Comorbidity treatment service model evaluation

Context

Page last updated: August 2009

The first program logic domain is concerned with the context in which treatment services operate. This section covers the following sub-domains: location of services and their catchment areas; density of the service system and workforce; and state regulatory or other issues with funding sources.

Location of services and catchment areas
Density of service system and workforce
State regulatory or other issues with funding sources

Location of services and catchment areas

The literature review reported great diversity in the type and nature of the settings where services are provided for those with co-occurring disorders. Comorbidity services cater to many different population groups, including young people, older people, people who are homeless, families, women, culturally and linguistically diverse (CALD), Indigenous Australians, prisoners and so on. When considering models of service delivery, the variety of sites of care and their ability to fit within any model(s) of good practice in comorbidity treatment service delivery (or the need for the models to accommodate the variety of care settings), need to be considered. Broadly, settings of care include: hospitals; community-based services and centres; aged care; general practices; private institutions; community residences; outreach services and prisons. These could extend to include educational institutions and the workplace. In Australia, comorbidity treatment or care may be administered by various levels of government and non-government (including charitable) organisations. Models of service delivery may vary in these different sectors, reflecting their level of access to resources and their individual funding, management, policy and service development structures. The federal and state policy environments also have an effect on the local approach to the management and of service delivery for comorbidity. The diversity of the type and nature of the settings where services are provided for those with comorbid disorders is reflected in the treatment services who participated in the Comorbidity Treatment Service Model Evaluation.

Seventeen treatment services participated in the evaluation. Six of these are located in Victoria; two each in New South Wales, the Northern Territory, South Australia, and Tasmania; and one each in Queensland and Western Australia. One service covers NSW and the ACT (see Table 1).

The catchment areas of the surveyed services ranged from local government areas to one organisation with services based in two states and occasionally servicing clients in additional states. The majority of services cover a region (n=5) or a state/territory (n=6). One service covers rural and remote communities. See Table 2 for further detail.
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Table 1: Number of participating treatment services by state

Response frequency
VIC
6
NSW
2
NT
2
SA
2
TAS
2
NSW & ACT
1
QLD
1
WA
1
Total
17

Table 2: Catchment area of service

Response frequency
Whole state/territory
6
Whole region
5
Local government area(s) or local government area and surrounds
3
Rural and remote communities
1
More than one state
1
Depends on contracts/funding
1
National
0
Total
17
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Density of service system and workforce

This sub-domain is divided into the following sections: types of service links and partnerships; links between child, adolescent, and adult services; effective links and partnerships; costing of links and partnerships; barriers to inter-agency communication; and barriers to treatment.

Types of service links and partnerships

The survey included a question that explored the nature of links and partnerships with other services. Respondents were offered a list of types of services/organisations and asked whether they had a networking, coordinating, cooperating or collaborating relationship with such a service. Networking, coordinating, cooperating, and collaborating were described as follows (see Himmelman, 2001):
  • Networking – exchanging information for mutual benefit; it does not require much time or trust nor the sharing of turf.

  • Coordinating – exchanging information for mutual benefit and altering activities for a common purpose; it requires more time and trust but does not include the sharing of turf.

  • Cooperating – exchanging information, altering activities, and sharing resources for mutual benefit and a common purpose; it requires significant amounts of time, high levels of trust, and a significant sharing of turf. Cooperating may require complex organisational processes and agreements in order to achieve the expanded benefits of mutual action.

  • Collaborating – exchanging information, altering activities, sharing resources, and a willingness to enhance the capacity of another for mutual benefit and a common purpose; it requires the highest levels of trust, considerable amounts of time, and an extensive sharing of turf. Collaboration also involves sharing risks, resources, and rewards.
Unsurprisingly, networking links were most commonly reported. However, the remaining three types of link were equally frequent. In particular, the large number of collaborative relationships with AOD (n=10) and MH (n=9) treatment services are noteworthy. See Table 3 for further detail.

In addition to the links detailed in the table above, one service reported having an MOU with a state government department for child protection, and another service listed networking with local government, as well as networking and coordinating relationships with primary health services and counselling services. A third service noted links with legal services, including a specialist Aboriginal and Torres Strait Islander Legal Service, sexual assault services, sexual health services, and a dental practice who 'offer bulk billing services to clients as private providers'.

Medium-sized services have the largest number of links with other services. Small organisations may not have the resources for a large number of links, while large organisations may not need a large number of links, as relevant services may be provided by their parent organisation.

