AOD Sector workshop (22 April 2016) - summary report

By Heather Wellington

Contents

Purpose of this report........................................................................................................1

The context........................................................................................................................1

The story so far – sector performance................................................................................2

Client pathways..................................................................................................................3

Using existing flexibility......................................................................................................6

Afternoon sessions.............................................................................................................7

Information and communication issues............................................................................................7

Data and demand issues....................................................................................................................8

Priority actions...................................................................................................................9

Concluding comments......................................................................................................11

Attachment 1 – Workshop agenda....................................................................................12

Attachment 2 – Workshop attendees...............................................................................13

Purpose of this report

The Department of Health and Human Services (‘Department’) convened a workshop entitled Adult Alcohol and Other Drug Community Based Service Provision Review on Friday 22 April 2016 at the Jasper Hotel in Melbourne.

The aim of the workshop was to provide practical and strategic advice to the Department on actions to be taken to address priority issues of concern and improve community-based service delivery.

The discussion drew on findings of the Independent Review of New Arrangements for the Delivery of Mental Health Community Support Services and Drug Treatment Services (‘Aspex Review’).

The workshop was facilitated by Dr Heather Wellington.

A copy of the agenda is at Attachment 1 and a list of attendees is at Attachment 2.

This is the report of the workshop.

The context

Ms Bridget Weller, A/Director, Drugs, Community Mental Health and Primary Care presented an overview of the context for the workshop. She explained that the purpose of the workshop was to provide further opportunity for stakeholders to communicate with the Department about the impacts of the reforms and contribute to future directions. Key points included:

The Department is accumulating a strong evidence base, which will inform its decision-making. Sources of information include the Aspex Review, the Victorian Alcohol and Drug Association (‘VAADA’) Regional Voices report and work undertaken by the Victorian Council of Social Service (‘VCOSS’). There are also regular discussions between the Department’s regional and head offices and the Department has had valuable discussions with service providers.

There are various perspectives in the sector about the impact of recent changes to the service system. Issues affect metropolitan and rural stakeholders differently, and those organisations that have multiple funding streams are affected differently to those with single funding streams.

The Aspex Review identified unintended consequences of service system reform together with areas where the funding model is not as well understood as it could be. Other key themes addressed in the Aspex Review included service delivery, partnerships and relationships, workforce, funding, performance management and monitoring and service planning and development. Intake and assessment arrangements are most concerning for most people. Barriers to service access need to be addressed.

A number of improvement initiatives are under way. With the amendment to collect data on bridging support, brief interventions and single sessions, there is better visibility of work. There has been some funding growth for traditional counselling and additional intake and assessment capacity, and funding contributed by the Department of Corrections has enabled

establishment of new residential rehab beds. Stage 2 of the ‘ice package’ will also enable establishment of more residential beds in the longer term.

Data collection continues to challenge providers and the Department. There are significant differences between data collected on the DTAU spreadsheet and data submitted through the Alcohol and Drug Information System (‘ADIS’). Working through differences with providers has been constructive. Work is proceeding on a new data collection system, with the Department currently procuring services to define a new data set by the end of 2016. The goal is to develop a system that will enable extraction of data from client management systems. There will be substantial engagement with the sector, including through a data collection reference group

The Department will release consolidated program guidelines and improved performance management documentation shortly.

The Department recognises there is a knowledge gap in the general community about who to call when they are concerned about AOD issues. The Department is keen to raise the profile of service access points and consider marketing and communication issues.

A statewide sector reference group has been convened. It is an expert group, focussed on the impact of the recommissioning process. Recognising the special issues affecting rural providers, the Department has also undertaken separate consultation with rural providers and is also working with consumers and families with the assistance of SHARC.

During discussion:

the status of the Aspex Review was clarified. Ms Weller confirmed that the report of the Review has been received by the Minister and is under consideration. An implementation plan has not yet been developed and would be informed by current discussions; and

it was suggested that consumers should have been included in the workshop. Ms Weller explained that there are other processes for engaging with consumers, however consideration could be given to a shared professional/consumer forum in the future.

