Mental Health Residential Services Review

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Mental Health Residential Services Review

Nelson Marlborough/Top of the South

Discussion Document for Consultation

July 2015

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Feedback on this report is welcome

Please provide feedback on this discussion document by Monday 7 September. This can be written (email, letter) or verbal (phone or meeting). It can be a personal submission or made by a group of people.

Please provide feedback to:

Email: Claire.mckenzie@nmdhb.govt.nz Post: NMDHB Private Bag, 18 Nelson 7042 Ph: 03 546 1664

Fax: 03 546 1747

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1. PURPOSE OF THIS REPORT

This paper is prepared in order to facilitate discussion as part of a review of the needs for and provision of residential Mental Health Services across the Nelson Marlborough district.

A discussion document for the review of residential services in Marlborough was released in October 2014 and submissions and discussion on that document were received from a range of individuals and organisations across the Nelson Marlborough district. Some key themes and preferred directions emerged from the Marlborough review. These have been used to shape the proposed directions for the way services are organised and delivered in the wider context of both Marlborough and Nelson Tasman.

In this context, feedback on this report and the key directions is now sought. The themes, future directions and questions for consideration are in Section 5 (page 14).

2. INTRODUCTION

2.1 Background

Service developments in Mental Health Services are guided by “Rising to the Challenge: The Mental Health and Addiction Service Development Plan 2012–2017” in which there are four overarching goals:

1. Actively using our current resources more effectively

2. Building infrastructure for integration between primary and specialist services 3. Cementing and building on gains in resilience and recovery

4. Delivering increased access

All goals are relevant to this review, particularly within goal 3 – actions to enhance social inclusion through increasing service flexibility in community living supports (Refer page 25 of Rising to the Challenge; Appendix 1 of this document, page 17).

The review of residential services started with a review of services in Marlborough in response to concerns about a lack of choice and staged options in residential services. The review is now extended to Nelson- Tasman residential services in order that decisions can be made in a district-wide context.

This process of review is led by the Mental Health Services Directorate of Nelson Marlborough District Health Board (NMDHB). It has included: collation of information, identification of current services, a literature scan, as well as collation of issues as understood from discussions with consumers, family/whānau and providers.

There is consideration of how well the current service configuration meets the need and what future options there are. Feedback has been received from stakeholders. Appendix 2 (page 18) outlines the people involved in this review so far.

2.2 Scope

The review considers services required by those with severe and enduring mental illness.

The review does not include: Addictions (alcohol and drug) services; CAMHS; Regional services (not provided in Nelson Marlborough); Health of Older People/psychogeriatric services; or Needs of people with Lifelong Disabilities.

2.3 Goal for the Review

The review seeks to identify the best use of available resources to maximise resilience and recovery for eligible consumers through better addressing their accommodation needs.

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2.4 The Populations of Need and Care Continuum

In 2008, the NMDHB Populations of Need report described different populations that have a need for mental health services. It also emphasised the importance of a continuum of care – that is, different levels of care being provided depending on the level of need of the consumers. It identified that achieving wellness or whānau ora is everyone’s responsibility: Mental Health Services, consumers, families/whānau and the wider community. Recognising this and taking a Mental Health Service consumers view, an Integrated Recovery Model of Care was also presented in the 2008 report. It puts the consumer at the centre of care, surrounded by the family, friends and the partners who are most likely to provide support to the individual. These models are available in the technical report (www.nmdhb.govt.nz...

It is emphasised that this residential review covers the services for those people most severely affected by mental health conditions (approx 4.7% of the population) and who are accessing the Specialist Mental Health Services. These services treat and support people to achieve recovery and resilience, moving to greater independence.

Recovery

The Substance Abuse and Mental Health Services Administration in the USA (SAMHSA) defines recovery as

“A process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential”. SAMHSA has delineated four major dimensions that support a life in recovery:

 Health – Overcoming or managing one’s disease(s) or symptoms and for everyone in recovery, making informed, healthy choices that support physical and emotional wellbeing.

 Home – A stable and safe place to live

 Purpose – Meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavours, and the independence, income and resources to participate in society

 Community – Relationships and social networks that provide support, friendship, love, and hope.

http://www.samhsa.gov/

2.6 Guidance and Expectations of all DHBs

BluePrint II

The Mental Health Commission’s Blueprint II: Improving mental health and wellbeing for all New Zealanders – How things need to be (June 2012) identifies the determinants of mental wellbeing as including housing, along with income, access to resources, educational level, employment, stress, social inclusion and discrimination. Achieving improved mental health involves cross-government and community action to enhance the protective factors that determine mental wellbeing i.e. creating living conditions and environments that support people to be mentally healthy.

Rising to the Challenge

Rising to the Challenge: The Mental Health and Addiction Service Development Plan 2012–2017 (the Plan) provides a strong vision to guide the Mental Health and Addiction sector as well as clear direction to planners, funders and providers of Mental Health and Addiction Services on Government priority areas for service development over the next five years. The plan includes 100 actions, to be delivered by the Ministry of Health, District Health Boards and Mental Health and Addiction service providers.

[http://www.health.govt.nz/our-work/mental-health-and-addictions/rising-challenge]

Of particular relevance to this review of residential services is the priority action to “Cement and build on gains in resilience and recovery for people with low-prevalence conditions and/or high needs” (page 21).

