Eastern Metropolitan Region,
Alcohol and Other Drug Sector
Service Coordination
Project
A review of current practices and
recommendations to support effective
service coordination for Alcohol and
Other Drug services in Melbourne’s
Eastern Region
Report Prepared by:
Kate Pascale – Service Coordination Project Officer
Knox Community Health Service
Phase 1: Project Report
Acknowledgements
The successful planning and implementation of the project was a result of the commitment of many people and organisations. Thankyou to everyone involved for sharing their knowledge, expertise and time to complete this project.
In particular, thanks to Eddy Holman (The Basin Centre), Kevin Porter (Wellington House), Jenny Langlands, Cathy Keenan and Sheryll Kay (DHS), Carolyn Bolton, Wayne Massuger and Jenni Thompson (KCHS).
Special thanks to the Service Coordination working group for your time, dedication and openness. Members of the working group include:
Caroline MacDonald (Strategy Co-ordinator, EMR Drug and Alcohol Strategy) Christopher Foley-Jones (Inner East Primary Care Partnership)
Dale Tesone (Maroondah Addictions Recovery Program) Eddy Holman (The Basin Centre)
Jacky Close (Outer East Health and Community Support Alliance) Jenny Langlands (Department of Human Services)
Judith Shapland (Reachout program, EACH) Kevin Porter (Wellington House)
Loretta Zeeck (Knox Anglicare)
Robyn Jones (Mental Health Alliance Project) Rosemary Andrea (New Life Program)
Tilak Abeyarama (City of Manningham)
Thankyou to the participants of the Service Coordination Audit Questionnaire, who volunteered their time to contribute to the project. This includes representatives from the following organisations:
Agendas Program, Knox Anglicare Box Hill YSAS Community Programs Carrington Road, Eastern Health
Eastern Drug and Alcohol Services (EDAS)
Eastern Residential Unit, Youth Substance Abuse Service (YSAS) Knox Community Health Service (KCHS)
Maroondah Addictions Recovery Program (MARP) New Life
The Basin Centre, Salvation Army Wellington House, Eastern Health
Glossary
ACSO
COATS
Australian Community Support Organisation (ACSO), Community Offenders
Advice and Treatment Services (COATS)
ADIS
Alcohol and Drug Information System
AOD
Alcohol and Other Drug, also referred to as Alcohol, Tobacco and Other
Drugs (ATOD) and Alcohol and Drug (A&D)
CCCC
Counselling, Consultancy & Continuing Care
CISP
Court Integrated Services Programs
COAG
Council of Australian Governments
DDCAT
Dual Diagnosis Capability in Addiction Treatment
DHS
Department of Human Services
EMR
Eastern Metropolitan Region
EOC
Episode of Care
EQuIP
Evaluation and Quality Improvement Program
IEPCP
Inner East Primary Care Partnership
INI
Initial Needs Identification
MCDS
Ministerial Council on Drug Safety
OEHCSA
Outer East Health and Community Support Alliance (The Outer Eastern
Region’s Primary Care Partnership)
PCP
Primary Care Partnership
PPPS
Practices, Processes, Protocols and Systems
QICSA
Quality Improvement & Community Services Accreditation
SCTT
Service Coordination Tool Templates
Table of Contents
Phase 1: Executive Summary ... v
Chapter 1: Introduction and Background ... 1
Initial Contact ... 2
Initial Needs Identification ... 2
Assessment ... 2
Care Planning ... 2
Referral ... 3
Key Service Coordination Resources ... 3
What are the Benefits of Service Coordination? ... 4
Existing Policy Context ... 5
Federal ... 5
Victorian ... 5
Eastern Region ... 5
AOD Service Structure in the Eastern Region ... 6
The EMR Alcohol and Drug Strategy Group ... 6
The Service Coordination Project ... 7
Project Rationale ... 7
Project Scope ... 7
Project Aim ... 8
Project Objectives: ... 8
Chapter 2: Methodology ... 9
Service Coordination Working Group ... 9
Primary AOD Services ... 9
The Basin Centre ... 9
Wellington House ... 9
Audit Questionnaire ... 10
Snapshot Survey ... 10
Chapter 3: Project Findings ... 12
Initial Contact ... 12
Initial Needs Identification (INI) ... 13
Assessment ... 15
Care Planning ... 16
Service Specific Care Planning ... 16
Interagency Care Planning ... 16
Referral ... 20
Sending Referrals ... 20
Pathways for Sending Referrals ... 21
Referral Tracking ... 21
Services provided different levels of service after referrals had been sent: 22
Pathways for Accepting Referrals ... 22
Source of Referrals ... 25
Provision of Feedback for Referrals Received ... 26
Privacy and Consent ... 27
Use of Tools ... 29
Access to Technology ... 29
Data Recording / IT Systems ... 29
Assessment and Care Planning Tools ... 29
Organisational Structure and Support ... 31
Governance ... 31
Support for Collaborative Planning / Practice ... 31
Funding Systems and Reporting Requirements ... 33
Accreditation ... 34
Perceptions of the Service Coordination Framework ... 35
Chapter 4: The client’s experience: a case study ... 36
Chapter 5: The AOD sector’s strengths and opportunities for improvement .... 37
Current Strengths of the AOD Sector ... 37
Workforce ... 37
Client Centred Care ... 37
Triage/Intake Systems ... 37
Assessment ... 37
Opportunities for Improvement ... 37
Perceptions about Service Coordination ... 37
Client’s Transition Between Services ... 38
Organisational Systems to Support Effective Information Sharing ... 38
Minimal Interagency Collaboration or Intersectoral Links ... 38
Clinician’s Knowledge of Local Services ... 38
Limited Resources ... 38
Funding and Reporting Structures ... 39
Privacy and Consent / Managing Client Information ... 39
Chapter 6: Project Recommendations ... 40
Chapter 7: Where to From Here? ... 50
Acknowledging Strengths ... 50
Utilising Existing Resources ... 50
Shifting Focus ... 50
The Role of the Service Coordination Working Group... 51
Development of Organisational Policies and Support Systems ... 51
Education ... 52
Evaluation ... 52
Gather Additional Information ... 53
References ... 54
Appendices ... 56
Appendix 1: Relevant Policy Context ... 57
Federal ... 57
Victorian ... 57
Eastern Region ... 58
Appendix 2: Original Project Plan ... 59
Appendix 3: Audit Questionnaire ... 63
Appendix 4: Snapshot Survey Template ... 69
Appendix 5: Project Summary ... 70
EMR AOD Service Coordination Project
Phase 1: Executive Summary
Background
This service coordination project, initiated in March 2009, was an initiative of the Eastern Region’s Alcohol and Drug strategy group. This report consolidates the information collected during the project and provides recommendations to ensure the EMR AOD sector can build on its current strengths and tailor services to effectively and efficiently meet the needs of people with substance use issues in Melbourne’s Eastern Region.
