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Partners in Recovery: information session video, part 2 - overview and guidelines

Overview and guidelines for Partners in Recovery (PIR) as presented at an information session.

Video - part 2 of information session
Transcript - part 2 of information session

Transcript

Overview of PIR and grant program guidelines

Ms Sue Campion, Acting First Assistant Secretary, Mental Health and Drug Treatment Division, Department of Health and Ageing

Sue Campion: OK, well, good morning everyone, thank you for coming.

Just some very brief background on the Partners in Recovery initiative.

As part of the development of the 2011/12 budget package on mental health, the minister undertook extensive consultation around the country and a key message that was communicated through those consultations was that there hasn’t been enough coordinated care for people with severe and persistent mental illness, particularly those with complex needs.

Slide: Background/context:

• PIR is Australian Government’s response to stakeholder concern about the lack of coordinated and integrated care available for people with severe and persistent mental illness with complex needs, who require a multi-agency response
• The 2011/12 federal budget provided $549.8 million from 2011/12 to 2015/16 for PIR
• PIR will get the services and supports from multiple sectors to work in a more collaborative, coordinated and integrated way

Sue Campion: So, the Partners in Recovery initiative is the government’s response to that and Partners in Recovery aims to better support people experiencing severe and persistent mental illness with complex needs and their carers and families. It will help by getting the services and supports from the multiple sectors that this target group come into contact with, to work in a more collaborative, coordinated and integrated way.

Partners in Recovery will do this through a range of means.Top of page

Slide: What is PIR?
PIR aims to improve the system response to, and outcomes for, people with severe and persistent mental illness who have complex needs (the target group) by:

• Facilitating better coordination
• Strengthening partnerships and building better linkages
• Improving referral pathways and
• Promoting a community based recovery model

Sue Campion: It will facilitate better coordination of clinical and other supports and services that people need, to deliver care that’s individually tailored to the client’s needs. It will strengthen partnerships and build better links between services. It will improve referral pathways and it will promote a community-based recovery model to underpin support services for the target group.

We’re hoping that Partners in Recovery will encourage innovative solutions to ensure effective and timely access to the services and supports required by those in the target group.

Slide: PIR principles
The implementation principles of PIR are:

• Recovery oriented and client focused
• Flexibility in roll out
• Complementary to existing service systems and
• Better coordination of systems]

Sue Campion:There are a number of principles that are underpinning Partners in Recovery. The first is that it will be recovery oriented and client focused. As I mentioned, we are deliberately allowing flexibility in how it’s rolled out, so that how it operates in one region may look very different from how it operates in another. And that’s because each region will need to take into account existing service delivery systems that are in place.

Partners in Recovery will be complementary to existing service systems. It will assist with, rather than complicate or duplicate system navigation.

Partners in Recovery will also help better coordinate existing systems, building pathways and networks across sectors and services in order to better meet the needs of the target group.

So, who is the target group? Top of page

Slide: PIR target group
PIR target group

• Around 600,000 Australians experience severe mental illness
• Of those, 60,000 have enduring and disabling symptoms with complex, multi-agency support needs
• PIR focuses on 24,000 people within this 60,000 group
• These people experience persistent symptoms, significant functional impairment, and psychosocial disability
• They are reported to often fall through the system gaps and require more intensive support]

Sue Campion: Around 600,000 Australians experience severe mental illness, and about ten per cent of those, or 60,000, have enduring and disabling symptoms, with complex multi-agency support needs. Partners in Recovery focuses on about 24,000 of those 60,000 and that people in that group have a severe and persistent mental illness, as I mentioned and complex needs, requiring multi-agency responses. These people have persistent symptoms. They have significant functional impairment and psychosocial disability.

They may have become disconnected from their family and support networks. They may have co-morbid substance or physical health issues, or both and they’re likely to experience difficulties maintaining stable accommodation and completing the basic daily activities.