These include:

 Enhance social inclusion opportunities

Work to enhance social inclusion for those people whose lives have been most disrupted by low- prevalence conditions (mental health or addiction). This work will involve:

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 increasing service flexibility so that community living supports are available wherever a person chooses to live; not only in inpatient and residential settings

 working with Housing New Zealand, private landlords and real estate agencies to find ways to:

o expand access to affordable accommodation options within communities o support people to maintain their existing housing.

Service Coverage

The Service Coverage Schedule (SCS) describes the expectations of all DHBs for funding of services. In relation to residential services for Mental Health and Addictions, the SCS describes the following:

 Services to support people to recover and develop resilience – to enable people with experience of mental illness and addiction to participate in the every day life of their communities and whānau including: …liaison and support with education, employment and housing for service users, including service user-led recovery services and peer support

 Services for people with mental health and/or addictions problems and/or damage from alcohol and other drug abuse and other causes needing long term support including:

o residential support (supports to live in the clients own home) including home support services;

o residential care, including hospital rehabilitation o planned respite.

3. CURRENT SERVICES & UTILISATION

3.1 Overview

A range of Mental Health Services are available across Nelson Marlborough, funded by NMDHB.

Marlborough has about one-third of the DHB’s population, while Nelson Tasman has two-thirds. The proportion of Mental Health Service consumers who live there and the proportion of services provided there do not match this proportion. Snapshots in 2008 and 2012/13 identify that 25-27% of Mental Health consumers live in Marlborough. Analysis of service utilisation for NGO (non-governmental organisations) residential and community support services indicate that 30% of consumers are Marlborough based (see 3.2 below). There is anecdotal evidence that there is some drift of Marlborough consumers to Nelson, either to access services, to re-locate away from an unsupportive peer group or for other personal reasons.

In terms of services provided in the NGO sector, a comparative analysis (below) shows the distribution of services across the district.

 There is proportionate distribution of: Adult community support and consumer advocacy

 Marlborough has a higher proportion of peer-led day activity, peer-led acute/crisis respite, and Family/Whānau support (Noting though, that Nelson also has a rehabilitative day programme run by the DHB at Nikau House in addition to the peer-led service)

 Nelson-Tasman has a higher proportion of vocational support adult supported accommodation, youth community support and youth supported accommodation.

Some specialist and high cost services are only provided in Nelson City as these are not clinically or financially feasible to provide in more than one location – i.e. inpatient admissions and residential rehabilitation – but these services are available to the district-wide population. Given this is the case, it might be expected that there would be a need for more community services and use of respite in Marlborough.

It is also noted that some consumers with mental health conditions are unwilling to engage with services regardless of what services are available – for reasons both related and unrelated to their condition.

The capacity of funded NGO services across the district, related to the scope of this review is in the following table:

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Capacity

Provider Services

Nelson

Tasman Marlborough Definition

Te Whare Mahana Adult Community Support 21

No. of consumers at any time

Te Piki Oranga Adult Community Support 52 32

Gateway Housing Trust Adult Community Support 179 33

Richmond NZ Adult Community Support 42

Total 252 107 359

% of total 70% 30%

Gateway Housing Trust Youth Community Support 22 4 _{No. of}

consumers at any time

Te Whare Mahana Youth Community Support 4

Te Piki Oranga Youth Community Support 24 8

Total 50 12 62

% of total 81% 19%

Gateway Housing Trust Adult Supported Accommodation 14 beds

Mental Health Support

Services Adult Supported Accommodation 35 5.5 beds

Total 49 5.5 54.5

% of total 90% 10%

Gateway Housing Trust Youth Supported Accommodation 5 beds

Total 5

% of total 100%

Care Marlborough Consumer Advocacy 30 _{No. of}

consumers per mth

Health Action Trust Consumer Advocacy 80

Te Whare Mahana Consumer Advocacy 9

Total 89 30 119

% of total 75% 25%

Care Marlborough Peer Led Day Activity 55 _{No. of}

consumers per mth

Gateway Housing Trust Peer Led Day Activity 10

The White House Peer Led Day Activity 62

* Nelson also has a DHB rehabilitative

day programme at Nikau House Total 72 55 127

% of total 57% 43%

Gateway Housing Trust Peer Led Acute Respite 4 beds

Health Action Trust Peer Led Acute Respite 4 beds

Total 8

% of total 50% 50%

SF Marlborough Family/Whānau Support 42 ^No.

families/

whānau per mth

SF Nelson Family/Whānau Support

52

Total 52 42 94

% of total 55% 45%

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Capacity

Provider Services

Nelson

Tasman Marlborough Definition

Te Ara Mahi Vocational Support 80 20

No. clients per mth

Total 100

% of total 80% 20%

% of population 68% 32% 100%

% of Mental Health current clients 73% 25-27% 100%

3.2 Residential Services

Residential Services Available

Current funded residential services in Nelson Marlborough are:

 Respite services in a residential setting are an option for people who would otherwise require admission to acute inpatient mental health services or who need a period of support to maintain or prevent deterioration of their mental health status. These services in NM are provided as peer-led services and are available as crisis respite or planned respite.

 Housing and recovery-focused support services for people who experience mental health disorders, and who would respond positively to a housing and recovery environment and actively agree to access this type of service. Staff sleep overnight on the premises, but are available to respond if required.