The story so far – sector performance

Ms Weller presented an overview of sector performance data.

She noted evidence of steady increase in activity since the Aspex Review was undertaken. Both intake and assessment activity increased in quarter 2, reflecting both a ‘settling in’ phase and improvement initiatives. The proportion of complex treatments delivered as non-residential withdrawal services has also increased markedly, although the underlying cause of that change is not entirely clear.

There are significant differences across areas, treatment streams and agencies. These differences reflect both differences in activity and differences in data capture and recording practices. There are significant discrepancies in data recorded on off-line spreadsheets, compared with data recorded on the Alcohol and Drug Information System (‘ADIS’). The Department is aware of a number of different contributing factors including attempts to manually calculate metrics rather than relying on the formulae in the spreadsheet, which causes multiple errors. It is likely that some episodes of care are not recorded on the spreadsheet once they have been recorded on ADIS, and there are also

definitional problems. One of the objectives of the proposed data management system is to eliminate the need for multiple entries of data.

In response to questions, it was noted:

the current data system does not enable a breakdown of hours spent with clients in supported accommodation settings;

definitions of ‘contact’ vary across organisations; the Department reports to Treasury on the basis of spreadsheet data, cross-checked against

ADIS. When the Department identifies discrepancies between the spreadsheet and ADIS, it initiates detailed discussions with the provider. These consultations have been valuable to ascertain underlying causes, which have differed in almost all cases; and

ADIS provides important client demographic information and contributes to the Alcohol and Other Drug Treatment Services National Minimum Dataset the Alcohol and Other Drug Treatment Services National Minimum Dataset.

Client pathways

Working in groups, participants were asked to consider and advise on priority issues and solutions to:

improving client access to intake, assessment and treatment ensuring clear client pathways ensuring effective client support.

Participants raised the following issues and potential solutions:

Issues Potential solutions

Lack of transparency and inconsistent messaging about the service system structure and what clients can expect

Lack of pathways for some client groups, including Indigenous clients

Limited awareness of how to access statewide and ‘out of scope’ services

Develop a communications plan with common terminology and definitions, clear and consistent messaging and strategies to improve understanding by referring clinicians, clients and families

Develop clear descriptions of the different types of care and pathways, that are understandable by clients and communities

Consider local and statewide approaches to communication

Consider establishing a statewide brand for AOD services, which all providers would incorporate into their communications

Establish a single, well-publicised and readily recognisable statewide telephone line, for initial contact

Fund and support community capacity building

Issues Potential solutions

Inconsistency, no guidelines and little accountability around distribution of clients by intake and assessment providers

Inconsistent and inequitable access in different regions, depending on local issues

Develop guidelines for client referral by intake and assessment providers

Establish accountability mechanisms for referral patterns

‘Bottlenecks’ in intake and assessment, lack of standardised processes and inflexibility of distribution of responsibilities between intake and assessment services and treatment services

Long waiting times between screening, assessment and/or treatment in rural areas

Inconsistent and potentially inadequate support for people on waiting lists

Inconsistent quality of client assessments, generally and in relation to CALD and indigenous clients specifically

Common assessment tool does not meet requirements of providers of residential treatment

Improve staff skills

Redesign and standardise the intake and assessment process, and its links with treatment, re-focussing on a ‘no wrong door’ approach

(Some participants strongly advocated for transferring the assessment role to service providers, however this was not a universal view)

Standardise information required for referral to residential treatment

Consider an accreditation requirement for all providers

The screening tool is perceived as excessively structured and inflexible

Redesign the tool, moving away from structured questions that are perceived as deskilling clinicians to a semi-structured tool that supports clinical discussion

Develop specific tools for young people, adults, dual diagnosis clients and families

