MULTI-PURPOSE SERVICES PROGRAM EVALUATION (VICTORIA)

Prepared for: Commonwealth Department of Health and Aged Care (Victorian) Department of Human Services

Prepared by: Sach & Associates in association with Centre for Applied Gerontology

November 2000 report final

CONTENTS EXECUTIVE SUMMARY...... I

PREFACE...... 1

1. ORIGINS OF THE MULTI-PURPOSE SERVICES PROGRAM ...... 1

1.1 POLICY PRECURSORS ...... 1 1.2 MULTI-PURPOSE SERVICES CONCEPT...... 2 1.3 FUNDING...... 5 1.4 CHRONOLOGY...... 5 1.5 CONCLUSIONS...... 7 2. FLEXIBLE SERVICE MODELS IN CONTEXT ...... 8

2.1 FLEXIBLE PROGRAMS CHRONOLOGY...... 8 2.2 STATE FLEXIBLE CARE SERVICE INITIATIVES...... 9 2.3 COMMONWEALTH FLEXIBLE CARE SERVICE INITIATIVES ...... 12 2.4 FLEXIBLE SERVICE MODELS COMPARED ...... 15 2.5 AUSTRALIAN AND INTERNATIONAL TRENDS ...... 15 3. OTWAY MULTI-PURPOSE SERVICE: demonstrated service integration...... 18

3.1 SERVICE CATCHMENT ...... 18 3.2 HISTORY ...... 19 3.3 THE OTWAY HEALTH & COMMUNITY SERVICES MODEL ...... 20 3.4 SERVICE EFFECTIVENESS ...... 24 3.5 CLIENT IMPACTS ...... 27 3.6 BARRIERS TO IMPLEMENTATION ...... 31 3.7 KEY FACTORS FOR SUCCESS...... 32 3.8 OVERVIEW OF FINDINGS...... 35 4. MALLEE TRACK MULTI-PURPOSE SERVICE: a service, not necessarily a centre ...... 36

4.1 SERVICE CATCHMENT ...... 36 4.2 HISTORY ...... 37 4.3 THE MALLEE TRACK MPS MODEL ...... 39 4.4. SERVICE EFFECTIVENESS ...... 40 4.5. CLIENT IMPACTS ...... 47 4.6 CLIENT IMPACTS LINKED TO SERVICE MODEL ...... 51 4.7 BARRIERS TO IMPLEMENTATION ...... 51 4.8 ISSUES FOR A MULTI SITE MODEL ...... 53 4.9 KEY FACTORS FOR SUCCESS...... 53 4.10 QUALITY ASSURANCE...... 54 4.11 OVERVIEW ...... 54 5. ALPINE HEALTH MULTI-PURPOSE SERVICE: linking across communities...... 56

5.1 SERVICE CATCHMENT ...... 56 5.2 HISTORY ...... 57 5.3 THE ALPINE HEALTH MPS MODEL ...... 58 5.4 SERVICE EFFECTIVENESS ...... 63 5.5 CLIENT IMPACTS ...... 64 5.6 BARRIERS TO IMPLEMENTATION ...... 68 5.7 ISSUES FOR A MULTI SITE MODEL ...... 69 5.8 KEY FACTORS FOR SUCCESS...... 70 5.9 OVERVIEW ...... 71 6. UPPER MURRAY MULTI-PURPOSE SERVICE:- integration with a population health focus ..... 76

6.1 SERVICE CATCHMENT ...... 76 6.2 HISTORY ...... 77 6.3 THE UPPER MURRAY HEALTH & COMMUNITY SERVICES MPS MODEL...... 77 6.4 SERVICE EFFECTIVENESS ...... 83

6.5 CLIENT IMPACTS ...... 87 6.6 KEY FACTORS FOR SUCCESS...... 89 6.7 QUALITY ASSURANCE...... 90 6.8 BARRIERS TO IMPLEMENTATION ...... 92 6.10 OVERVIEW...... 93 7. FAR EAST GIPPSLAND MULTI-PURPOSE SERVICE: optimising service range for rural communities...... 96