Timely and appropriate information sharing is an essential component of effective service coordination with tangible and sustainable benefits for clients and services. This can be facilitated through the development of effective and efficient referral practices. For clients, comprehensive and consistent referral practices can support improved continuity of care, reduced duplication and promote seamless access to, and transfer between, drug and alcohol services. Additionally, sharing information, as a key component of effective service coordination, is proposed as an effective strategy to reduce the risks of relapse and deterioration during the client’s transition between services. From a service perspective, consistent and effectual referral systems support staff in maximising client outcomes, the efficient use of limited resources and hold potential for increasing service capacity. This project was therefore conducted with the aim to provide recommendations to support effective service coordination for AOD services in the EMR. A number of objectives were identified to achieve the project’s goals. These include:
Developing recommendations for systematic procedures across the EMR for sharing information between AOD services
Reviewing organisational supports in place to support effective service coordination Reviewing the applicability of SCTT based templates and tools for the AOD sector
Providing advice on strategies to develop a shared understanding of service coordination and develop a common language around sharing information among AOD services.
Initially, this project sought to understand and improve links between AOD services and the broader health sector. Initial consultation identified concerns about sharing sensitive client information with other services, particularly those outside the AOD sector. In conjunction with a limited understanding of the principles of service coordination, this was identified as a major limitation of the current system. It was therefore decided to focus on developing mechanisms for effective information sharing between AOD services. It is proposed however, that the recommendations are equally applicable and supported to promote effective information sharing with other relevant sectors.
Methodology
Over six months (March – August 2009), the project worker, supported by the AOD service coordination working group, conducted extensive stakeholder consultation, an audit of current practice, snapshot surveys of current referral pathways and a brief literature review to identify best practice guidelines. Information was collated to understand the strengths in the existing system and identify opportunities for improvement.
Strengths of the Current System
Service strengths focussed on a highly skilled and committed AOD workforce, delivering client centred, flexible and responsive services to meet the needs of their clients. Evidence demonstrates that services conduct thorough initial needs identification and assessment processes and facilitate early client engagement where possible.
Consultation identified that staff have a high level of understanding of the rationale for service coordination and are proactive in applying it’s principles within the boundaries of the existing service system. Some services demonstrate high levels of collaboration and information sharing with GPs, when supported by organisation protocols.
Limitations of the Current System
Misconceptions of the purpose and structure of service coordination were identified. Some services perceived service coordination as a strategy designed to ‘gate keep’ referrals and provide a mandated set of processes that voided organisation’s ability to develop and implement appropriate, local solutions. It is interpreted that the perceived resistance to service coordination is as a result of a cultural and language barrier, rather than concerns related to the philosophy or framework of service coordination.
The organisational structures and supports available to promote information sharing and effective referral processes were identified as key barriers. The complex service structure in the EMR has created disparate policies across the sector and a silo approach to client care and service development. Service’s processes and capacities to support clients as they are transitioning between services is an issue, raising ambiguities around service’s duty of care at this key stage.
Services universally raised concerns about limited resources available to meet the increasingly complex needs of their clients and the growing length of waiting lists. Staff were opposed to the development of new tools, reporting concerns about the additional time required to complete formal referrals. Concurrently, services reported that existing practice is often inefficient and time-intensive, when services attempt to gather client information from other services. Inconsistent data recording and IT systems were also identified as a barrier to easily sharing information.
Services reported concern that the existing funding structure, based on Episodes of Care, and the associated DHS reporting requirements, do not support services to provide evidence of the quality or intensity of care provided to meet client’s increasingly complex needs.
Driven by the principle that ‘a self referral is an empowered referral’, the AOD sector broadly promotes client’s independently initiating referrals for treatment. While relevant, this has reduced the formal interaction between service providers and places responsibility solely on the client to initiate and track referrals and repeat baseline information throughout their engagement with the sector.
Additionally, staff report concerns about inadequate knowledge of the services provided across the region. Currently, communication of service information is largely based on personal relationships, and informal collaboration rather than effective organisational processes.
Project Recommendations
Staff are encouraged to consider the client’s episode of care in their service, as one component of a client’s journey towards and through recovery. This client centred approach, supports a shift away from fragmented and episodic care, towards seamless, integrated and interagency service delivery. Sharing client information between services is a key component of this approach and is identified as both time efficient and cost effective.
The project identifies that effectively sharing information is not reliant on the use of specific tools or templates, nor does it require uniform information collection strategies across the sector. For this reason, the routine application of SCTT tools was not flagged as a priority. Currently, despite the use of different assessment tools and data collection strategies, services routinely collect the same set of information for each client. Service are therefore encouraged to share that information, with a view of reducing duplication and assisting the client to move forward in their journey. It is identified that this information sharing does not need to be mutually exclusive from the process of self referrals. It remains appropriate for clients to initiate referrals, however services can provide background information to support both the client and clinicians.
With these overarching principles in mind, services are encouraged to develop and implement organisational systems for a range of recommendations including:
Early identification of client’s previous treatment history
Appropriate and timely handover of client information (e.g. assessment form and discharge summary), upon request from receiving service
A standardised feedback loop to demonstrate acknowledgement of referral. Additional feedback endorsed where appropriate
Enhanced use of service registers, shared AOD training and orientation initiatives to support staff developing and maintaining up to date information about AOD services across the EMR
Ongoing work with PCPs to provide ongoing education regarding service coordination to the AOD sector
Ensure assessments include a thorough exploration of client’s broader health and social needs Establish clear guidelines regarding duty of care for clients during transition between services Establish and implement guidelines for the management of clients after unplanned discharges Support clinicians to provide clear rationale for sharing client information
Liaise with the Dual Diagnosis working group regarding project findings and develop strategies to support clients with coexisting AOD and mental health issues
Review the applicability of existing reporting requirements and funding structure for the AOD sector
Further detail of these recommendations is provided in chapter 6 of this report. To support the successful implementation of these recommendations, the development of compliance KPIs is supported. Such KPIs should be built into the organisational monitoring and evaluation systems as part of each service’s continuous quality improvement initiatives.