In contrast to the literature review, which found that collaboration between the AOD and MH sectors is very poor (e.g. Pennebaker et al., 2001), the surveyed services appear to be well-linked with other relevant services.
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Table 3: Types of links with other services

Networking Coordinating Cooperating Collaborating
Hospital
12
2
3
2
GP
11
8
6
6
Community health service
9
5
5
7
Housing/supported accommodation
10
7
7
6
Employment
11
2
2
2
Centrelink
9
2
5
2
Child care
8
0
0
1
Financial counselling
11
0
2
1
AOD treatment service
6
8
7
10
MH service
8
8
9
9
Indigenous health service
11
3
2
5
Criminal justice system
8
9
8
6
Welfare
9
7
5
5

Note: more than one entry per row was possible. For example, a networking relationship with one housing service and a cooperating relationship with another housing service

Table 4: Number of links with other services and service size

Mean number of links*Median number of links*
Small
19
14
Medium
28
22
Large
15
15

* includes 'other' links

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Links between child, adolescent, and adult services

The survey also asked about links between child, adolescent, and adult services. Fifteen services responded to this questions, and with the exception of one service all described relevant links. One Indigenous service reported not having links with children's services because the 'only contact with children's services tend to be negative with [name of state government department] removing children from clients etc.'. Three services that cater for children, adolescents, and adults noted that they make internal referrals if appropriate, or have the same electronic case file. Being mindful of CALD clients' cultural needs, one of these commented that internal referrals are often made 'when it is identified that a client of a particular aged group needs support from a staff member specialised in that area. For example it would be culturally inappropriate for a staff member of young age to service a parent or elderly client'.

Nine services listed a range of services with whom they have links, such as child protection services, youth services, justice organisations, parenting groups, housing groups, self-help groups, educational institutions, peer mentor programs, arts-based programs, GP networks, research centres, and government departments.

Effective links and partnerships

The links most commonly cited as being most effective were those between MH and AOD services (n=6), including links between an AOD and a MH service and vice versa , as well as the links between one type of AOD service and other types of AOD services, to 'support clients beyond [the] limitations of [the] agency's service type'. Links with GPs or divisions of general practice and the criminal justice system were nominated three times each. For example, a youth service commented that partnerships with the criminal justice system 'are most effective because of the similar practice frameworks, a long history of collaborative work, high number of referrals from this source, and legal mandates to obtain AOD treatment'. A similar view was put forward by another respondent, who made the following comment: 'Criminal justice can be effective as so many formal structures [are] guiding practice'.

The value of links between AOD and MH services and GPs or divisions of general practice was articulated in the following way:

In terms of comorbidity/ dual diagnosis the links between AOD & Mental Health services are critical to achieving better outcomes for many of the cohorts of persons with comorbidity. General Practice provides the greatest amount of treatment for both mental health and substance use disorders so, of course, the partnerships between General Practice and specialist AOD & Mental Health services are critical–I am a big fan of the ADGP10 'Teams of Two' initiatives for building these relationships.
Another respondent noted that links with GPs are 'essential for withdrawal medication and ongoing client care'.

Several respondents described in general terms the types of links or partnerships that work well, without referring to particular types of services. The following is a tongue-in-cheek comment, which also reflects the struggle for resources: 'I have been thinking about this recently—getting ready for accreditation. The best links are the one where we get max value for our clients with minimal input on our part. Probably not very PC!' Another respondent noted that the most effective links are those where the services 'have been working together the longest', while another person stated that a 'collaborative partnership has allowed [name of service] to gain many in-kind resources from other partners to expand on the strategies of our project'.

A youth service found that the most effective links are those 'where you are either co-located or have a specific MOU and regular contact. Partnerships need to have direct benefit for both services. We have a lot of experience in this area'. A similar view was expressed by another youth service which noted that since the service had 'formal agreements for collaborative practice it is much easier to get results'. 'Other community services' were thought to be most effective because they are 'able to provide practical support'.
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Costing of links and partnerships

Survey respondents were asked whether they had costed the work involved in linking or building partnerships with other organisations, and how such work is funded. Most services reported not costing this work (n=12) or they did not know (n=1). One service that reported not costing this activity noted that part of the program's funding 'is dedicated to building partnerships with external agencies as well as sustaining and maintaining them'. One small service reported that the 'project has been funded $150,000 per year over three years to ensure that treatment coordination improves', while a youth service stated that 'this work is not funded by the program but with funds raised from other sources about 20% of our resources are spent on this work'.