This can lead to extensive reliance on multiple health and community services to keep them in the community and outside of institutional care, but because the system can often be difficult to navigate, it can mean that they also fall through the cracks.

So, Partners in Recovery will be rolled out through what we’re referring to as Partners in Recovery organisations. These organisations will work at the systems level and be the mechanism to drive collaboration between sectors, services and supports within the region.

Slide: Role of PIR organisations
System-level focus to drive collaboration and develop innovative solutions collectively owned by PIR partners within the region.

• One PIR organisation in each of the 61 Medicare Local geographic regions
• Engage and join up the range of sectors, services and supports within a region
• Build partnerships, establish/improve collaborative ways of working together
• Drive collaboration and develop innovative solutions
• Complement, support or influence care coordination activities already underway in the region]

Sue Campion: In general, we’re looking to establish one organisation in each of the 61 Medicare Local regions and on page six of the guidelines we outline the types of tasks that these organisations will be required to undertake. They include things like joining up the range of sectors, services and supports that people with severe and persistent mental illness with complex needs require. Building partnerships and finding collaborative ways of working together. Complementing or influencing care coordination activities that may already be underway in the region. Identifying and proactively engaging the potential clients. Supporting carers and families. Managing referral pathways and also managing stakeholder relationships.

Partners in Recovery organisations will do this through the engagement of support facilitators. Top of page

Slide: Role of support facilitators
Engaged by, and undertakes the day to day tasks to support the PIR organisation

• Deliver the benefits of system collaboration
• Support the facilitation with a coordination focus
• Manage referrals, assess client needs
• Develop, monitor and regularly interview PIR action plans
• Work with existing case managers (not replacing them)
• Build service pathways, networks of services and supports needed; and
• Be a point of contact for PIR clients, their families and carers

Sue Campion: The support facilitators will do the day to day tasks associated with Partners in Recovery, which will include things like reviewing referrals to the Partners in Recovery organisation, assessing the needs of clients, developing a Partners in Recovery Action Plan, which I’ll talk about a bit later, and that action plan outlines things that need to be taken, by whom and when, to meet the client’s needs.

In terms of referral pathways, Partners in Recovery isn’t about creating a new pathway to access services. The guidelines are deliberately silent on what the referral pathway into Partners in Recovery will be. We are looking for you and your applications to tell us what the referral pathway should be, based on what’s available in your region. However we do expect that the referral pathways will reflect where people in the target group are likely to present. So, hospital emergency departments, homelessness shelters and employment services, mental health services, to name a few.

Slide: PIR referral pathways
PIR is not intending to create a new pathway into services

• Referrals will be made to PIR organisations and assessed by the support facilitators
• Applications are to specify referral pathways to match the proposed model
• A standard PIR referral template will be provided to PIR organisations for use within the region

Sue Campion: Applications will also need to outline what steps will be undertaken to ensure early and thorough communication by Partners in Recovery organisations across each region, to assist in maximising referrals of people in the target group to the organisation.

And we are developing a referral template that Partners in Recovery organisations may choose to use within the region.Top of page

Slide: Inclusion criteria
The client:

• Has complex needs that require substantial services and supports from multiple agencies [main criteria]
• Is diagnosed with a mental illness that is severe in degree and persistent in duration
• Has had recent engagement with services; and
• Consents to being involved in PIR

Sue Campion: The inclusion criteria for Partners in Recovery will include, that the client has complex needs that require substantial services and supports from multiple agencies. And this is one of the main criteria for Partners in Recovery, given it’s about bringing together the range of services that people in the target group might require.

The client has a diagnosed mental illness that’s severe in degree and persistent in duration and is willing to be referred for ongoing clinical treatment. We do recognise that not everyone on referral may have a current diagnosis, or may not have even had a diagnosis at any stage. What we are recommending or requiring in those circumstances is that the support facilitator arrange for that client to have a diagnosis as soon as is practicable.