Incorporate domestic violence into the screening tool

Additional costs incurred in assessment by residential service providers

Modify funding formula to recognise additional costs

Issues Potential solutions

Lack of an overarching model of care, with inconsistent approaches to treatment

Develop and communicate a model of care based on common principles and standards, and allow with flexibility in application depending on local circumstances

Data issues – lack of transparency of system performance, little data on quality of treatment, no independent auditing and therefore little accountability, inability to ‘count’ brief interventions in all service types (not limited to assessment)

Implement a data framework

Establish capability to collect outcome data

Ensure transparency of performance data

Inadequate focus on, and uncertainty about what is happening with, ‘out of scope’ services, impacting on the workforce and consumers

Departmental clarification of plans

Poor connections and integration with the rest of the health care system, particularly with general practitioners (‘GPs’)

Develop and implement a communications strategy that includes targeted information for GPs

Workforce impacts of change

Staff have lost skills as a result of increased specialisation of provider roles

The increased competition between providers has had a negative impact on staff morale

Invest in workforce development, particularly if further changes are contemplated

Many participants reported there is widespread confusion about the system design and how to access services. Establishment of a single telephone information line was strongly supported.

Some frustration was expressed about repetition of discussion about the issues raised in the Aspex Review and Regional Voices, however it was explained that the purpose of this forum was to allow a broader range of people to engage in proposing solutions, and to add detail to and prioritise potential reform initiatives.

There was strong representation that:

the client pathway should be seamless, but remains fragmented;

targets are putting undue pressure on services; poor quality assessment leads to poor treatment; and a consumer voice should be incorporated in all discussions about further reform.

A number of participants strongly advised that the assessment process needs to be re-integrated with treatment processes. Others suggested there is a need for redesign of roles, responsibilities and linkages in relation to intake, assessment and treatment, but did not support reallocation of assessment responsibilities to treatment providers. It was also suggested that there should continue to be an option for clients to select their own pathways.

It was noted that any major structural changes (e.g. changing responsibilities between intake and assessment and treatment providers) would have significant flow on consequences, including funding consequences, and would not be achievable in the short term.

There was a general view that many agencies have established ‘workarounds’ to manage the new system, and that while sharing these approaches may be helpful the underlying design problems in the system need to be addressed.

Although there was general support for a communications and marketing initiative, some stakeholders were concerned that such an approach would increase demand in a system that has limited capacity to respond.

Stakeholders reported that despite the challenges recommissioning has caused, there is still collaboration and goodwill within the sector. It was suggested, however, that the sector’s focus has become very inward-looking, and the challenge will be to refocus on client needs.

Establishment of smaller working groups and development of detailed reform proposals was proposed.

Using existing flexibility

Participants were asked to discuss and advise on the utility of the flexibility currently incorporated in the system, with a focus on:

Should there be greater flexibility in the drug treatment activity unit (‘DTAU’) targets? What are the benefits and challenges of greater flexibility? Does the current data collection accurately capture all functions?

It was confirmed that the question of flexibility in the allocation of targets across catchment boundaries was not ‘within scope’ for this discussion but could be considered in a different setting.

There was consensus that the existing 20% flexibility in DTAU targets is valued but its use is probably not being optimised. The following issues were raised:

There are concerns about the accuracy of data and the ability to assess the benefits of flexible funding without a strong evidence base.

To make a valid assessment of the impact of flexible funding, much more information about client outcomes is required.

Consortia arrangements make it difficult to understand activity levels and targets.

It can be difficult to offer flexible services in the context of greater specialisation of services and staff. Flexibility works better in larger, more diversified services. Smaller services may be better off focusing on their core responsibilities.

There are concerns in the community health sector that offering flexible services may ‘open the flood gates’ of demand, which will not be able to be met. There is a preference for focusing on core services.

There are also concerns that flexible service delivery may be masking existing dysfunction in the system (e.g. unmet demand). Some participants thought it should not be used to mask what they see as a core structural problem related to the separation of assessment from treatment services. Others suggested that excessive use of flexible funding could result in gravitation of the system away from its intended outcomes.