7.1 SERVICE CATCHMENT ...... 96 7.2 HISTORY ...... 97 7.3 THE FAR EAST GIPPSLAND MPS MODEL ...... 98 7.4. SERVICE EFFECTIVENESS ...... 101 7.5 CLIENT IMPACTS ...... 108 7.6 BARRIERS TO IMPLEMENTATION ...... 112 7.7 KEY FACTORS FOR SUCCESS...... 114 7.8 QUALITY ASSURANCE...... 115 7.9 OVERVIEW ...... 115 8. MULTI-PURPOSE SERVICES PROGRAM EVALUATION FINDINGS ...... 119

8.1 NATURE AND EXTENT OF CHANGE DUE TO THE MULTI-PURPOSE SERVICES MODEL ...... 119 8.2 EFFECTIVENESS OF THE MULTI-PURPOSE SERVICE PROGRAM ...... 121 8.3 IMPACT OF THE MULTI-PURPOSE SERVICE MODEL ON CLIENTS ...... 127 8.4 KEY FACTORS FOR MPS SUCCESS...... 128 8.5 BARRIERS TO SUCCESSFUL MPS IMPLEMENTATION...... 131 8.6 MULTI SITE VERSUS SINGLE SITE IMPLEMENTATION ISSUES ...... 134 8.7 LIKELY IMPACT OF CURRENT INITIATIVES...... 136 8.8 PROGRAM ACCOUNTABILITY ...... 138 8.9 RECOMMENDATIONS...... 143 APPENDICES ...... 144

APPENDIX 1. PROJECT BRIEF...... 145

APPENDIX 2 LITERATURE REVIEW...... 148

APPENDIX 3 FOCUS GROUP RESULTS ...... 163

APPENDIX 4 CONSULTATIONS...... 173

Acknowledgments

The Multi-Purpose Services Program Evaluation involved a large number of people and considerable logistical support to achieve the outcome within the specified timeframe. Over 3,000 kilometres was covered and many interviews and group sessions held in a wide range of rural localities. Government Departments and all Multi-Purpose Services provided information and extensive support to assist the Review and their assistance is acknowledged and appreciated.

Particular thanks is extended Bruce Watson and Jodi Hallas of the Department of Human Services, Mila Cichello of the Department of Health and Aged Care, Jeanette Grant from Otway Health & Community Services, Lindsay Lynch from Mallee Track Health and Community Service, Lyndon Seys from Alpine Health, Frank Evans and Mary Hoodless from Upper Murray Health & Community Services and Jill Vagg from Far East Gippsland Health & Support Service.

Executive Summary

Executive Summary

The joint Commonwealth/State Multi-Purpose Services Program, which commenced as a pilot in 1992/93, aims to provide a flexible approach to health and community service delivery to small, isolated rural communities. The defining features of the Multi-Purpose Services (MPS) model includes the amalgamation of all or most services (ranging from acute hospital care to residential/community health/Home and Community Care [HACC]/community services and others), governance by a single Board, the cashing out of former Program funds into a single budget and the development of services according to identified community needs.

There are 36 MPSs in Australia, including seven in Victoria, five of which have been established for more than three years and are examined in this project.

The primary objective of the project was to evaluate effectiveness the Multi-Purpose Services Program as a whole. It was not a site specific financial evaluation and no conclusions are made on this issue.

Multi-Purpose Service Highlights • Otway Health and Community Services Otway MPS, located at Apollo Bay, supports a population catchment of 3,225 persons. From a small, disparate set of separately managed and delivered services, Otway Health and Community Services has expanded its base to include over 37 services which are provided in a coordinated, client centred manner. A population health philosophy guides the model. Otway MPS demonstrates how service breadth and depth can be introduced into small rural communities without loss of traditional services. A particularly strong aspect of the Otway model is the integrated approach to service planning and management.

• Mallee Track Health & Community Service Mallee Track Health & Community Service is a multi site MPS with the main facilities based at Ouyen (population 1400) and service centres at Patchewollock (population 200), Underbool (population 450) and Murrayville (population 350). Located in a wheat/sheep farming community and extending over a 110 kilometre catchment, this MPS has established a secure base for health services that were formerly at risk of survival due to their isolated and uncoordinated service models. The service range has also been extended, with a greater emphasis on health promotion. More appropriate use is made of bed based services through the flexible management of acute and residential care places. The Mallee Track MPS also demonstrates the links that can be developed between health and community development objectives, with the MPS being a contributor to small community survival.