Conclusion
Applying the principles of service coordination to the AOD sector provides an opportunity to efficiently and effectively promote continuity of care, maximise patient outcomes and reduce demands on service providers. Services are encouraged to utilise the clinical reasoning skills of their staff, harness their commitment to providing high quality care and develop information sharing strategies that maximise the use of existing information.
Chapter 1: Introduction and Background
The Alcohol and Other Drug (AOD) sector, provides an important contribution to the health and wellbeing of Victorians through the provision of services designed to minimise the harm associated with substance misuse (DHS 2008b).
More than 26,000 Victorians access AOD services each year (DHS 2008c; DHS 2008b). Of these, it is identified that only a small percentage of clients are able to reduce or cease their substance use after receiving a single episode of advice or care (e.g. 1/8 alcohol, 1/10 tobacco) (MCDS 2004). The risk of relapse therefore remains high, the implications of which are widespread. The potential morbidity and mortality for the individual is clear, however relapse also impacts negatively on staff, health services and the broader community with substantial financial costs, reduced productivity and increased demand on health and community services (MCDS 2004; DHS 2006b; DHS 2008b).
Problematic substance abuse is therefore often a chronic and relapsing condition and it is widely acknowledged that people with substance use problems often experience a number of co-morbidities, concurrent health issues, welfare and social disadvantage (Wilson 2008). Therefore a holistic approach is required to recognise and manage the complexity of clients’ needs and ensure that the risk of relapse is not exacerbated by weaknesses in service delivery or organisational processes (DHS 2008d; Wilson 2008).
It is also recognised that clients’ pathways through the service system are rarely linear. The complexity of client’s needs requires the provision of a range of service options to provide care throughout different stages of a person’s recovery. Additionally there is a need to support clients through sustained engagement with the broader health system as well as welfare and other sectors (DHS 2008b).
The AOD sector therefore provides a broad array of services, focussed on prevention, early intervention, treatment, harm minimisation and recovery. Care is offered by a network of providers across the spectrum, from population level health promotion initiatives to comprehensive treatment programs for those affected by substance abuse.
While the unique attributes of addiction are acknowledged, many facets of effective service delivery are shared with other chronic and complex diseases. This includes negotiating complex systems of care, sharing sensitive information, identifying relevant resources and managing complex needs and co-morbidities such as mental health and psychosocial issues (Wagner et al. 2001). It is therefore reasonable to assume that the broad principles of effective chronic disease management can be applied to the AOD sector.
What is Service Coordination?
Service Coordination is a state wide initiative to promote functional service integration across the Victorian health sector (DHS 2001). Service Coordination seeks to align the practices, and systems of organisations to enable agencies to work collaboratively, while retaining their organisational autonomy (PCP Victoria 2007c). This framework promotes state wide consistency in practice and a common language to define and describe the range of processes that commonly occur across the health system (DHS 2001). The goal of service coordination is to provide a seamless and integrated service system to maximise client outcomes and organisational efficiency (PCP Victoria 2007b). Service Coordination is underpinned by the following principles:
A central focus on consumers Partnerships and collaboration The social model of health Competent staff A duty of care
Protection of consumer information Engagement of other sectors.
Service coordination provides a framework that outlines key practices, processes, protocols and systems across key elements of client’s care. These elements are designed to be incorporated into the context of existing organisational structures. This approach seeks to enable services to work together to develop and implement effective local solutions. The key elements of service coordination, as describers in The Victorian Service Coordination Practice Manual are outlined below (PCP Victoria 2007c).
Initial Contact
Initial Contact is the first point of contact with the service system and includes the provision of information and directing the client’s access to services.
Initial Needs Identification
Initial Needs Identification (INI) is an initial assessment process within which client’s issues are explored to understand the client’s risk, eligibility and priority for service.
Assessment
Assessment involves the collection and interpretation of information about the consumer in order to understand relevant issues and develop a care plan.
Care Planning
Care planning commences at the first point of contact with the AOD system and is completed on final exit from the system. It incorporates a range of activities including care coordination, case management, referral, feedback, monitoring and review. Care planning involves understanding and prioritising client needs and collaboratively developing appropriate actions.
Referral
Referral can occur at, or out of, any of the elements of Service Coordination. Referral is defined as “the transmission (physically or by other means) of personal and/or health information relating to an individual from one agency to another agency/agencies with the individual’s consent and for the purpose of further assessment, care or treatment” (PCP Victoria 2007c).
The Victorian Service Coordination Practice Manual depicts the following service co-ordination model.
Figure 1: Service Coordination Elements and Supporting Resources (taken from Victorian Service
Coordination Practice Manual)
Primary Care Partnerships (PCP) have taken a lead role in service coordination throughout Victoria. PCP Victoria have developed a range of assessment tools, referral forms and provided training to health professionals. Generalised and specialist resources have been provided, including AOD specific assessment tools and training for AOD clinicians.
Key Service Coordination Resources
The Victorian Service Coordination Practice Manual sets out the agreed Practices, Processes,
Protocols and Systems (PPPS) which support service coordination across Victoria (PCP Victoria 2007c). Within the EMR, the Service Coordination Protocol Manual builds on the state wide manual to support local agencies (OEHCSA 2002).
Good Practice Guide for Practitioners has been designed for clinicians to understand agreed
practice guidelines for the implementation of service coordination (PCP Victoria 2007b).
Continuous Improvement Framework is a tool designed to assist agencies to monitor and
continually improve service coordination implementation and practice. This is also identified as useful to assess organisation’s readiness and the infrastructure and practice change required (PCP Victoria 2007a).
The Service Coordination Tool Templates (SCTT) are a suite of tools that have been developed by DHS in consultation with the funded sector. They support Service Coordination practice by assisting with identifying the initial needs of clients and providing a vehicle to collect and share core client information in a consistent way across diverse programs and agencies. These tools are not assessment tools and are designed to support, not replace agency processes (DHS 2006c).