There is a need to ensure services are client focused, and clients are not simply ‘slotted into’ service types that suit the provider rather than meet the needs of the client.

Various examples of the benefits of flexibility were given:o Flexibility has been useful when service providers are providing intake and

assessment for complex clients.o One provider gave an example of using flexible funding to improve engagement with

homeless and aboriginal communities. o Another provider explained how they used the funding effectively to streamline

communication between GPs and nurses working in non-residential withdrawal services.

There is some uncertainty about what flexible funding can be used for, and messages from the Department have not always been consistent.

Afternoon sessions

Concurrent sessions were held in the afternoon, addressing the topics of:

information and communication; and data and demand.

Information and communication issues

Participants were asked to consider and advise on:

What elements of the service system need further clarity? How can the workforce be better supported through system changes? What are suggestions for ongoing future sector engagement?

It was agreed that there is very poor understanding outside the sector of the structure and functioning of the service system. Participants advised that all elements require clarification, including ‘in scope’ and ‘out of scope’ services. There was very strong consensus that a communication plan is required that targets communities, clients, families and health care professionals, with the objective of improving understanding of:

how the service system is configured;

the roles and responsibilities of each participant; how the service system can be accessed; the pathways that link elements of the AOD service system to each other, and to other parts

of the health care system; the overarching model of care that applies across the service system; the different types of treatment, and when they are likely to be appropriate; the outcomes (including key performance indicators) the service system is expected to

achieve, and how they are monitored; the outcomes that are achieved.

The following specific suggestions were generally supported:

development of local directories of AOD services; development of local communication strategies that enable GPs and other stakeholders to

understand how their systems work locally; more frequent, comprehensive and consistent communication from central and regional

offices of the Department; expansion of communities of practice, especially in rural areas; provision of specific tools and resources to support rural providers; maintenance of the Department’s ‘question and answer’ page; continuing funding of peak agencies (including VAADA) to support communication within the

sector; education of the AOD sector on services available in the broader health sector, and vice

versa; establishment of a reference or advisory group to the Department, to assist with policy

development and advise on governance and technical issues; and engagement of consumers and carers in all aspects of communication.

It was suggested that communication needs to involve all providers, not only lead agencies. Communities of practice, network meetings and conferences (including via teleconferencing) were seen as important vehicles for communication.

Communication with the AOD workforce was also identified as a priority. The workforce needs sufficient time to understand and respond to changes.

There was strong support for better sharing of performance data.

Data and demand issues

There was general concern about the accuracy and reliability of data. A number of participants also expressed concern about the lack of auditing of data at present. There was strong support for establishing a clear data management framework, including definitions and rules.

The long lead times necessary to implement changes in data requirements were noted.

The challenges of recording data multiple times and the burden of data collection on clinicians and organisations were noted. Difficulty capturing data in some areas was discussed, including data about services to clients in supported accommodation, clients requiring intensive case management,

group work and family work. Training in data collection is an issue and it was suggested that very clear case examples should be included in the framework. The importance of providing feedback to people entering the data was also noted, to assist in data accuracy.

The high burden of data collection on clinicians and the very high burden of multiple reporting frameworks currently experienced by some organisations were noted. It was agreed that data need to reflect clinicians’ work in a meaningful way, and be applied effectively and transparently to system planning and improvement. Where possible, data should be drawn from existing administrative data sets.

There was strong support for collecting outcome data, establishing systems to track clients across AOD services over time and using data more effectively at local, catchment and statewide levels.

It was noted that consortia have adopted different approaches to data management, with some reporting in aggregate while others have encouraged direct reporting by their members. This variation is believed to affect both the consistency and transparency of data.

There was support for establishing working groups to develop the new data collection.

Ms Weller advised that the planned new data system will address requirements for multiple entry, inconsistency of results, ability to link treatment and intake data and other priority issues, and there will be a focus on applying the data to service improvement and planning.

Priority actions

During the final workshop session, consensus was achieved that the following actions should be prioritised. Note that these priority actions are not ranked relative to each other.

