthened accountability at the local level • Increased capacity for specialist (clinical and PDRSS) mental health services to AMHS registered clients manage service demand aged 16-64 who have a • Reduced repeated contacts with other service systems i.e. hospital, corrections, severe, enduring mental homelessness, and emergency contacts (police and ambulance) illness and psychiatric Assessment, development, coordination disability and: 20 Care and review of personalised Integrated • multiple, unmet Coordinators Care Plan service needs delivering up to System • a history of accessing a 300 Integrated outcomes range of services in an Care plans at System advocacy ad hoc and often • Improve any one time chaotic way. treatment and Note: Clients who are care of multiple currently receiving SECU need/high need diversion and Case Conferencing clients Brokerage substitution or IHBOS Health, social • Reduce system funding are not eligible for this and economic ($500 per pressures response client outcomes client) Links to wide range of clinical, psychosocial, rehab, physical health and social services. CLIENT OUTCOMES • $2M per annum Health Standardised • 20 new positions • Improved self-management of illness, medication and treatment compliance, Brokerage services intake and • Indicative worker to relapse prevention and symptom stability assessment client ratio - 1:15 • Improved physical health and engagement with GP services framework • Selected PDRS service • Decreased psychiatric crisis, suicide, self-harm and other • Sustained engagement with health, drug and alcohol, primary mental health and providers medical services as appropriate • Improved client and carer experience of care, improved client and carer input into treatment care planning Social: • Sustained stable housing Source: Nous Group and Department of Health • Increased social and community engagement/connectedness • Improved social relationships, including with significant others Economic: • Engagement in educational and vocational training, and employment 9 nousgroup.com.au
Recommend
More recommend