Human Services Directory is an online resource that aims to provide service providers with access
to accurate and up-to-date information about health, social & disability services in Victoria (DHS 2009b). A consumer focussed version, is also available on the Better Health Channel website (DHS 2009a).
Workforce development initiatives have been undertaken in a range of formats. Service
Coordination: What? Why? How?: Self Paced Training Module is a freely available web based
training program designed to provide practitioners with an overview of the context, purpose and PPPS of service coordination (PCP Victoria 2009).
What are the Benefits of Service Coordination?
Consumers often experience a service system that is fragmented, difficult to navigate and at times, not responsive to their needs (DHS 2008b). Service coordination aims to link services more closely, provide a more seamless system and ensure clients can access a cohesive service system.
This integrated, interagency model of service provision is identified as appropriate, cost effective and efficient, particularly in the management of chronic disease (Institute of Medicine 2001; Wagner et al. 2001). It supports organisation’s ability to achieve service objectives and facilitates sustainability in the delivery of high quality, safe and effective health care (NSW Health 2001; ACSQHC 2003; NPSA 2003).
Given a relatively small investment, service coordination can achieve tangible benefits for clients and services including:
a more systematic approach for clients with complex needs access to the right service at the right time
earlier identification of client needs better management of waiting lists improved service navigation reduced assessment duplication
increased coordination and collaboration in service delivery, planning and development greater operational efficiency (PCP Victoria 2005).
Existing Policy Context
In order to understand the relevance, applicability and prioritisation of service coordination for the AOD sector, it is important to understand the existing framework of services and the policy structure that guides the program’s implementation. A range of Federal, State and local policy documents exist that provide key directions for the AOD sector and support and guide service coordination. Relevant policies are outlined below, while this list is not exhaustive, it provides insight into the complexity and breadth of the policy environment. Each of these policies demonstrate a commitment to intersectoral practice and support the principles of service coordination as effective in optimising outcomes for clients and services. Please refer to Appendix 1 for a brief summary of each policy.
Federal
The National Drug Strategy: Australia’s integrated framework 2004-2009 (MCDS 2004). National Cannabis Strategy 2006 – 2009 (MCDS 2006).
The National Action Plan on Mental Health 2006 – 2011 (COAG 2006).
Victorian
Improving health, reducing harm: Victorian Drug Strategy 2006 – 2009 (DHS 2006b). A new Blueprint for the Alcohol and Other Drug Treatment Sector (DHS 2008b). Restoring the Balance: Victoria’s Alcohol Action Plan 2008 -2013 (DHS 2008c).
Shaping the future: The Victorian Alcohol and Other Drug Quality Framework (DHS. 2008). Better Access to Service: A policy and Operational Framework (DHS 2001).
Dual diagnosis: Key direction and priorities for service development (DHS 2007a). Victorian Health Promotion Plan 2007 – 2012 (DHS 2007b).
Care in Your Community: A planning framework for integrated ambulatory health care (DHS 2006a).
Eastern Region
Outer East Health and Community Support Alliance (OEHCSA) Community Health Plan 2006 – 2009 (OEHCSA 2006).
Service Coordination Protocol Manual: Representing the Practices, Processes, Protocols and Systems (PPPS) of member agencies of the Outer East Health and Community Support Alliance
.
(OEHCSA 2002).AOD Service Structure in the Eastern Region
The Eastern Metropolitan Region (EMR) comprises seven Victorian municipalities including the cities of Boroondara, Knox, Manningham, Maroondah, Monash, Whitehorse and the Yarra Ranges. It represents a diverse range of urban and rural populations and includes almost 20% of Victoria’s population (DHS 2008a).
The Department of Human Services (DHS) EMR provides and/or funds the full range of DHS services in the region, with the exception of hospital-based services. AOD services in the EMR represent an annual recurrent budget for 2009/2010 of $8.8 million. These include alcohol and drug withdrawal, residential rehabilitation, counselling, supported accommodation and outreach services.
Services are provided through a network of organisations, who receive funding from a range of sources, such as State and Commonwealth Government funding. Organisations range in size and have varying governance structures.
The EMR Alcohol and Drug Strategy Group
The Eastern Metropolitan Region (EMR) Alcohol and Drug (A&D) strategy coordination initiative was formed by the DHS EMR in 2007. Following extensive policy and data analysis, stakeholder consultation and evaluation, a strategic action plan was developed (Wilson 2008). In order to direct, coordinate and monitor the implementation of this plan, the EMR AOD strategy group was established, comprising members from DHS, Government funded A&D services, local government, regional police and mental health.
The plan aligns with Victoria’s key AOD policies and comprises four strategic areas, each of which are driven by working groups:
enhancing collaboration through service coordination enhancing collaboration through dual diagnosis integrated, place-based A&D health promotion workforce development.
The objective of the service coordination working group is identified as:
“To build a sustainable and effective collaboration with EMR PCP to support enhanced coordination of services between AOD agencies and other services” (Wilson 2008).
The service coordination working group aims to enable:
The AOD sector to be fully engaged with service coordination mechanisms Increased number of referrals between AOD agencies and other providers
Better support for consumers awaiting entry into withdrawal services or who are in transition between service types
The Service Coordination Project
This project forms a key initiative of the service coordination working group. Established in March 2009 and auspiced by Knox Community Health Service, the project employed a part time project officer for 6 months, to conduct an analysis of current practice, identify it’s strengths and weaknesses and provide recommendations to guide future service coordination initiatives.
Project Rationale
Over the last decade, the AOD sector has experienced significant change. The scope of service delivery and models of care have shifted to reflect, among other things, the increasingly recognition of the complexity of client’s needs (DHS 2008b). The treatment system therefore needs to be diverse, delivering timely, quality, evidence based treatment and interventions to clients throughout their journey towards and through recovery.
This has however, created complexity for clients moving in and between different treatment types and services and created an AOD system is not readily understood by prospective clients, their families or by other services. The need to create a more integrated system with clear pathways into, through and beyond AOD services is a priority (DHS 2008b).