 Housing and recovery-focused support services for people who experience mental health disorders with higher levels of acuity with 24-hour support, provided by appropriately trained and qualified support workers and access to clinical staff are required to meet individual needs

Details are:

Description Provider Volume

Adult Crisis Respite – pre/post- acute – both are peer-based services

(MHA03)

1. Hapai Te Ora in Blenheim managed by a partnership of Gateway Housing Trust, CARE Marlborough and SF Marlborough 2. Kotuku in the Tasman district run by

Health Action Trust

4 beds, Blenheim 4 beds Tasman district Total of 8 beds, 2920 bed nights per annum Housing & Recovery services

with full day awake /responsive night support (MHA25)

1. Gateway Housing Trust – Motueka, 4 beds 2. Gateway Housing Trust – Nelson City, 10

beds

3. Mental Health Support Services Ltd – various locations in Nelson City – 20 beds

4 beds Motueka 30 beds Nelson City Total of 34 beds, 12410 bed nights per annum

Housing & Recovery services with full 24/7 awake support (MHA24)

1. Mental Health Support Services Ltd – Lewis St, Blenheim, 5-6 beds

2. Mental Health Support Services Ltd – various locations Nelson City, 15 beds

5.5 beds Blenheim 15 beds Nelson City Total of 20.5 beds, 7482.5 bed nights p.a.

From time to time, Marlborough consumers utilise services in Nelson. This may be following admission to the Mental Health Admission Unit (MHAU) or direct referral to a residential service if the Nelson-based services better meet their needs, or if there is no placement available in Marlborough. It is also possible for Nelson people to use Marlborough services, although in practice this is rare.

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Residential Services Utilisation Respite

The Marlborough service, Hapai Te Ora, experienced a period of very low occupancy in November 2013 and February 2014. Steps have been taken to increase the occupancy to make better use of the service and this has been the case in more recent months

Overall the total occupancy for the MHA03 services has been:

Provider Occupancy over 2013/14 Occupancy Jul-Feb 2014/15

Gateway (Hapai Te Ora) 54% 67%

Health Action (Kotuku) 83% 71%

Total 68% 69%

Number of clients using the respite services has been:

Provider Average per month

2013/14

% Bed nights 2013/14 % Bed nights Jul13-Oct14

Gateway (Hapai Te Ora) 10 39% 40%

Health Action (Kotuku) 25 61% 60%

Total 35 100% 100%

Housing & Recovery Service – responsive nights (‘sleepover’)

Mental Health Support Services 83% 87%

Gateway’s Motueka service 57% 89%

Gateway’s Nelson City services 86% 85%

Total 81% 87%

Housing & Recovery Service – awake nights

Across all these MHA24 services, occupancy has been:

Mental Health Support Services - Blenheim 76% 83%

Mental Health Support Services - Nelson 91% 86%

Total 87% 85%

Length of Stay in Supported Accommodation

In February 2015, there were 49 people in supported accommodation – of these, 9 (18%) had been there less than a year, 28 (57%) between 1 and 5 years and 12 (24%) for more than 5 years.

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Comparison to other DHBs

The following chart shows that NMDHB has a high number of residential beds per head of population in relation to other DHBs.

Source: “Key Performance Indicators (KPI) for New Zealand Mental Health and Addiction Services – National Adult Mental Health Services (Financial Year 2013, published version)”, March 2014

Residential Services Discussion

In the distribution of services relative to the population size, Nelson Tasman has a higher proportion of residential accommodation; a lower proportion of respite beds and a proportionate level of adult community support.

Overall, Nelson Marlborough has a high number of residential beds than other DHBs. Availability influences utilisation to an extent, in that if a service is available and funded it will be used.

A higher proportion of the bed nights for respite are utilised in Blenheim than population numbers might suggest. However, as there are no inpatient services and fewer residential beds in Blenheim, respite is sometimes utilised to prevent admission to the inpatient unit.

For consumers using any of the residential Mental Health Services, the clinical care plan remains under the oversight of the Specialist Services care team.

3.3 Community Support Services

Community Services Available

Community Support is a key service is supporting people with mental illness to live well in the community.

The services are provided by non-clinical workers that do a range of support work such as: assistance with household activities like cooking and cleaning; supporting access to community activities and events; and accompanying consumers to appointments e.g. with Work & Income or health services.

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Services for adults currently provided are:

 Richmond NZ – Marlborough

 Te Whare Mahana - Golden Bay

 Gateway Housing Trust – Nelson, Tasman and Marlborough

 Te Piki Oranga (Kaupapa Māori) – Nelson, Tasman and Marlborough Community Services Utilisation

In total, Community Support Work is provided across the district for an average of 164 people per month, within the capacity of between 214 and 278 with the 21.4 FTE. The expected caseload is between 10 – 13 people at any one time per fte – and will vary depending on the level of need for each client.

73% of the CSW clients were in Nelson/Tasman in 2013/14 and 27% in Marlborough. 70% of client contacts were in Nelson/Tasman and 30% in Marlborough, reflecting a slightly higher number of contacts per client in Marlborough (9.3 per month) than in Nelson/Tasman (8.2).

Currently, Richmond Services are providing some evening and weekend supports (e.g. medications) which are assisting consumers to manage more independently than might otherwise be the case.

Note that this utilisation analysis excludes the Kaupapa Māori services. Prior to July 2014, Te Kahui Hauora o Ngati Koata provided Kaupapa Māori adult community support and since then services are being provided by Te Piki Oranga. Due to this restructuring of providers and contracts, the reporting is not comparable between these periods.

3.4 Other Mental Health Services

As outlined in 3.1 above, there are a range of other community-based services provided by non- governmental organisations (NGOs) in Nelson Marlborough:

 Consumer Advocacy Service (Care Marlborough; Health Action Trust; Te Whare Mahana)

 Family/Whānau Support (Supporting Families, with branches in Marlborough and Nelson)

 Vocational Support (Te Ara Mahi)

 Through NASC, carers for respite are accessed in the community.