Review, redesign and clarify the distribution of responsibilities between providers for screening, assessment and treatment

This is clearly a priority for all participants, although there were varying views about the preferred allocation of responsibility for assessment.

This action may incorporate work on the screening tool.

Publish consolidated program guidelines

A large number of issues were identified that would be addressed by the publication of clear program guidelines. This is also a very high priority for participants.

Design and implement a communications strategy

This may include work on:

rebranding the sector; adoption of consistent terminology; Communication of a clear description of the configuration of the service system and the

roles and responsibilities of providers; and

a redesigned statewide 1800 number (may be existing DirectLine number) to enable system access.

Develop a data and performance framework

This may include work on:

data consistency and reliability; data tracking across services; simplified reporting; transparency including waiting lists and intake; and data extraction and use.

Enhance service provision

This may include work on:

documentation and communication of a model of care prevention and early intervention inclusive of all cohorts (families parents, outreach models,

acknowledge of different models) and weighting of funding to recognise services for homeless and CALD people, rural clients and specialist services;

integration of services currently considered ‘out of scope’; new treatment types for people with complex co-morbidities; a genuinely integrated service model for high risk clients; and culturally safe and sensitive service provision.

Continue to refine the funding model

This may include additional work on DTAUs.

Other suggestions

A range of other suggestions were proposed, including:

increase system capacity, including residential rehabilitation and access to addiction medicine and nurse practitioner support;

address the problem of clients having to ‘tell their story’ multiple times; mandate providers to seek consumer feedback to inform services and programs, including

feedback from people who currently can’t access the system; invest in and increase the transparency of catchment planning, informed by data; and acknowledge and address the negative cultural outcomes of the recommissioning process.

Concluding comments

The workshop concluded with a brief question and answer session. In response to questions, Ms Weller advised:

the Department:o has recently commenced publishing an email newsletter, with summaries of recent

initiatives and links to more detailed information. All workshop participants will be included in the distribution list and its availability will be published in relevant publications including VAADA and VACCHO publications;

o will continue to maintain the currency of its internet page;o is also linking with complementary communication streams, including community

health, GP and primary health network communication streams;o is keen to establish some broader governance structures, to allow an ongoing

mechanism for communication with the sector as a whole. There may be subcommittees or working parties formed to provide advice in specific areas. A data group has been developed;

o will continue to work with providers to improve data accuracy, and is considering a data audit to better understand inconsistencies in the way providers are working with data;

program and performance management guidelines will be published shortly. providers are encouraged to liaise with regional offices on opportunities to use flexible

funding more effectively; further consideration will be given to:

o ways to improve the management of complex clients;o linkages between ‘in scope’ and ‘out of scope’ services, and between the AOD

system and other parts of the health care system; and there will also be an ongoing Departmental focus on workforce support and development.

Ms Weller concluded by thanking all participants for their engagement in the workshop.