• Alpine Health Alpine Health is an instructive contrasting case study. It is a multi-site service based at Myrtleford, Bright and Mt Beauty in north east Victoria. Many of its features differ significantly to other MPSs including its larger population base (13,046), its quasi-rural status (it being one of the most significant recreational destinations for over 1 million visitors each year), the presence of three towns each with its own hospital and service systems, its significant general practitioner numbers (13, compared to two or three in most other MPSs), its geographic discontinuity (with distinct communities in separate river valleys) and its relationship to a complex arrangement of regional and local government services.

Multi-Purpose Services Program Evaluation, Victoria i Executive Summary

Alpine Health has experienced significant difficulties from the outset. Only the hospitals and their associated residential aged care service joined the MPS and significant viability issues impacted on two of the three hospitals. Management instability and continuing financial issues encumbered MPS progress, although acceptance of the changes has now been achieved and a base is developing for a more optimistic future. The Alpine Health case study demonstrates that it is difficult to implement an MPS model unless certain pre-conditions are met.

• Upper Murray Health & Community Services The Upper Murray MPS is based at Corryong in an isolated rural community of 3,264 people on the Victorian/New South Wales border. This MPS is a clear representation of many of the principles inherent in the MPS model. It demonstrates that whilst the MPS model provides the conditions for flexible service provision manner, it requires sound management, vision and entrepreneurial vision to fulfill its potential. (Similar, observations also apply to Otway and Far East Gippsland MPSs). Upper Murray Health & Community Services has developed a sophisticated approach to service planning and development. It uses evidence-based needs assessment, combined with epidemiological and socio demographic profiling to present health issues to its community. A significant community democracy approach is then applied to empower the community to set its service priorities. These in turn are linked into an integrated Corporate Plan which guides service delivery and development. Many service innovations have also been developed and these provide instructive examples of the outcomes that can be achieved from the MPS model when management fully understands its potential.

• Far East Gippsland Support Service Far East Gippsland MPS is based at Orbost on the eastern Victoria coast and services a extensive farming and timber production area of approximately 4,500 people. It has developed a service response that directly reflects the culture and needs of its community. It maintains a wide range of services including specialist services (such as family violence counselling and youth programs) and maintains a workforce of 125 people in 71 EFT positions, thereby serving a significant employment and community development role in its own right. Through service developments and opportunistic management, Far East Gippsland MPS has expanded its budget from $2.2 mil. to $4.8 mil. since 1994/95. The Far East Gippsland MPS has also resolved issues associated with health professional recruitment to small rural communities. Considerable attention has also been given to the enhancement of acute hospital services and supporting the general practitioner base.

Multi-Purpose Services Program Evaluation Findings The evaluation of the Multi-Purpose Services Program has identified significantly improved health and primary care service gains to small rural communities in Victoria. It has established that the application of a single, flexible funds pool for each Multi-Purpose Service is a significant contributing factor to the success achieved in delivering coordinated and client centred health, residential aged care, primary health and community care service provision. Whilst the Program is producing effective outcomes in an innovative manner, it has also been established that existing procedures are inadequate for whole of program accountability, although most Multi-Purpose Services have developed appropriate management information processes in their own right.

Overall, the Program is meeting its objectives. It serves as an exceptional demonstration of a flexible care service model for small rural communities. The flexibility inherent in the model

Multi-Purpose Services Program Evaluation, Victoria ii Executive Summary provides the foundation for that success, but it has also been established that experienced management, vision and an entrepreneurial perspective is required to realise its potential.

The key findings related to the Project Objectives include the following:

Issue 1: Nature and extent of change due to the Multi-Purpose Services model What actually changed in communities that adopted the Multi-Purpose Service model?

Four significant themes have been identified; - Management and service delivery structures changed through the introduction of a single governance model. This change of itself was a significant contributor to service development given that pre-MPS Boards and committees often lacked the expertise to effectively manage program developmental and accountability requirements, even though service delivery volumes were relatively low.

- Service integration occurred. Service integration provided the basis for service expansion and reform. In particular it permitted existing services to expand and new services to be introduced.

- Services expanded. All MPSs have demonstrated post-MPS service expansion, often of significant proportions. Communities that previously had narrow, traditional service regimes can now demonstrate a range of community services comparable to those of provincial cities.