Previous service reviews found that existing AOD treatment system is fragmented with inconsistent connections between AOD services and the broader public sector (DHS 2008b). It was therefore proposed that due to limited participation in service coordination initiatives, AOD clients received a less holistic response (at least initially) than community health clients (DHS 2007a; Wilson 2008). This project was therefore prioritised to develop an understanding of service coordination in the EMR and to identify opportunities for improvement.
Project Scope
Initially, this project sought to understand and improve links between AOD services and the broader health sector. Initial consultation identified that clinicians had concerns about sharing sensitive client information with other services, particularly those outside the AOD sector. In conjunction with a limited understanding of the principles of service coordination, this was identified as a major limitation of the current system.
It was therefore decided to focus this project on developing mechanisms for effective information sharing between AOD services. While this is an essential component of the ‘referral’ element of service coordination, it is proposed that sharing information effectively will also have positive impacts on the service’s capacity to effectively and efficiently identify client’s needs, assess, plan and deliver care for it’s clients. Additionally, while the project provides specific recommendation to support information sharing within the AOD sector, the recommendations are equally applicable and supported to promote effective information sharing with other relevant sectors.
Project Aim
Provide recommendations to support effective service coordination for AOD services in the EMR in order to:
enhance continuity of care for clients
improve client access to, and transfer between AOD services and the broader service system support clients to negotiate care pathways in the AOD sector
maximise patient outcomes by reducing risk during transition period between service engagement
reduce need for client to provide duplicate information maximise efficiency in use if of finite resources
reduce demands on clinicians/organisations through effective information sharing.
Support the provision of quality, effective care through timely information gathering and sharing of appropriate information
Project Objectives:
Develop recommendations for systematic procedures across the EMR for sharing information between AOD services
Review organisational supports in place to support effective service coordination Review the applicability of SCTT based templates and tools for the AOD sector
Provide advice on strategies to develop a shared understanding of service coordination and develop a common language around sharing client information among AOD services.
Chapter 2: Methodology
At the commencement of this project, a detailed project plan was created, outlining an intention to create and pilot tools and processes within two ADO agencies to support effective service coordination. Please refer to Appendix 2 for the original project plan.
Initial needs analysis and stakeholder consultation identified that the breadth of services delivered and their disparate governance and organisational structures were perceived as key barriers for effective service coordination. Additionally, there was a consensus that it was important to enable input from a range of services to gather feedback and create a shared understanding of the project’s intent and objectives (and that of service coordination more broadly).
In order to ensure that the project’s recommendations were applicable and appropriate across the EMR region, the project’s methodology was subsequently redirected. A number of approaches were used to understand the application of service coordination principles to the EMR AOD sector. Outlined below is a brief summary of the project’s methodology.
Service Coordination Working Group
Representatives from EMR AOD agencies, local government, PCPs and the mental health and housing/homelessness sectors, formed a working group to guide the development and implementation of service coordination initiatives, as part of the overarching EMR AOD strategy group. The working group met monthly to share their expertise, review and guide the project’s progress and ensure that project recommendations were relevant to the context and structure of the AOD sector.
Primary AOD Services
The Basin Centre and Wellington House were approached and engaged as the primary sites for the project. These services were chosen as they represent crucial and different components of AOD services delivery, operate within different governance structures and are well established in the EMR.
The Basin Centre
The Basin Centre is a 36 bed, residential recovery service for people with alcohol and drug addictions. Auspiced by The Salvation Army, it is a state wide service and accepts referrals via a range of pathways, predominantly self initiated and forensic referrals. The Basin provides a 16 week program for adults (after detoxification), incorporating a range of individual and group interventions.
Wellington House
Wellington House is a 12 bed, inpatient alcohol and drug withdrawal facility that forms part of Eastern Health’s alcohol and drug service. Intake and assessment processes are centralised across Eastern Health’s AOD services and are managed by ‘Carrington Road’. Services are available for adult residents of the EMR.
The project officer met with key contacts at each organisation periodically to provide informal education about service coordination and collect information regarding current practice, guiding philosophies, organisational structure, protocols and reporting mechanisms. Data collection strategies included informal interviews, audit questionnaires and a snapshot survey of incoming referrals (see below). Following the collation of data, the accuracy of project findings and key themes were discussed and the feasibility and applicability of recommendations reviewed with the key contacts.
Audit Questionnaire
An audit questionnaire was developed to collect information regarding current practices, perceived strengths and opportunities for improvement in service coordination. The questionnaire was conducted in person, or by phone, to ensure consistent data collection and to allow open ended questions to be thoroughly explored. A total of ten surveys were conducted, with a range of AOD services across the region. Respondents included:
2 youth specific services
4 inpatient services (providing withdrawal/detoxification, residential rehabilitation and supported accommodation services)
A range of outpatient services providing Counselling, Consultancy & Continuing Care (CCCC), outreach and specialist pharmacotherapy support etc.
State wide and location specific services
Combination of AOD specific organisations and those that provide AOD programs as part of a broad range of services.
Results from the audit were collated and used as baseline data to inform the project’s recommendations. Individual responses were also recorded and provided back to the participating organisation for review. Please refer to Appendix 3 for a copy of the questionnaire template.
Snapshot Survey
It was identified that many AOD agencies did not request or record information regarding the source of incoming referrals. Snapshot surveys were therefore conducted to collect information regarding referral pathways for incoming referrals. Please refer to Appendix 4 for a copy of the snapshot survey template.
Broader Stakeholder Consultation
In order to understand existing practices and potential areas for improvement, it was decided to broaden the scope of consultation. This was also considered an important opportunity to provide informal education about service coordination and the purpose of this project.
The project officer attended a local Eastern Collaboration of Alcohol and Drug Agencies (ECADA) meeting to provide an overview of the project and a project summary information sheet was supplied (see Appendix 5). ECADA attendees and working group members were then invited to participate in the audit questionnaire and provide feedback regarding their experiences with service coordination. Further consultation was held with representatives from DHS, local PCPs and the mental health sector to understand previous service coordination initiatives, existing practice, strengths and challenges related to engaging with the AOD sector.
Literature Review
A brief literature search was conducted to identify best practice literature and strategies for effective service coordination relevant to the AOD sector. Grey literature from the Federal and State Governments and particularly Primary Care Partnerships (PCP) Victoria, were reviewed to provide the essential context and ensure the appropriateness of project recommendations.