Dr Heather Wellington17 May 2016

Attachment 1 – Workshop agenda

Attachment 2 – Workshop attendees

Attendees –Morning registrationName Surname Job Title OrganisationAlan Murnane General Manager ISCHAmanda Exley Program Manager Anglicare Victoriaandrea andersen Team Leader ISIS AOD ServicesAnne-Maree Kaser CEO Windana Drug & Alcohol Recovery IncAnnie Trainor Senior Manager VAOD & MHCSS ACSOBrad Roberg Senior Team Leader Specialist Services Drug Health Services Western HealthBrad Pearce Program Manager VAADABrendan Fitzhenry Manager Salvation Army, AOD & JusticeCallum Wright Executive Director Bendigo Community Health ServicesCaroline Radowski Executive Manager Community Services Youth ProjectsCraig Holloway Manager, Workforce and Wellbeing Unit VACCHODanny Alcock SE AOD Manager TaskForce Community AgencyDarrell Hinga Manager SalvoCare EasternDavid Scott Acting Manager Rehabilitation Services WindanaDavid Hunt Area Coordinator SA, TAS, VIC SMART Recovery AustraliaDebra Lindsey Senior Manager CaranicheDonna Ribton Turner Director Clinical Services ReGenEric Allan Executive Manager Odyssey HouseFiona Lewi Psychologist ReconnexionGabby Cohen Assistant Manager Rehabilitation Services WindanaGaby Thomson Senior Service Manager AnglicareGavin Foster Manager Turning Point EasternGurdip Chima Service Development Officer The Salvation ArmyHarry Majewski CEO Inner East Community Health ServiceJeff Gavin Manager APSUJennie Allen Clinical Operations Manager InspiroJennifer Black Director MHDAS BarwonHealthJulia Carroll Coordinator Jesuit Social ServicesJulyan Howard Divisional Director Primary Care Goulburn Valley HealthKate Graham Manager Withdrawal & Coordinated Care WindanaKatrina Clement AOD Team Leader, Family & Community MacKillop Family ServicesKent Burgess Director of SErvices VACkitty vivekananda manager treatment services turning pointLaurence Alvis CEO UnitingCare ReGenleanne acreman General Manager Jesuit Social ServicesLisa Pearson Manager Goulburn Valley HealthLoretta Foster Mental Health Program Manager Gateway HealthMaria Yap Manager. Inner East PIR Program EMPHNMartin Wilkinson Executive Director - Primary Health Eastern Melbourne PHNMary D'Elia General Manager MacKillop Family ServicesMel Thomson AOD Program Manager Peninsula HealthMelissa Knight Manager Mental Health Murray PHNMichael Girolami Director, Community Support Services ISIS Primary CareMichal Morris Director, Mental Health and AOD Reform Melbourne Primary Care Networkmoses abbatangelo senior manager - AOD Response cohealthNeil Loxston Manager AOD & Mental Health Services SalvoConnect BarwonRay Blessing CEO TaskForce Community AgencyRebecca Steunenberg manager VincentCare VictoriaRichie Goonan General Manager Launch Housingroger chao General Manager Penington InstituteRuben Ruolle Community Programs Manager Drug Health Services Western HealthRuth Fox Executive Manager Service Delivery Sunraysia Community Health Services

Salina Bernard Senior Policy Officer VACCHOSally Mitchell Executive Director Community MH, AOD cohealthSam Biondo EO VAADASandra Opoku Policy And Project Manager Stepping UpSharon Sherwood Operations Director Peninsula HealthSharon ‘Molly’ O'Reilly Manager AOD SEMPHNShelley Cross General Manager Stepping UpSimon Gibbs Manager - Social Support Services Nexus Primary HealthStana Stojic Team Leader Drug Health ServicesStefan Gruenert CEO Odyssey House VictoriaSuzanne Miller CEO Nexus Primary HealthTamsin Short Manager Inner East Drug and Alcohol ServiceVenetia Brissenden Catchment Manager INM UnitingCare ReGenVeronica Pascall Better Life Dual Diagnosis Case Manager Grampians Community HealthVictor Bilous SW Catchment Manager Odyssey HouseWayne Wright Manager Southern Dual Diagnosis Service

Additional Eventbrite registrationsName Surname Job Title OrganisationAlison Skeldon Exec/Dir Comm. Support & Connection Latrobe CHSAnne-Maree Rogers Manager AOD EACHBen Leigh CEO Latrobe CHSCath Peake Manager Barwon Health DASChantel Churchus Project Officer VAADAChris Wood General Manager, System Outcomes South Eastern Melbourne PHNGeorgia Whiting Performance Analyst GV HealthGillian Smith Primary Care Manager InspiroKim Sykes Chief Executive Officer Bendigo CHSLiz March CEO Castlemaine District CHPenny Anderson CEO Darebin Community HealthPeter Wearne Director of services YSASRob White Team Leader FaMDAS Peninsula HealthTheresa Lynch Manager The Royal Women's AODS