The Consumer Advocacy Services support some consumers in relation to accommodation. This might include when people needed to change accommodation due to changes in circumstances, illness, poor quality of housing or moving into or out of the area. Housing-related support offered includes help with filling out forms, liaison with Housing NZ, help with disputing rent increases and support during housing inspections.

3.5 Needs Assessment Service Coordination (NASC)

All Mental Health Service consumers have access to the Needs Assessment Service Coordination (NASC) which identifies the services they need in the community and links individuals with these services. It includes access to funded packages of care. The following are some of the things that can be funded, but it is not an exhaustive list as packages aim to respond to individual needs:

 supporting physical activity (e.g. gym passes, swim concessions)

 planned or crisis respite in motels/hostels, in own home or in carer’s home

 support for transport (bus, taxis)

 activities for children and adolescents

 household management support

 referral to other services such as Te Whare Mahana, Tipahi Mental Health

 Unmet Needs Projects

 initiatives for children of parents with mental illness or addictions (COPMIA).

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The proportion of NASC Services allocatedJuly 2013 – April 2014 was:

Proportional split

Crisis Respite

Planned Respite

Planned Respite - Kaupapa

Māori

Needs Assessment - Kaupapa Māori

Outsourced Clinical Services

- Other

Grand Total

Child &

Youth Respite

Nelson/Tasman 76% 94% 31% 60% 50% 65% 39%

Wairau 24% 6% 69% 6% 50% 34% 59%

Unknown 0% 0% 0% 34% 1% 1% 1%

100% 100% 100% 100% 100% 100% 100%

Proportionately, more Adult Planned and Crisis Respite care is utilised in Nelson than Wairau. Planned respite for Māori is utilised more in Wairau. Other elements are spent evenly across the district, which is disproportionate to the population distribution. The allocation for Child and Adolescent Mental Health clients’ respite care (planned and crisis respite) is over represented in the Marlborough region.

4. INFORMATION / HEALTH NEEDS

4.1 Health Needs

Based on the Te Rau Hinengaro estimates of prevalence, the NMDHB Mental Health Populations of Need Report 2008, identified that 4.7% of Nelson Marlborough’s population, around 6100 people, experience a serious mental health disorder over a year. For Marlborough this is about 2100 people and for Nelson Tasman 4000 people. As noted, the actual location of consumers at any time varies with about 25-27% of Specialist Mental Health Services consumers living in Marlborough.

Some mental illnesses are long lasting and can significantly affect the quality of people’s lives, especially if they are not treated or well-managed. Some people only experience a single episode of mental illness;

others may have longer-standing problems or will face on-going challenges throughout their lives. Despite this, they can enjoy a high quality of life and full participation in society. However, the personal, social and economic costs of mental illness can be significant. The stigma attached to mental illness and the social barriers that surround it increase its direct effects and provide hurdles for the life chances of people with mental health problems.

People more likely to experience mental illness are younger people, people with less education, people with less income, people who live in more deprived areas and Māori and Pacific People. Māori and Pacific People are also less likely to make contact with health services for mental health reasons. (See Appendix 3 for more detail, page 19).

Mental Health consumer needs for residential support can be broadly grouped into four levels of need:

 Long term – high need for intensive and on-going support – some consumers are complex, others are stable and relatively straightforward to provide for.

 Medium term support – 6 weeks to 6 months, to facilitate rehabilitation and recovery after an acute illness episode

 Short term – acute illness episode or urgent need when usual support is disrupted

 Respite – either acute, crisis, pre-crisis or planned.

There is a change in the consumer population overall. There also a change in approach to mental health residential services from the past where residential support was available on a long term basis. The numbers of people who have been supported long term will reduce over time and for most of the younger people coming into Mental Health Services, long term residential care is not the best option. Rather, residential support should be a short to medium term option when a person is un-well, with a transition back to independent accommodation.

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4.2 Community and Provider Themes

A summary of the community and provider themes arising from discussion leading up to and during this review is as follows. (More information is in Appendix 3.)

 Limited options for meaningful day activities

 Lack of rehabilitation options

 Needs of individual consumers fluctuate through the progression of their mental health status on a continuum between severe illness and recovery and wellness or stability

 A number of people have unmet needs for housing/residential setting, but numbers vary over time

 Need for better transition between levels of residential support

 More family engagement from services to share information to support quality care

 More flexibility in use of respite care – more frequent access, longer periods of time, as a ‘preventive’ or maintenance option rather than only for those currently being supported by the Specialist Services, availability for people with co-existing problems

 Need for a variety of accommodation options

 The importance to consumers of having their own place – some prefer to live by themselves while other are happy in shared flats. Generally however, the preference is for smaller units rather than having larger groups in a single house. Need to guard against risk of loneliness for consumers in private houses.

 Short term and emergency accommodation is hard to find

 Some discrimination experienced in finding tenancies

 Insecurity of tenure in rental accommodation

 Discussion about having different accommodation options supplemented with packages of care (that can be increased or decreased in response to the individual’s level of wellness) and/or medication management support. Rather than funding residential services which may or may not be utilised, the individualised packages could be provided into wherever the person was living.

Supporting Families Marlborough surveyed family/whānau about their experiences of using the local residential services, to inform this review. In general, people found the respite services good, but had some suggestions for better involvement of family/whānau members and also for improved access to respite.