The client will have had recent engagement with services where there’s been a pressing concern expressed about their mental health and/or related issues. Existing service arrangements or coordination between services have failed and contributed to the problems being experienced by the client and are likely to be addressed through Partners in Recovery and the client also needs to, obviously, consent to being involved.

Slide: Exit criteria
The client may exit the PIR initiative when:

• There are stable arrangements in place
• The client is accessing the required services and supports needed, and
• There is no further need for additional coordination or flexible funding support

Sue Campion: In terms of exit criteria, we’re expecting that a client might exit Partners in Recovery when stable arrangements are in place. They’re accessing the required services and supports that they need to meet their needs and there’s no need for ongoing coordination or access to the flexible funding, which I’ll talk about in a moment as well.

However, arrangements will need to be put in place, obviously, to enable clients to re-enter Partners in Recovery should their circumstances change. Organisations will also need to think about how they’ll handle referrals to Partners in Recovery, where those clients don’t actually meet the entry criteria, so that they can also be provided with the support that they need.Top of page

Slide: Assessment and PIR action plan
The PIR action plan will identify how the client’s clinical and other support needs will be addressed. The support facilitator will:

• Undertake an initial assessment of the client’s service and support needs
• Develop a PIR Action Plan in collaboration with the client, their carer and family, and other relevant partners;
• Arrange for the relevant parties to co-sign the plan (committing all stakeholders to deliver what they have agreed to deliver); and
• Regularly review the PIR Action Plan

Sue Campion: In terms of the assessment and action plan, the support facilitators are, as I mentioned, will undertake an assessment of the client service and support needs and they’ll have access to a range of tools to help them with this.

The assessment will also identify the client’s existing capabilities and capabilities that Partners in Recovery can build on, identifying skills and strengths, which can be used to assist in recovery. The support facilitator might also need to review assessments that have already been undertaken, or previously been undertaken of the client, if they’re available, recognising that this target group is likely to have had a number of assessments over time.

And based on the assessment, the support facilitator will develop an action plan.

As I said before, that will identify how the client’s needs will be addressed and by whom and when. That action plan will be developed in collaboration with the client and their carer and family, as well as the Partners in Recovery partner organisations. It will be signed by all relevant parties, committing them to undertake the action that’s specified in the plan and the plan will be regularly reviewed by the support facilitator.

Slide: PIR flexible funding
A limited funding pool which can be drawn on to meet the immediate needs of the client

• Used to purchase services and appropriate supports when not immediately available
• Used to build system capacity, not to divert responsibility from existing service providers
• Can cover a range of short term expenses to meet priority needs, pending longer term solutions, such as:
  • Supporting access to clinical care
  • Urgent accommodation or other social support needs
  • Travel assistance to get to servicesTop of page

Sue Campion: Partners in Recovery organisations will have a limited amount of flexible funding and they can use that funding to purchase services and appropriate supports when client needs are identified, but aren’t able to be immediately met through existing channels and services. So, it will enable the Partners in Recovery organisation to buy in the services and build system capacity, but it’s not about taking responsibility away from existing services and providers in the region.

In the main, we’re expecting that Partners in Recovery clients will be drawing on existing services in the region. The flexible funding, if it’s used to actually duplicate what other organisations are already responsible for, will very quickly run out. It’s not designed to meet the ongoing needs of clients.

The success of Partners in Recovery will rely on the strengths of sector and service partnerships created and maintained at the regional level and as I mentioned before, the sectors and services that will be coordinated will reflect what’s already available in the region that are required by the target group. We’re expecting Partners in Recovery organisations to bring these partner organisations together, to promote collective ownership and encourage the development of innovative ways to meet the needs of the target group.

We’re expecting that private, government, either Commonwealth or state funded services and non-government services and supports will all be involved in the initiative.