Chapter 3: Project Findings
The findings reported in this chapter synthesise the evidence gathered through the multifactorial data collection strategies employed for the project - evidence of current practice in the EMR and key components of best practice guidelines. As this project focused on promoting effective service coordination, the project findings are presented in relation to the key elements of service coordination as identified in the Victorian Service Coordination practice manual (PCP Victoria 2007c). Due to the scope of the project, some elements are explored in more depth. This does not indicate their relative importance in effective service coordination, it is simply reflective of this project’s focus. Additional findings are reported in relation to key themes.
Within this report, current practices of individual organisations are not reported, however, individual audit reports were provided to participating organisations for internal review.
Please note: When current practice is discussed in terms of a percentage of organisations, this relates to information gathered from 10 AOD services involved in consultation and the audit questionnaire.
Initial Contact
90% of services utilise an intake or centralised point of referral. Depending on the size and nature of the service, this may comprise a dedicated intake service, a duty worker system, the service manager or administration staff accepting referrals. The other service reported that ‘all staff’ are involved in a client’s initial contact however it is important to note that this is a very small service.
Services consistently reported confidence in their ability to provide clients with accurate information about the services offered by their organisation.
Currently, services made information about their services available in a range of formats. The most common sources of information were organisation’s websites, phone enquiries, Directline and service brochures. 70% of services reported collecting information about other services challenging – services reported concern regarding lack of up to date information and being unaware of new services or changes to existing AOD services in the region.
The ability for clinicians to efficiently gather appropriate and current information about access points for other services was also identified as a barrier to effective system navigation. Some services report referring clients to Directline to obtain information about appropriate services in order to self refer.
Recommendation:
Increase staff knowledge of AOD services across the EMR
Support AOD inclusion on the Mental Health Electronic Resource Manual (hard copy and CD-ROM now available – to be included on Eastern Health intranet in September 2009 and made available on Eastern Health website in future)
Increase information sharing regarding AOD initiatives and training opportunities with all service staff
Interagency Orientation Program: Bi-annual orientation for staff to receive information about services across the EMR. Orientation to include provision of information about: service offered, intake processes, inclusion/exclusion criteria. Opportunities to develop specific AOD sector orientation and/or link in with orientation programs being facilitated by the mental health alliance should be considered
Initial Needs Identification (INI)
Across the sector, terminology such as triage, pre-assessment and screening were used to describe the process of INI. As such, different processes were in place at each organisation and conducted by different team members (e.g. intake, service manager, counsellor/clinician). The priority of INI was consistently identified as risk screening. Participants’ existing INI processes were identified as effective in understanding the client’s needs and eligibility for their service.
Variable eligibility criteria and funding structures necessitates that services use different information to prioritise their clients. Services generally maintain a ‘no wrong door’ policy and therefore report that very few referrals (<5%) are deemed inappropriate. Residential programs reported the lowest rate of appropriate referrals (65%) reporting that their intense programs often did not meet the needs, or expectations of the client.
The existence of the ‘no wrong door’ policy, also means that in many services, clients are not subject to specific eligibility criteria or structured prioritisation systems. Instead senior staff applied their clinical reasoning to assess a client’s risk and balance the service’s capacity to effectively manage their care. Factors that may affect a client’s prioritisation include pregnancy, child protection issues and the client’s age (some services provided youth specific services or prioritised young people). A recent review of the sector identified that ‘wrong doors’ do exist as well as the phenomenon of ‘too many doors’. The report identified this as a barrier to achieving a holistic response and was mirrored within this project’s findings around system navigation (Wilson 2008).
Limited handover between services was identified as a major barrier in relation to timely risk screening. Clients not providing an accurate presentation of their situation, past experiences and/or treatment history was frequently identified. Fears were also raised that clients may not be accepted into a program if information was provided (by the client or a staff member) related to challenges in previous treatment and/or behavioural issues. Clinicians acknowledge their duty of care to provide accurate information to ensure the safety of clients and staff. It appears that this may be a reason that information sharing between staff is avoided in some instances, responsibility for the provision of accurate information is therefore left to the client.
Recommendation:
Ensure Organisational policies support sharing of information between agencies,
incorporating the early identification of client’s previous treatment history.
Standard practice at Initial Needs Identification to include:
Question regarding engagement with other AOD services (and other sectors e.g. mental
health and housing)
Disclosure of information form to be signed during first contact (or verbal consent gained
and recorded in client’s file as necessary)
Request that client include previous worker’s details (e.g. on assessment form or key
contact list) to enable staff to provide basic handover information via phone
Best practice guidelines emphasise the need to ensure that client screening identifies complex medical, social and emotional needs and service responses are holistic and integrated with other health and welfare service providers. Again lack of information about referral pathways and the availability of other services was identified as a barrier.
In accordance with the sector’s directive, the Dual Diagnosis screening tool has been integrated into the INI systems of many services. This tool is used to identify the potential for mental health issues. When mental health issues are identified, staff do not always have the capacity to provide the appropriate support to manage these mental health concerns prior to the client’s admission.
Additionally, staff report they do not have the expertise and qualifications required to manage mental health issues internally and have difficulty accessing care for clients in crisis or supports for clients experiencing high prevalence disorders (anxiety and depression) that fall outside of the clinical mental health system.
The efficacy and appropriateness of collecting this information during INI is highlighted and questions are therefore raised about whether services:
Have a duty of care to act immediately?
Have a responsibility to delay the Dual Diagnosis screen until the client is admitted and can be supported to access support?
Should not be conducting the Dual Diagnosis screen until appropriate systems are in place to provide support to meet client’s needs?
Recommendation:
Review guidelines for dual diagnosis screening and ensure that organisations understand
Assessment
Services existing assessment practices were universally identified as a strength of current service delivery. Conducted by highly skilled clinicians, services consistently provide evidence of comprehensive assessment of their clients’ drug and alcohol issues and the application of this information to inform goal setting and care planning.
Although different tools were utilised, services gathered remarkably consistent information within their assessments. This includes:
Demographic information Social status and supports Drug history Medical history Medications Psychiatric history Legal history GP details
Varying evidence was identified however, of services assessment of a client’s need for broader health and social services. Residential AOD services and those situated within a community health setting, demonstrated enhanced capacity and application of this. Consideration is required however, of the varying duration and intensity of services provided across the sector and their relative ability to conduct these broader assessments.