Longer term residential services were also appreciated but compatibility with others in the same residence can sometimes be a challenge. Areas for improvement were transition to other accommodation, promoting healthy activities and discouraging the unhealthy, involving families/whānau and managing visitors. Other feedback was broadly about services being responsive to and commensurate with individual needs. (See Appendix 3).

4.3 Community Housing

There have recently been changes to the way in which community housing needs are assessed and financial support given, including for people with mental health-related need. These changes came into effect on 14 April 2014. The Ministry of Social Development (MSD) now manages applications for social housing and refers people on the waitlist to social housing providers. The Government has also opened up the income- related rent subsidy to more housing providers. This means people on the waitlist for social housing could be referred to Housing New Zealand or to a registered community housing provider when a suitable property becomes available. MSD is responsible for:

 assessing people's eligibility for social housing

 assessing people's need for a house

 managing the waitlist for social housing

 referring people to social housing providers

 calculating and administering income-related rents

 paying income-related rent subsidies to housing providers.

More information about these changes to social housing is available at: http://www.housing.msd.govt.nz/

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4.4 Literature Scan

Housing is a key determinant of health. It is recognised that access to affordable, appropriate, safe, secure and lasting accommodation is important for mental health consumers’ recovery and resilience. More detail on the Literature Scan is in a ‘Technical Report’ available on request.

Housing Issues for Mental Health Consumers

The nature of housing difficulties identified by a study by the Ministry of Social Development in 2002 for all mental health service consumers regardless of ethnicity, age or gender were: affordability of housing relative to income and medical costs; lack of choice in housing options; and discrimination while finding and retaining housing.

That study noted that encountering housing problems, the negative impact of poor housing, financial stress and limited social contact contributes to deteriorating mental health status, makes recovery difficult, increases vulnerability to other health problems, puts pressure on health services and raises the probability of re-hospitalisation.

Alternative Models of Residential Care and Support

In a report for NMDHB in 2008, Alternative Models of Care – Residential Mental Health Services by Tehaupua Associates, a review of models operating in other parts of New Zealand found a variety of service models endeavouring to increase the availability of housing options. All the models were seeking flexibility and responsiveness to an individual’s need, with a view to finding appropriate and sustainable housing situations through having the right type and level of support.

This report also presented some options for residential services:

 Increasing flexibility by funding individual packages

 Individualised packages of care could include a range of options such as supported landlord services and or friendly landlord services, independent living choices, easy access housing, community recovery support, kaupapa Māori residential support options, and increased options for women.

 Enable mental health service consumers to remain in their current accommodation when the need of support is stable, increases or decreases, by relocating services not the people

 Strengthen needs assessment and service coordination to enable seamless access to an increased range of options

 Strengthen respite services (crisis and planned) to support increased residential options

 Investigate and establish an intersectoral housing bureau

 Actively contribute to and monitor other agency strategic planning that impacts on housing

 Ensure that the workforce required for this model of care is adequately planned for.

DHBs across New Zealand strive to find ways to improve the responsiveness to consumer needs in the delivery of services. Some examples of this are:

 Hawkes Bay funded packages of care developed by the NASC in conjunction with providers and service users. They were a combination of bulk funding through FTEs and some flexible funding. They also used flexi-funding to pilot and implement other services, e.g. a friendly landlord scheme, independent living skills and a medication run scheme. (Source: Mental Health Commission, Mental Health and Addiction Funding – Mechanisms to Support Recovery. 2010)

 Capital and Coast DHB (CCDHB) identified in their Mental Health and Addictions Plan 2011-14 ‘The Journey Forward’ an intention to ‘increase the proportion of people supported in their own homes through reduced utilisation of supported accommodation’. (http://www.ccdhb.org.nz/)

 Auckland and Waitemata DHBs have implemented a ‘Support Hours Model’ in response to a variety of issues. In this model, providers are funded to provide an agreed number of support hours, with providers having flexibility about how they allocate these to individuals, based on their knowledge of the consumer and when their needs increase and decrease. (National Planning and Funding Sector meeting presentation 11/09/14).

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International examples of responses to housing need

Pathways to Housing in the USA use their Housing First model to address homelessness among people with psychiatric disabilities. The Housing First model provides housing first, and then combines that housing with supportive treatment services in the areas of mental and physical health, substance abuse, education, and employment. Research studies have found the programme has a consistently significant positive impact and few or no negative effects. (see http://pathwaystohousing.org/our-model/)

In Australia, the Haven Foundation’s operating model is based on providing the following:

 Housing which is decent, clean and permanent

 Accommodation that includes flats with support services

 Housing which is located in neighbourhoods which are safe and close to shopping, transportation, health and other amenities and services

 A Tenant’s Assistant who works in mutual partnership with a tenant, as well as assessing and responding to individual needs within the context of the accommodation environment offered.

An example is Haven South Yarra in Melbourne – a complex of 14 one-bedroom units for long term housing for people living with menta illness in order to create a sense of permanency and a home for life. Individuals are supported by NGO rehabilitation and support services complementing clinical mental health services.

The Foundation has another two similar developments in progress (http://www.havenfoundation.org.au) NZ National Service Specifications

Mental Health Services are purchased in line with a national service framework which must be utilised by all DHBs. The services provided for within the national service framework are:

 Housing Coordination Services – to assist Mental Health consumers to access a range of housing options

 Housing and Recovery Services – daytime and awake night support for consumers with higher needs

 Housing and Recovery Services – daytime/responsive night support:

 Supportive Landlord Service – recovery-oriented, regular practical contact and social support to persons with mental illness in their own rented accommodation.