- Service viability has improved. In all pre-MPS communities the financial viability of key services had been at risk. In most cases this applied to the hospital but it also included residential aged care facilities. Whilst not expanding the budget, the Multi-Purpose Services Program permitted service substitution and rationalisation which contributed to improved cost effectiveness. In several instances (but not all), under utilised acute beds have been reduced and community services expanded, without reductions in occupied bed days. In other instances, some residential aged care beds have not been required to achieve financial viability, thereby releasing funds to support previous service gaps. This has been achieved without loss of acute or residential aged care services.

Finding 1: Nature and extent of change due to Multi-Purpose Service model Management and service delivery structures were enhanced; service integration occurred; services expanded and service viability improved. The Multi-Purpose Service Program has delivered significant benefits to small rural communities in Victoria including improved governance, service integration, service expansion and overall service viability. The future success of the model is dependent on the size and mix of the funds pool.

Issue 2: Effectiveness of the Multi-Purpose Service Program A related inquiry is to determine the extent to which effectiveness improvements are due to the Multi-Purpose Services model.

Issue 2a) Targeting community needs Cultural fit demonstrated: The Multi-Purpose Service Program has clearly demonstrated improved targeting to meet identified community needs. Most Multi-Purpose Services in Victoria demonstrate advanced "cultural fit" between identified community needs and the

Multi-Purpose Services Program Evaluation, Victoria iii Executive Summary service profiles. Basic support services have been retained and improved and a health prevention dimension provided to address community well-being issues. Small, traditional health and community services have been replaced with integrated systems encompassing treatment, prevention, health promotion, rehabilitation and community development.

Community needs identified Community needs were comprehensively identified in the initial phases of Multi-Purpose Service formation and several services are in the process of completing second round surveys. The Multi-Purpose Services Program provides an effective framework for integrated service delivery and the service providers have demonstrated how health service structures can directly reflect identified community need and evidence based interventions.

Client satisfaction Whilst all Multi-Purpose Services undertake individual service assessments (often as a component of their quality accreditation processes), there is limited evidence of a consistent assessment of client satisfaction across all services within a Multi-Purpose Service. Each Multi-Purpose Service can demonstrate high levels of client satisfaction for individual services, but Boards of Management and Executives generally have no overall measure of community satisfaction and they are unable to quantitatively demonstrate changes to community attitudes to the service performance over time, other than through anecdotal feedback and service specific surveys. However, focus group sessions undertaken as part of this project suggest the likelihood of a high degree of acceptance of the Multi-Purpose Service does exist.

Health outcomes In common with other health and community service providers, all Multi-Purpose Services use process indicators or output indicators as indirect measures of health outcomes. Both the range and volume of service has been found to have measurably increased.

Finding 2a: Targeting community needs The Multi-Purpose Service Program in Victoria has demonstrated a high level of responsiveness to the identified needs of small rural communities. Improved time series measures of client and community satisfaction would assist in monitoring future service responses.

Issue 2b Access Improved access to services has occurred in all Multi-Purpose Services since their introduction and this is demonstrated in the following dimensions:

Increased range of available services Most Multi-Purpose Services have increased the range of services available to the community, including significant service additions and developments.

Increased individual service utilisation A significant increase has occurred in the use of community health, community and home based services. A more appropriate use of services has also occurred, with bed-based services managed according to need. Acute, aged residential high and low care beds are being managed as a continuum, with a flexible transition at the inter-service boundaries. Whilst all services maintain a core of beds in each service type, flexibility exists to modify use

Multi-Purpose Services Program Evaluation, Victoria iv Executive Summary according to need. There is no program-wide evidence of reduced access to acute beds as a result of the Multi-Purpose Services Program, with acute services offered to the community being similar in the pre and post MPS periods.

Finding 2b: Access The Multi-Purpose Service Program has significantly expanded the range of services available to small rural communities in Victoria, particularly community and primary health services. New service relationships have been developed without detriment to previously existing services.

Issue 2c Coordination, flexibility and innovation Coordination and flexibility are the hallmarks of the Multi-Purpose Service model. Specific service approaches are also occurring but such methods are only innovative relative to traditional programmatic responses.