Recommendation:
Ensure Assessment tools contain an assessment of clients’ broader health and social
needs and systems are in place to support clinicians to access appropriate support.
Duplication of assessments was raised as a key concern by 100% of audit questionnaire participants and stakeholder interviews. Despite being identified as best practice, only 20% of services consistently forwarded assessment information to other AOD services when aware of a referral and only 10% of services had organisational policies to support this practice.
Recommendation:
Ensure Organisational policies support sharing of information between agencies,
incorporating appropriate handover of information between AOD services.
Care Planning
Service Specific Care Planning
Services reported confidence in their abilities to work collaboratively with clients in the development of service specific care plans. Again, different terminology was used to describe these plans, however 100% of services reported completing individual treatment plans, care plans or client action plans. Each of these tools involves the development of client goals and appropriate action plans. Care plans were also identified as useful in monitoring clients’ progress and discharge planning.
Interagency Care Planning
People with chronic alcohol problems find temptation to relapse is strongest immediately after exiting withdrawal services (DHS 2008c). Transition between services more broadly is identified as a high risk period for clients. Long waiting lists, particularly for residential AOD services are common, indicating a need for effective strategies to support clients while awaiting services.
Best practice guidelines therefore indicate the need for effective planning during the transition between services. This necessitated collaborative care planning that is supported by strong working relationships and effective communication pathways between services (DHS 2008b).
The ability to access appropriate support for young people transitioning from youth services, to adult services was identified as a particular concern. The ability for adult services to be tailored to meet the needs of young people, was also highlighted as a challenge as they move through the system.
Recommendation:
Review opportunities to support young people in their transition from youth specific to
adult AOD services
There was no evidence of care plans being shared between AOD agencies. Stakeholder discussion did identify however, that in circumstances where Integrated Treatment Plans (or shared care plans) were used for clients engaged in the mental health and housing/homelessness sectors, they had been an effective tool to support collaborative interagency practice.
Recommendation:
Consider the applicability of Integrated Treatment Planning
Integrated Treatment Plans, otherwise known as consumer recovery plans or shared care
plans, are client centred, interdisciplinary and interagency care planning tools.
Shared ITPs could be created at the client’s initial point of entry into AOD services to record a
client’s journey throughout their entire episode of care, across services. Pathways would
contain the client’s goals, progress of achievements and relapse prevention strategies. ITPs
provide the potential to further enhance the client’s continuity of care and support active
engagement with services. ITPs may be specific to the AOD sector or shared across other
sectors including mental health and homelessness.
Effective implementation will be dependant on organisational support for interagency
collaboration and care planning and support from DHS.
No service reported a coordinated, interagency approach to support clients while on waiting lists for residential services. If already engaged, the majority of outpatient CCCC services reported ongoing service provision while the client awaited admissions and often re-engaged with the client on discharge. For those clients not already engaged with an AOD service, no system was identified to support clients awaiting admission. 50% of in-patient services reported providing phone based support for clients while on their waiting list, however this was client initiated and very restricted in scope. It was also identified that some clients remain on multiple waiting lists at different services throughout the sector.
Recommendation:
Introduce standard practice for clients to access appropriate support while on waiting
lists for in-patient programs.
This may include:
Providing information and support to enable clients to access appropriate CCCC services
while awaiting admission
Development of case management service to ‘gap fill’ and address clients’ urgent needs
Unplanned discharges
Unplanned discharges are a common event in AOD service delivery. These may occur as a result of the client choosing to cease their participation or when a client breaches the terms of their service agreement/contract, and are then asked to leave the program (particularly relevant to inpatient services).
Concerns were raised about services’ capacity to provide an appropriate discharge plan for clients following an unplanned discharge. While this was identified as a particular challenge for inpatient programs (100%), outpatient services also acknowledged poor consistency and limited organisational processes to support these clients.
Recommendation:
Establish and implement consistent guidelines for the management of clients
following unplanned discharges.
This should include:
developing an appropriate discharge plan to ensure the client’s safety and access to other
appropriate services
consistently gathering consent to share information with other services in the event of an
unplanned discharge (e.g. AOD service, GP or mental health team)
Residential services also reported receiving referrals for clients with no fixed community address and that this raised questions about whether these AOD services are being accessed to ‘solve’ homelessness issues. This is of particular concern in the case of unplanned discharges as the AOD service is often unable to access appropriate crisis accommodation for the client. Significant concerns were raised regarding the service’s duty of care to these clients. To manage this, one residential service reported that if a housing worker is not engaged to support the client with appropriate housing, the client may be declined from their service until a housing worker can be engaged.
Recommendation:
Engage with the housing and homelessness sector to identify strategies to support
Accepting and Ceasing Responsibility for Clients
Services were asked about organisational policies related to accepting and ceasing responsibility for clients as they progress through their service. Services reported a lack of clear direction and understanding about their organisational policies or the associated legislative requirements.
DHS’ incident reporting requirements indicate that “persons who have completed an episode of care or have had an agency contact in the past month (30 days) should also be considered as active clients” (DHS 2004). While not definitive, this provides an indication of the Department’s expectations in regard to a service’s duty of care to their clients. Further information is required to understand this more completely.
Varying practices were reported, however these appeared to be based on clinician’s clinical reasoning, rather than clear protocols. The current practices are broken down below to account for the differing context of inpatient and outpatient programs.
Inpatient Services:
Accepting responsibility (duty of care) for client: 75% on admission
25% at assessment
Ceasing responsibility (duty of care): 75% on discharge
25% when engaged at next service
Outpatient Services
Accepting responsibility (duty of care) for client:
33% at initial contact (if risk identified, staff have responsibility to address it, or, acknowledge a responsibility to ensure that referral is actioned and that the client and/or referrer is informed of outcome)
66% at assessment / when placed on waiting list Ceasing responsibility (duty of care):
50% when service no longer clinically indicated 50% when engaged at next service
Recommendation:
Establish clear guidelines regarding admission and discharge including:
service’s duty of care for clients on admission and discharge
indicators for opening and closing an episode of care
Referral
Given the nature of substance dependence, the need for an approach that provides effective guidance through the possible treatment pathways is of critical importance (DHS. 2008). Effective referral systems are a crucial element of this and formed a key component of data collection for this project.