Supported Landlord and Housing Coordination are not currently used in Nelson Marlborough. More information from the Service Specifications is available in the Technical Report or on request.

5. DISCUSSION AND KEY DIRECTIONS FOR THE FUTURE

There is a range of services currently available to provide for the needs of mental health service consumers.

The DHB has to decide what is the best level and configuration of service to provide for the needs of consumers in a cost effective way. Key considerations include services that will be:

 consistent with the national Mental Health directions

 flexible and responsiveness to an individual’s need, providing the right type and level of support

 appropriate and sustainable in the context of service provision across the District and available resources.

Information has been collated in this report on the current services and other background information that informs the thinking for the future. This Section outlines the key themes emerging through the review and identifies the likely implication for the future directions of service delivery.

Discussion

Key principles that are important in Mental Health & Addictions are:

 Focus on recovery and independence

 Flexibility to respond to individual need

 Flexibility to respond to overall level of need in the community

 Making best use of resources.

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Flexibility in service provision arrangements benefits the consumers (so that their needs can be responded to appropriately and promptly) and the Mental Health & Addictions sector (so that services deliver the best value for money). It is a feature of mental illness that consumer needs change over time as they move along a continuum from wellness to illness to wellness. It is also important to have a range of services available – to offer consumers some choice and so there are services that increase and decrease the intensity of care and support as an individual’s needs change. It is also beneficial to have flexibility because the total level and type of need within the whole district population changes.

While this review is primarily about residential services, other community services are also considered, as part of the range of services supporting Mental Health consumers.

It is well known that housing is important to wellbeing. Mental Health consumers can face particular challenges in accessing appropriate accommodation. But the weight of evidence pointing to the need for stable accommodation suggests that as far as possible mental health consumers should be supported into their own accommodation and enabled to stay there with services provided into their home as needed.

Recent changes in the delivery of community housing via MSD will be significant for mental health consumers, so maintaining and enhancing service relationships with MSD will be important. Other community housing resources are limited. For example, Nelson has Franklyn Village and emergency accommodation (e.g. night shelter) which are utilised by Mental Health consumers, but this type of accommodation is not available in Marlborough. Sometimes specific arrangements can be made with backpacker hostels or motels in both areas.

Currently there is crisis respite and fully supported housing and recovery services but no other ‘step down’

accommodation options specifically for mental health consumers. There is some underutilisation of services but there is a tension between having services fully occupied and then having openings available for people in crisis.

In late 2014, a discussion document was released and feedback provided by stakeholders for the Residential Review in the Marlborough district. Submissions were received from a variety of sources spanning the Mental Health Sector – providers, consumers and family – some from individuals and some on behalf of groups.

In the Marlborough Review discussion document some options were presented to get feedback on how well people thought these options would respond to the consumer needs.

1. Having two different types of service run from one facility received some favourable comment, but overall was not supported as it was felt this might be difficult to manage for staff and consumers 2. There was a lot of support for planned and crisis respite as a crucial part of the continuum of services

that need to be available to support consumers.

3. It was agreed that secure and appropriate housing is an important factor in supporting people’s mental health. The concept of consumers having support to find appropriate housing was supported, but a separate housing coordination service is not supported. Demand would fluctuate and sometimes the service may not be needed for periods of time and there was also concern about how this would develop the knowledge and relationships needed across the district. The functions involved can be undertaken by social workers and community support workers.

4. The need for flexibility to respond to individual needs through individualised packages of care was supported. The ability to provide an increasing or decreasing level of care as required, regardless of where a person is living, is important.

5. Enhancing meaningful day activities that provide choice and encourage and assist consumers with community integration was also supported.

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Key Themes

From the Marlborough Review feedback and discussion, the following themes emerged as key directions for the future. They are:

1. Responsive services are needed across a continuum of care.

2. Access to individualised packages of care that increase and decrease , responsive to consumer needs 3. Availability of a choice of day activities that appeal to consumers would support wellbeing

4. Services need a rehabilitation focus and actively work to transition people towards recovery, resilience and greater independence

5. Access to planned and crisis respite reduces the need for admission and supports recovery and maintenance of wellbeing

6. Social Work support for consumers can include support to access & maintain appropriate accommodation

7. Some level of short to medium term accommodation is needed for those needing transitional support before managing in their own homes

8. Those needing longer-term residential support will be those with higher needs because of being more unwell.

Future Directions

Mental Health Services operate with the vision of a recovery model – where people who experience mental illness move through a transition back to optimal mental and physical health. Services need to reflect this model.

Following the themes and the options that were supported (outlined above) the implications are that, over time, it is intended that there would be:

 An increased focus on providing individualised support for people in their own homes

 A reduction in the number of supported accommodation beds (in Nelson/Tasman where most beds are)

 An increase in individualised packages of care, including day activity options and community support, including some service provided in evenings and weekends. Packages will be holistic, addressing the physical and mental health needs of the consumers

 An increase in day activity options in Marlborough, particularly options engaging for young people

 Increased access to Social Work support in Marlborough to assist access to appropriate housing options

 Maintenance of, or perhaps a small increase in, respite services to ensure that capacity for both crisis and planned respite is available

 Ongoing access for consumers to general practice as the ‘health home’

 Increased liaison and consultancy support to GPs from Specialist Mental Health Services when needed to enable support of consumers within primary care

 Responsive or ‘easy’ entry and return to Specialist Services when needed, planned or ‘easy’ exit from service when independence is re-gained

 Greater integration of services across the sector and improved clarity about the recovery/rehabilitation focus and what is expected from each service to achieve this for consumers

 Continuing to build relationships with and collaboration between services and sectors to provide for people with dual diagnosis and/or complex needs.