Innovation is not an objective of Multi-Purpose Services but it is a common outcome. Most services demonstrate unconventional approaches in all dimensions of the service including management, staff and service development. A marked feature of the Program is the high level of staff satisfaction, relatively flat organisational structures, program management delegations, flexibility of staff to respond to client needs, inter-disciplinary work practices, opportunities to influence the service system and expanded opportunities for professional development.

Finding 2c: Coordination, flexibility and innovation The Multi-Purpose Services model provides a flexible structure for the coordinating and facilitating services that are responsive to the needs of people living in small rural communities in Victoria. The combination of continuity of care best practice and funding flexibility raises service responsiveness to a high level. The introduction of improved client information systems would facilitate an improved understanding of processes and support service accountability measures.

Issue 2d Cost effectiveness "Cost effectiveness" may be defined as the attainment of beneficial outcomes with the funds available for that purpose, and contrasts to "cost efficiency" which seeks to maximise productivity within a given budget. For most Multi-Purpose Services cost effectiveness is a process outcome rather than a targeted and measured objective. Many examples exist to support cost effective objectives but there is a need for a consistent data set to support whole- of-program assessment.

Cost effectiveness surrogates have been identified in the following areas: - service delivery indicators - budget efficiency indicators - economy of scale indicators - workforce indicators - cost saving indicators Details on each item are included in the main report

Multi-Purpose Services Program Evaluation, Victoria v Executive Summary

Finding 2d: Cost effectiveness The Multi-Purpose Service Program has provided the conditions for a more cost effective service structure. Cost effectiveness indicators are being developed in service delivery, budget efficiency, economies of scale, workforce development and service cost savings. Evidence based analysis has found that a high prevention, high support based model of service delivery has the highest utility for small rural communities.

Issue 2 Cultural appropriateness Otway, Mallee Track, Upper Murray and Far East Gippsland MPSs all support rural catchments predominated by people of English speaking backgrounds and cultures. The Alpine Health catchment includes a long standing community of Italian heritage who relate to the generic services. Given the small numbers of people from other cultures no Multi- Purpose Service was found to take particular approaches for people from diverse linguistic and cultural backgrounds.

Far East Gippsland also includes an Aboriginal and Torres Strait Islander community. A positive working relationship exists between the MPS and the Moogji Cooperative was identified.

Finding 2: Overall finding on program effectiveness Detailed comparative program indicators have not been developed to quantify effectiveness measures. However, there is site related evidence of effective targeting of community needs, high levels of service satisfaction, increased service access (particularly to community health, community care and well-being services) without loss of acute services, exemplary levels of service coordination and individual client focused service development. These service developments have been achieved without budget supplementation, other than that derived from additional contracts competitively attracted by Multi-Purpose Services. Evidence has been established to support the finding that high prevention, high support based models of service delivery produce the highest utility (effectiveness and cost effectiveness) for rural communities.

Issue 3: Impact of the Multi-Purpose Service model on clients The evaluation also considered the following question: "What impact has the Multi-Purpose Services model had on clients and have community needs been appropriately met?"

There is clear evidence that the client service choice, appropriateness of care and continuity of care have improved in communities supported by Multi-Purpose Services and, in several instances "best practice" case studies have been identified.

Links between Multi-Purpose Services and sub regional services have also been well established and all Multi-Purpose Services incorporate regional services (such as mental health counselling) into their services. Further consideration needs to be given to effectiveness of these arrangements.

The single identified weakness of the Multi-Purpose Service Program for clients relates to issues of client rights and safeguards. Although all services accord a high priority to client rights there is no consistent program-wide approach or access to an independent complaints resolution system.

Multi-Purpose Services Program Evaluation, Victoria vi Executive Summary

Finding 3: Impact of Multi-Purpose Services model on clients The Multi-Purpose Services model has increased choice, care coordination and client centred care for small rural communities in Victoria. The range of services has expanded and is responsive to identified community needs. Available indicators, including community feedback, suggest that the Multi-Purpose Service has produced significant benefits for rural clients.

Issue 4: Key factors for MPS success It has been possible to identify pre-conditions that should be met to implement a successful Multi-Purpose Service. They are:

- Small communities All successful Multi-Purpose Services examined in this project have small catchments, commonly populations of 3,000 to 4,000.

- Contiguous service boundaries It can be demonstrated that successful MPS implementation occurs when amalgamating core services have contiguous service boundaries. Instances of multiple catchments within a single service area creates complexities for funds pooling and service amalgamations.