Barriers to inter-agency communication and treatment coordination

Respondents listed numerous barriers to inter-agency communication and treatment coordination. Most of these relate either to resource issues or differences in culture and ideology. Resource-related issues were mentioned by 11 services and include high workloads resulting in overworked, overwhelmed, and stressed staff; competition for funding; and high staff turnover. Consequently, time-poor staff may not use 'opportunities and time for inter-agency coordination' and lack awareness of services provided elsewhere. Further, it was noted that there is not sufficient time 'to engage in more intensive collaboration such as case review'. One respondent noted that the 'stretched human resources [and] funding [resulted in] difficulty securing regular service by GPs'.

Four respondents cited barriers related to ideology and culture, such as 'working within different models of care. ... A lack of professional respect from services such as mental health and [name of state government department] towards the case work practice of our AOD workers'. Different ideologies lead to 'competing priorities', as well as different approaches, language, and tools. This is illustrated in the following comment:

Differences in tools, for example, MH sector does not use the SCoTT11 tools which can assist in service coordination. Agreement with and training in the use of screening tools used in each sector. Language, AOD sector needs to use the same language as the MH sector, for example conducting MSE, using the DSM-IV. Culture differences. The use of the medical model in the MH sector which will not always apply in the AOD and primary health settings. MH clinicians are often time-poor due to heavy service demands which affects opportunities and time for inter-agency coordination.
Barriers related to ideology and culture are also reported in the literature (e.g. Richmond & Foster, 2003).

Other barriers listed included 'the excuse of privacy laws' and a statement that 'many agencies do not want to have formal collaboration and only want to have informal links'. Similarly, one respondent commented that inter-agency collaboration is 'not seen as productive', unless it involves treatment coordination 'as this [is] seen as client focused'.
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Barriers to treatment

Eleven respondents indicated that clients and potential clients experience barriers to accessing their treatment services, while five thought that no barriers exist. One respondent did not answer this question. Barriers were thought to be associated with the following circumstances and/or client characteristics:
  • Language and culture – this includes lack of appropriate information in community languages, shame barriers and stigma associated with seeking AOD and MH treatment, and fear of seeking help from government services.
  • Homelessness.
  • Geographical barriers and transport difficulties.
  • Waiting lists and limited out-of-hours access for clients.
  • Limited services in the area – if people do not like a particular service, they do not have other service options.
  • 'Lack of involuntary treatment options for AOD clients with chronic intoxication and likely (untested) cognitive limitations'.
  • The treatment service provides 'a highly structured program requiring at least a moderate level of social skill to be able to participate. Some clients are not able to cope with this for various reasons and as we can not meet all needs we do refer to other agencies. This is not something which is able to be changed as the clients that do access us need the level of structure etc. we provide'.
  • Violent behaviour.
  • 'Sexual/paedophile behaviour charges'.
  • 'Unstable psychiatrically and untreated'.
The most frequently listed barriers were those relating to language and culture, waiting lists and limited hours of service, and transport (particularly in rural and remote areas).
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State regulatory or other issues with funding sources

Of the 11 comments in response to the question 'Are there any State regulatory requirements or other issues with funding sources that impact on your service? If so, how?', eight related to insufficient funding. The areas that were reported as insufficiently funded or not funded include the following:
  • Family and group treatment.
  • Case management (particularly for clients with disability/ABI12).
  • Ongoing mental illness recovery/prevention for some groups (e.g. borderline personality).
  • Infrastructure costs.
  • 'Brokerage funding for forensic services plus two retainer positions'.
  • Education and prevention activities, health promotion activities in schools and in the community.
  • 'Creative based treatment programs', workshops.
  • Community development initiatives.
  • A psychologist position.
  • Accreditation.
  • Volunteer coordination.
One service noted that there 'has been no increase in funding for Youth Outreach for 8 years despite an increase in demand for these services', and that federal funding cuts have impacted on state funding. Another service pointed out that the agency receives:

a lot of referrals from mental health agencies to service clients with only mental health issues, we currently do not have funding for this service and these clients do not fit in to our comorbidity criteria. Therefore we need services funded to provide services to clients experiencing mental health issues without the drug issues.
Another issue that was identified refers to billing practices and was described in the following way:

Almost all the comorbid work that we do is done on Medicare access (psychologists) or bulk billing by doctors so we depend on the good will of these providers, who are at times not as competent as our own staff. No Clinical Direct for 30+ staff etc. etc. etc. Getting all the external providers to case manage is often difficult because they don't get paid to do this. Also, there is constant pressure on the service due to the level of comorbidity that we serve, intensive WHS13 and risk management is not factored into funding.. There are many more of these hidden service costs.
Identified issues that did not relate to funding included over-reporting, duplication of services, and the 'NT Minimum Standards'. No detail was provided regarding the latter.

Footnotes

10 Australian Divisions of General Practice
11 Service Coordination Tool Template
12 Acquired brain injury
13 Workplace Health and Safety

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