Questions for Discussion

We would like your feedback on the key themes and directions for the future.

1. Do you agree with the future directions indicated, as being an appropriate way forward for Mental Health Services in the Nelson Marlborough District?

2. What do you think are the most important developments?

3. Are there any associated concerns or risks that you would like to have addressed as the services develop into the future?

Details for providing your thoughts on these questions or for any other feedback are on page 2.

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APPENDIX 1 – Extracts from “Rising to the Challenge”

Rising to the Challenge is the national Mental Health and Addictions Service Development Plan 2012 – 2017, released by the Ministry of Health in 2012.

Goal 3: Cementing and building on gains in resilience and recovery for people with low-prevalence conditions and/or high needs

(Psychotic disorders and severe personality disorders, anxiety disorders, depression, alcohol and drug issues or co-existing conditions.)

The Ministry of Health will:

Enhance social inclusion opportunities

Work to enhance social inclusion for those people whose lives have been most disrupted by low- prevalence conditions (in terms of both mental health and addiction). This work will involve:

 continuing national efforts to reduce stigma, including continuing and refreshing of the Like Minds Like Mine programme,¹ with consideration given to incorporating addiction into the programme

 working with the Ministry of Social Development to find ways to expand support for employment and educational opportunities

 working with Housing New Zealand and DHBs to better understand housing issues for people with low-prevalence mental health and addiction issues, with a view to collaborative work to better address needs in the future

 working to ensure mental health and addiction services are coordinated more closely with justice agencies.

Mental health and addiction services (NGO and DHB) will:

Enhance social inclusion opportunities

Work to enhance social inclusion for those people whose lives have been most disrupted by low- prevalence conditions (mental health or addiction). This work will involve:

 increasing service flexibility so that community living supports are available wherever a person chooses to live; not only in inpatient and residential settings

 working with Housing New Zealand, private landlords and real estate agencies to find ways to:

– expand access to affordable accommodation options within communities – support people to maintain their existing housing

 developing strong cross-sectoral relationships between forensic mental health services, mental health and addiction services, the courts, the Department of Corrections and youth justice

 strengthening working relationships and responsiveness between mental health and addiction services and the New Zealand Police

 providing a seamless transition of care and minimising stigmatisation for people who are leaving forensic mental health services.

1Like Minds Like Mine is a Ministry of Health-initiated national programme to counter stigma and discrimination against people with mental illness.

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APPENDIX 2 – Review Process

Steering Group

Robyn Byers, GM Mental Health, Review Sponsor

Heather McPherson, Mental Health Services Clinical Director - Specialist David Greer, Manager Witherlea Mental Health Services

Katrina Martin, CARE Marlborough – client perspective / Top of the South NGO group Lyn Caughey, SF Marlborough – family perspective / Top of the South NGO group John Allen, Unit Manager – Community teams, NMDHB Mental Health Services Susan O’Connell, SF Nelson – family perspective / Top of the South NGO group Pauline Nevin, Consumer Advocate, Health Action – Top of the South NGO group Megan McQuarrie, Unit Manager, NMDHB Mental Health Services

Role is to review information, issues and options and formulate solutions; make recommendations to the NMDHB Executive Leadership Team and the Board.

Working Group

Bernard Pomfret-Brown, Outcome and Information Analyst Claire McKenzie, Alliance Support Manager

Rita van Iddekinge, Manager Mental Health Needs Assessment Service Co-ordination David Lingard, Business Analyst

Role is to support the Steering Group by:

 collating and analysing information and generating ideas and options

 prepare reports to assist discussion and the generation of solutions

 undertake stakeholder consultation.

Feedback and input has been sought from the Consumer Collective, family and whānau and several providers of services.

Submissions on the Marlborough Review were received from:

1. Top of the South Mental Health NGO group 2. Consumer Collective

3. Gateway Housing Trust

4. Mental Health Support Services Ltd 5. Health Action Trust

6. Individual (consumer) 7. Individual (family/whānau) 8. Witherlea team

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APPENDIX 3 – Health Needs & other Information

The NMDHB Mental Health Populations of Need Report, 2008 identified that:

Mental disorder is common. Of the Nelson Marlborough District Health Board (NMDHB) population it is estimated that just under 27,000 people experienced a mild to serious mental illness within the previous 12 month period.² This comprises of 8,585 (6.6%) with a mild disorder, 12,226 (9.4%) with a moderate disorder and 6,113 (4.7%) with a serious disorder. It is also predicted that 46.6% of the population will meet the criteria for a disorder at some time in their lives. That is just under half of our population.

Of Specialist Mental Health Services, 50% of consumers reside in the Nelson district, with the other 50%

relatively evenly split between Tasman and Marlborough.

The need and risk is higher for younger people (across age ranges), people with less education, people with less income and people who live in more deprived areas. There are a number of high deprivation areas within NMDHB district, some are centrally located to health services, others are rurally based.

Māori have higher 12 month prevalence rates (than Pacific and ‘Other’ populations), 8.7% mild disorders, 12.6% moderate and 8.2% with serious mental disorders. Māori are also less likely to make contact with health services for mental health reasons. Given the near double prevalence for serious mental disorder, this identifies a need to prioritise Māori. Of note the Māori access rate to Nelson Marlborough specialist mental health services is higher than the ‘other’ population. Māori access rates are similar between the three territorial local authorities with 11.11% (90 out of 810 consumers) in Marlborough, 9.48% (159 out of 1676 consumers) in Nelson and 8.18% (65 out of 794 consumers) in Tasman. The Māori population is 8% (10,953).