- Single set of pre-MPS services Services that include multiples of the same service type (such as hospitals) may create barriers for the successful implementation of a Multi-Purpose Service. However, it is possible to establish a multi-site Multi-Purpose Services where several services of the same type exist, provided that the proposed changes do not threaten existing structures.

- Common community Areas with a common community have greater success in forming a Multi-Purpose Service than those with several towns of similar size and structures. Ideally the community should also be supportive of the proposed change.

- General practitioner support The attainment of general practitioner support for the change is also important. Far East Gippsland MPS clearly understood this issue and worked closely to ensure that they provided the infrastructure, skilled professional staff and support services to enable doctors to provide a medical service to the community. Other Multi-Purpose Services which experienced conflictual relationships with general practitioners who felt threatened by loss of control and perceived reduced service access, had difficult gestations.

- Capital incentives Although facility redevelopment grants are independent of Multi-Purpose Service Agreements, all Multi-Purpose Services examined in this project came with the undertaking of capital funding. All Boards indicated that the promise of redevelopment grants was foundational in achieving community acceptance for the change to a Multi-Purpose Service.

- Management expertise The attainment of appropriate management expertise is fundamental to Multi-Purpose Service success. Successful Multi-Purpose Services are those that have a Chief Executive Officer

Multi-Purpose Services Program Evaluation, Victoria vii Executive Summary with the following skills: program knowledge, management expertise, vision and entrepreneurial skills.

Finding 4: Key factors for MPS success The key factors for success (KFS) of a Multi-Purpose Service occur in two broad groupings. Group 1 may be termed "pre-MPS conditions" and include a small population, contiguous service boundaries for core existing services, a single set of services and a common community. Group 2 KFSs may be termed "developed conditions" and include general practitioner support, capital incentives and management expertise.

Issue 5: Barriers to successful MPS implementation a) Development phase Barriers during the development phase were the most challenging for Multi-Purpose Services. Four of the five Multi-Purpose Services experienced considerable problems over a long period (up to four years) before a stable, successfully operating service was established.

The Development Phase barriers may be broadly grouped into the following categories:

- Uncertainty and suspicion Most Multi-Purpose Services considered that the proposed model was being imposed upon them. There were two related agendas which included the establishment of viability for small rural hospitals around the time of case mix funding introduction and the introduction of a new Commonwealth/State initiative (the Multi-Purpose Services Program) which offered the potential for improved health services but came without additional funding.

- Chief Executive Officer selection. Most communities felt that they had neither the control, the expertise nor the resources to effectively negotiate the change process with Government. There were multiple expectations from Government Departments (amalgamations, needs identification, legal negotiations and maintenance of existing services in an environment of uncertainty) but not the resources nor initially the expertise, to address these expectations.

- General practitioners and staff participation Existing service providers often considered that they were peripheral to the decision making process and placed in defensive positions. b) First triennium Many of the issues that existed during the development period had not been fully resolved at the time of the signing of the MPS Tripartite Agreements and this created implementation complexities whilst Boards and management sought to resolve establishment challenges and commence service redevelopment.

The identified barriers during this phase may be broadly grouped into the following categories: - Continuing uncertainty. - Multiple expectations. During the initial years of operation there was a pressure to meet multiple expectations and this occurred in a climate of uncertainty and major change. - Facility redevelopment delays. Facility redevelopment delays lead to loss of community confidence in the model.

Multi-Purpose Services Program Evaluation, Victoria viii Executive Summary c) On-going Four main themes have been identified as on-going issues for Multi-Purpose Services in Victoria. They are: - Program guidelines. The development of comprehensive program guidelines would assist many of the identified barriers to Multi-Purpose Service implementation. - Program management responsibility. It is not clear to whom MPSs are responsible in Government Departments. - Program accountability. The existing MPS Program Accountability arrangements are also similarly have been found to be inconsistent, unreliable, overlapping and incorporating elements of both program and pooled funding models. • Testing the limits of the Multi-Purpose Service model. Some Multi-Purpose Services have extended the service model to its current limits and have few options for further budget expansion or financial leverage.