Slide: Partnerships
The success of PIR will rely on the strength of sector and service partnerships created and fostered at the regional level

• Public community and specialist mental health services
• Private psychiatrists and psychologists
• Primary and secondary health care services
• Alcohol and other drug treatment services
• Disability services
• Income support services (e.g. Centrelink)
• Supported accommodation services and other accommodation providers
• Personal Helpers and Mentors Program providers
• Providers of community based living skills programs
• Vocational rehabilitation, education and employment services and
• Parenting support, child protection, domestic violence and justice services]

Sue Campion: There’s a range of them listed on this slide; as you can see they include public, community and specialist mental health services, disability services, alcohol and other drug services, income support, education, employment, housing and so on.

We are undertaking a number of projects concurrently that will support Partners in Recovery and the organisations. The first is an evaluation and monitoring project.Top of page

Slide: PIR supporting projects
The success of PIR will rely on the strength of sector and service partnerships created and fostered at the regional level

• Evaluation and monitoring project
  Evaluate the impact of PIR at the system and client level, examine its effectiveness, and monitor its delivery.
• Resource development project
  Collate existing and develop new resources and tools to assist with implementation.
• Capacity building project
  Enable national networking and information sharing, and build the capacity of PIR organisations and support facilitators.

Sue Campion: We’re in the process of finalising a tender to appoint an organisation to undertake the evaluation and monitoring of Partners in Recovery.

Our aim is to start evaluating and monitoring from day one, so it will be an ongoing data collection and assessment process and the evaluation will focus on the impact of Partners in Recovery at both the system level and at the client level. Partners in Recovery organisations and support facilitators will be required to contribute to these activities.

We’re developing a range of tools and resources that can be used by the organisations and the support facilitators. That’s another tender that we’re currently in the process of finalising.

These tools and resources will be available to assist the organisations. They’re not essential, other than perhaps the first one, which is Partners in Recovery operational guidelines. There will be a referral tool that I mentioned. There will be the action plan template that can be used. There will be an assessment framework that can be used as well.

Information booklets that can be provided to consumers, as well as the carers and families, to explain what the initiative is about and examples of partnership building and governance tools. so, it might include, for example, a draft MOU template that the Partners in Recovery organisation can use with their partner organisations.

We’re also about to go to market for a capacity building project.

What we envisage the project will do, will enable the 61 organisations to network nationally, share experiences, build capacity, share best practice examples and those sorts of things. So, it will be an ongoing information sharing mechanism over the life of the initiative.Top of page

The information paper that we’ve released on our website, which is separate to the guidelines, includes a case study. I don’t know if anyone’s had a chance to look at it yet, but if you haven’t, I’d strongly encourage you to do so. If you’re trying to get a feel for what might it look, from a client’s perspective.

That case study is about a client and it shows their transition from accessing services on a crisis basis, moving around the country, losing access to those services and then, being hospitalised because of their mental illness and then, showing how they move from that, with the help of a support facilitator, to develop an action plan.

I think in that example, about seven different types of services are identified for that client, who also has associated drug, or alcohol misuse issues.

Shows how the support facilitator works up that action plan monitors it over time. Also how they access the flexible funding pool to meet some short term needs that aren’t available for the client when they need them. So, as I said, if you haven’t had a chance to read it, it will give you a bit of a sense of how it might work from the client’s perspective.

Slide: When successful, PIR will deliver…

• Individuals will be better supported in navigating the range of services and supports they need across different sectors
• A more integrated and coordinated service response (and experience) by the client that meets their full range of needs
• Services will work better together
• There will be more regular communication between services in determining how best to meet the needs of PIR clients
• Governance arrangements will be in place between services (e.g. MOUs, service level agreements) outlining who will do what for the target group
• There will be collective ownership and shared responsibility across services and sectors for meeting the needs of the target group]

Sue Campion: We’re also trying to finalise case studies that will show Partners in Recovery from a systems perspective and also, from a clinical perspective and as soon as we finalise those, they’ll also be on our website.