Pacific people also have high 12 month prevalence rates (than the ‘Other’ population), 7.6% mild, 11.5%

moderate and 5.9% serious mental disorders. Pacific people are less likely to make contact with health services for mental health reasons.

COMMUNITY VIEWS ON MENTAL HEALTH SERVICE NEEDS

In 2008, NMDHB undertook a project to ‘identify the best possible range of services for residential mental health services’. The project document “Alternative Models of Care – Residential Mental Health Services – FINAL DRAFT”, (for NMDHB, February 2008) explored the views of key stakeholders:

 mental health service consumers require services that “encourage, empower, allow people to make mistakes, work with, sometimes leave alone, allow freedom to choose, follow best practice models and are safe (physically, environmentally, clinically and culturally)”. Consumers want more choice and flexibility of service, services that have them at the centre, services that see them as people first and staffed by competent professional caring people.

 family (parents, sisters, brothers, spouses and friends of people who experience mental illness) needs are: to be heard, to be involved when able in decision making, have confidence in the providers of care, openness from the providers to whatever support can be provided from whānau/ family, and realistic expectations of what they can do.

 Māori consumers wanted kaupapa Māori residential services, flexible for mild to severe and open to those with forensic or addiction histories.

 The DHB wants residential services that can respond to the needs of the people they serve, services that are clinically safe and know boundaries of care i.e. when to call on secondary services and when not too.

 NGO providers want a close working relationship with the DHB provider across a continuum of care, their perspective to be heard and long term contracts to enable providers to plan and grow.

2 Te Rau Hinengaro – the New Zealand Mental Health Survey national findings were extrapolated to the NMDHB 2006 Census population data. Te Rau Hinengaro researchers used a survey design and sample frame consistent with best practice, so the survey generates estimates of acceptable precision that can be generalized to the New Zealand adult population.

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CONSUMER VIEWS ON RESIDENTIAL SERVICE NEEDS

The Consumer Collective has provided some feedback on what they feel is needed:

 Somewhere to go after admission to the Mental Health Admissions Unit; short term options

 Those discharged from Witherlea cannot access the residential service options

 Favoured respite being peer-led

 Flat-type accommodation is needed

 Putting more care into a persons home when they need it

 Peer support workers to go into people’s homes

 Need a mix of options – Housing NZ, private rental, own homes. Work & Income assist now but few options

 Some experienced discrimination from real estate agents

 Insecurity of tenure

 Can get lonely in private houses

 Difficult to afford accommodation on benefits

 Short term/emergency accommodation is difficult to find – sometimes use backpackers but this is expensive.

FAMILY/WHĀNAU EXPERIENCE OF RESIDENTIAL SERVICES

Families/Whānau of consumers were asked as part of the Marlborough residential review, for their views on current services³. These are summarised as follows:

 Respite Services

For those who had used the service the comments were generally positive and people appreciated the service (e.g. good, fabulous, well looked after, suited needs well).

However there were also comments about not being aware of the respite option; that it was difficult for people with co-existing problems to access respite; and sometimes respite was not available frequently or for long enough. Not being able to access the service when not under the care of Witherlea was a negative for some as, for example, it was not available as a ‘preventive’ or ‘maintenance’ option. There was also a comment that it was difficult to access respite for Māori families as the ‘system changed’. A suggestion was for family members from outside the area to be able to use the respite service when not suitable to stay at the family home.

Other areas people saw could be improved were:

 Better involvement of families – at needs assessment and care planning; meeting the support worker so they know them and can discuss issues; able to assist decision-making when a person was very unwell;

 Access to respite for children when ill or for a child when a parent is unwell

 Access to respite for people with co-existing problems

 Longer Term Accommodation

Several good comments were received, with appreciation of the service (e.g. fantastic, really great, OK, relaxed and calm atmosphere). One issue was compatibility with the others in the residence who are very unwell. Several people commented on the need for better transition to the next level of accommodation – community, home or independent living. There was concern about the level of smoking with one saying it had become ‘normalised’.

Other areas suggested for improvement included:

 Better communication with families

 Need for more ‘healthy’ and interesting activities for residents

 Better supervision of and rules for visitors

 Transport availability (to support access to activities).

3 With thanks to Supporting Families Marlborough for undertaking this work.

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 Barriers to all Respite Options/Other information and feedback

A number of comments were made about services for teenagers – mentors may be better than respite;

need in-home help for motivating and supporting young people; need more support for transition to flatting

There were also a number of comments about not being able to access ACC-funded support – for teenagers, for residential support for post-traumatic stress, for respite.

Gaps in transition were noted, with sufficient support needed to ensure a person is managing well. The level of supervision/support needs to be in line with the person’s level of functioning and offered for long enough. A need was seen for steps between the two current options of Hapai Te Ora and Lewis St and a ‘step under that as well’. Support needs to be available before a situation becomes critical.

A gap was seen to be in services for those just below the threshold of Support Works – support would be available with a diagnosis, but the cost of assessments is beyond many people.

Family engagement with the Support Worker was mentioned as important to enable questions and passing on of information.

SPECIALIST SERVICES VIEWS ON SERVICE NEEDS

Staff of the Specialist Services at Witherlea report three areas of unmet need:

 Supported accommodation with a rehabilitation focus

 Increased access to meaningful daytime activities/groups/day programme

 Intensive rehabilitation for those in their own homes or private rentals

Mental Health Residential Services Review