Finding 5: Barriers to successful MPS implementation Significant barriers occurred for most Multi-Purpose Services during their development and initial operational phases, and it took several years to establish stable, successful services. These barriers can be addressed through the introduction of program guidelines, affording priority to the development of MPS Boards, the early recruitment of skilled Chief Executive Officers, the development of an appropriate sequence of developmental activities and the introduction of reporting arrangements and accountability systems designed to relate to MPS Program objectives.

Issue 6: Multi site versus single site implementation issues "Under what conditions are multi-site Multi-Purpose Service models successful?"

Finding 6: Multi-site versus single site implementation issues Multi-site Multi-Purpose Service arrangements are of benefit and best suited to communities where services in small outlying centres are maintained and reinforced by their association with a larger service centre. Multi-site models incorporating several towns with similar size each with a hospital and similar service structures are likely to have significant barriers to effective implementation.

Issue 7: Likely impact of current initiatives The enquiry relates to the future of the MPS model relative to the emerging flexible and coordinated health service initiatives.

Whilst being a major success, Multi-Purpose Services may not be appropriate for all rural communities and the Program represents one option for coordinated and enhanced rural health service delivery. The recently introduced Regional Health Services (RHS) Program provides an added option, as does the State funded Rural Healthstreams Program.

The Victorian Primary Care Partnerships (PCP) strategy may also be considered as a complementary development. It seeks to develop primary care systems across both urban and rural communities and is based on voluntary alliances between existing service providers. The two programs have been found to be potentially mutually supporting, the main benefits for Multi-Purpose Services being improved linkages to regional and specialist medical services and access to larger scale health promotion programs and the associated funding. It

Multi-Purpose Services Program Evaluation, Victoria ix Executive Summary also offers the opportunity to localise health promotion services which would be otherwise unavailable to small rural communities. PCPs can also benefit from the experience of Multi- Purpose Services.

Finding 7: Likely impact of current initiatives The range of programs encouraging flexibility and integration available to rural communities are complementary to each other.

Issue 8: Program accountability The most significant issue to emerge from the evaluation of the Multi-Purpose Services Program has been the need for improved program accountability and the question to be addressed in this concluding section is "What actions are necessary to develop a Multi- Purpose Services Program Performance Accountability Framework?"

The following problems have been identified: Program Guidelines There are no detailed guidelines to provide a baseline for program development and operation.

Funds pool There is a lack of clarity in the relationship between the formation of the MPS funds pool and Program financial accountability.

Relationship between performance indicators and reporting systems. Multi-Purpose Service Tripartite Agreements specify performance indicators but there is no relationship between these indicators and the current MPS reporting system, and hence it is not possible to quantitatively or consistently assess performance against specified objectives.

Data recording definitions. There is no standardised framework for data reporting and this creates problems for both intra-MPS and inter-MPS comparisons.

Incomplete records. Several instances exist of incomplete data. This may be due to changes in recording systems within a Multi-Purpose Service and be reflective of the developmental nature of the services. Most Multi-Purpose Services have sound information collection systems and have demonstrated the application of the data in monitoring program performance at their sites.

Finding 8: Program accountability The Multi-Purpose Services Program requires the further development of guidelines and an accountability framework. Whilst significant benefits can be demonstrated at each service site, the current reporting arrangements are inadequate to quantify program performance on a consistent basis across sites and time periods.

Towards an MPS Performance Framework There is a need to develop an MPS Performance Framework that clearly addresses the identified problems. The main report includes an outline for a MPS Performance framework.

Multi-Purpose Services Program Evaluation, Victoria x Executive Summary

RECOMMENDATIONS

The Multi-Purpose Service Program has demonstrated the effective application of a population model of health service delivery, expanded services in small rural communities, client centred continuum of care, service innovations, integrated service systems, community development, efficiencies without loss of services and exemplary service management and leadership. The only significant issue identified for priority consideration relates to relates to the formalisation and improvement of program wide accountability.

It is recommended that: 1. Clear points of contact be established for the Multi-Purpose Service Program within the Department of Human Services and Department of Health and Aged Care for: a) program policy, program development, program-wide accountability and liaison within and between Departments, and b) monitoring of each Multi-Purpose Service's service plans and accountability.

2. Multi-Purpose Service Program Guidelines be prepared to assist the development, implementation and monitoring of MPS services.

3. Commonwealth and State Departments develop a Multi-Purpose Services Quality Framework that ensures the achievement of comparable outcomes to mainstream programs.