Evidence demonstrates that established and agreed referral processes between services can achieve tangible benefits for clients and services. These include reducing delays for client care, minimising duplication in assessment and treatment and promoting continuity of care (KPMG 2004; PCP Victoria 2005; PCP Victoria 2007c)
Effective referral practices are the responsibility of all organisations involved. Therefore referral systems for sending and accepting referrals are discussed.
Sending Referrals
There are two main types of referral:
Self referral: This is where a consumer takes responsibility for contacting another agency to make a
referral on their own behalf. The guidelines recommend that when clients’ make a self-referral, clinicians should support them by providing handover information including their agencies contact details and a copy of completed assessment tools (PCP Victoria 2007c).
Assisted referral: This is where practitioners, given client consent, make a referral to another service
provider on behalf of their client (PCP Victoria 2007c). In 2006, the IEPCP facilitated the development of Assisted Referral Guidelines for the AOD sector (IEPCP 2006a). These guidelines outline the circumstances within which an assisted referral is indicated. Please refer to Appendix 6 for a copy of the guidelines.
In some circumstances a referral can be made without consumer consent, this includes when referrals need to be made to “statutory services (e.g. Child Protection) specialist services (e.g. Mental Health) or where an immediate referral is in the best interests of the consumer” (PCP Victoria 2007c). The AOD sector broadly promotes client’s independently initiating referrals. This is driven by the principle that a ‘self referral is an empowered referral’ and is identified as an appropriate tool to ensure the motivation and commitment of clients and to facilitate clients taking responsibility to be pro-active about their care. Currently, when a client makes a self referral, AOD services are not routinely providing a handover of information to other AOD services to support the client’s transition.
Recommendation:
Ensure organisational policies support sharing of information between agencies,
incorporating:
Handover of information regardless of whether self referrals or assisted referrals are
made.
Pathways for Sending Referrals
20% of services used a standard form/format to send referrals
50% of services reported the need to use specific referral forms for some agencies as a key challenge and barrier in discouraging them from sending referrals / handover information
Limited knowledge of the services offered by other organisations and their referral pathways was identified as a barrier to effective referral systems by 50% of participants.
Referral Tracking
30% of services had processes in place to ensure that a referral had been received (via follow up phone call or fax receipt confirmation)
50% reported referrals were not tracked
20% relied on client feedback to track the progression of referrals
100% of services reported that details of outgoing referrals were recorded only in client files and used solely for individual client care.
Services reported that aggregate data regarding referrals would be beneficial to create stronger networks and referral pathways with commonly used services and support stronger information sharing. Staff queried the capacity of data recording systems (e.g. ADIS and TrakCare) to generate this data.
Recommendation:
Develop and implement standardised mechanism for referral tracking. This should
include:
allocation of responsibility to track referrals
standard practice for follow up (particularly when delayed / declined)
Review the capacity for existing IT systems (ADIS/TrakCare) to generate reports
related to referral pathways
If available, reports should be used to:
monitor compliance to support client’s referral
identify and monitor common referral pathways
encourage
collaborative
interagency planning
Services provided different levels of service after referrals had been sent:
30% of services remain in contact if initiated by the client
40% of services remain engaged with the client until the client is accepted at the next service 30% of services had no contact with services after discharge/referral sent
Pathways for Accepting Referrals
AOD services across the region accept referrals through a variety of pathways. The majority of services accept referrals through a combination of formats and from multiple sources.
Referrals are accepted in a variety of formats – phone, fax and email/electronic referral systems are most common. Only 10% of services accept referrals via S2S at their centralised intake system (although this was rarely utilised for AOD referrals).
90% of services retain records of all referrals and enquiries received – hard copies and/or electronic information is recorded and used to initiate a client’s episode of care. For those enquiries that are not activated, data is archived.
10% of services are required to use data regarding incoming referrals in reporting requirements for funding pathways.
Recommendation:
Ensure organisational policies support sharing of information between agencies,
incorporating: Services to accept referral information in a range of formats
Organisational policies should accept handover information from other AOD services that is
provided using the sending agencies existing formats/tools
100% of services reported that client information should be shared between AOD services sharing client care. Benefits identified by participants included; optimising client outcomes, reducing assessment duplication and time savings for the client and clinician. Limited information sharing in the existing system was identified as a key barrier and reported that existing practices to follow up previous service providers are time intensive and at times deemed too inefficient to warrant. 90% of services reported that implementing systems to facilitate easier handover of information between AOD services would make it easier to accept, process and prioritise incoming referrals. Some services reported concerns about the accuracy of information provided by clients (when collected by other services) and therefore felt it was necessary to independently collect the information.
Recommendation:
Ensure organisational policies support sharing of information between agencies,
incorporating: Appropriate and timely handover of client information
Service to utilise existing data to provide handover information. Guidelines of appropriate
information to include:
Demographics / SCTT consumer information
Social status
Drug history (including type and nature of drug use)
Co-morbidities (medical history including key issues e.g. pregnancy, mental health issues
etc.)
Risk screening (e.g. self harm, suicidal ideation etc.)
Medications
Psychiatric
history
Legal
history
Treatment
history
GP details
NB: Inappropriate to handover information gathered from other service providers (e.g.
Forensic or child protection reports) without specific client consent.
Additionally, limitations were identified by some service’s restrictions to only accepting self referrals. This raised questions about potential delays in providing appropriate information and made it more difficult for other services to provide a handover.
Recommendation:
Ensure organisational policies support sharing of information between agencies,
incorporating: Services to accept referral information from other service providers and
assisted referrals where appropriate.
Handover information should be accepted from other services, regardless of whether a self
referral or assisted referral has been made. Additionally, all agencies must accept assisted
referrals from other agencies when appropriate.
The complexity of referral pathways was identified as a key concern. Challenges accessing local mental health services were frequently identified. Referrals to clinical mental health services in the Eastern region are triaged through a central intake service. It is therefore advertised that referrals can be made by calling one centralised number. While this appears to be a straight forward system, the reality is much more complex. Particular challenges include:
Referrals to centralised number declined/ deemed inappropriate Information unavailable regarding more appropriate service
Minimal feedback provided to referrer (referrer unsure if referral is accepted, actioned or timeline for service delivery)
Similar issues were identified regarding the referral pathways into AOD services.