4. An MPS Performance Framework be developed by 30 June 2001.

5. All Multi-Purpose Services be required to prepare an agreed MPS Performance Plan by 31 December 2001 in accordance with a framework that includes common core MPS indicators plus MPS site-specific indicators.

6. The Department of Human Services and Department of Health and Aged Care produce a Victorian Multi-Purpose Services Program Annual Report incorporating the proposed core MPS data and highlights of program performance.

7. All Multi-Purpose Services be requested to demonstrate appropriate Complaints Resolution structures encompassing all aspects of their services.

8. Consideration be given to the enhancement of the Multi-Purpose Services program as an exemplar model of health service delivery for small rural communities, and that specific consideration be given to expanding the range and linkage of services, including the pooling of that proportion of regional service program funds delivered to an MPS catchment in instances where the MPS has the capacity and expertise to deliver those services to its community.1

1 Examples include Hospital in The Home, Post Acute Care Program, regional mental health services and others.

Multi-Purpose Services Program Evaluation, Victoria xi Preface

Preface

The Commonwealth Department of Health and Aged Care and Victorian Department of Human Services jointly commissioned this evaluation of the Multi-Purpose Services Program in Victoria.

The Multi-Purpose Services Program commenced as a pilot program in 1992/93, with three Multi-Purpose Services (MPSs) established in Victoria in 1995. The MPS Program is a response to the maintenance and development of health and community services in small, isolated rural communities, particularly in instances where service viability is limited by stand-alone program based management arrangements.

The MPS philosophy and objectives are: • To improve the flexibility of health and aged care programs • To provide health and aged care services more cost effectively • To improve the targeting of health and aged care services to each community's specific needs • To improve the coordination of health and aged care services, both locally and regionally.

A Multi-Purpose Service has defining features that make it distinctive, and in many respects unique as a service model. First, it is based on a vertically integrated governance, with a single Board of Management encompassing all services that agree to join the Multi-Purpose Service. Secondly, amalgamated services usually include a core of acute, residential aged care and Home and Community Care services, but commonly also include community health and community services (such as a neighbourhood house program). Thirdly, each MPS receives a pooled budget that is created by the cashing out of participating program budgets. Fourthly, MPSs are not subject to the accountability, accreditation or quality assurance obligations attached to each Program from which the budget contribution is sourced. MPSs account to Government in accordance with a specified set of reports.

The Multi-Purpose Services Program is underpinned by a flexible approach that enables each MPS to shape their service profile to evidence based needs assessments of their communities. Thus, for example, a Multi-Purpose Service may decide to substitute some bed-based services for home or community-based services, without threatening the funding viability for a nursing home or hostel, or for acute care beds.

This evaluation examines five of the seven Multi-Purpose Services in Victoria that have been operating for more than three years and seeks to determine the overall Program effectiveness and identify any issues that may benefit from review. The experience of the individual Multi- Purpose Services was used to derive the general findings. The five sites are as follows: • Otway Health & Community Services based at Apollo Bay on the south west coast • Mallee Track Health & Community Service, a multi site MPS with a primary centre at Ouyen and service delivery points at the small rural settlements of Underbool, Murrayville and Patchewollock, in the north west farming country • Alpine Health, another multi site MPS with centres at Myrtleford, Bright and Mt Beauty in an area of high tourist value in north west Victoria • Upper Murray Health & Community Services, a small isolated community in the extreme north west of Victoria, and

Multi-Purpose Services Program Evaluation, Victoria Preface

• Far East Gippsland Health & Support Service, a rural community centred at Orbost in the eastern coast of Victoria, with a catchment extending to the New South Wales border.

The Evaluation Project Objectives, in summary, encompass the following terms of reference. (Appendix 1 for details). i. Evaluate the effectiveness of the Multi-Purpose Services Program at 5 Victorian sites which have been operational for at least the period of one Tripartite Agreement (3 years), focussing in particular on the extent to which each of the following Multi-Purpose Services objectives have been achieved: • improved targeting of services to meet needs in the community • improved access to appropriate services • increased co-ordination, flexibility and innovative service delivery • more cost-effective services • delivery of culturally appropriate services. ii. Identify the key factors that maximise the opportunities for successful implementation of the Multi-Purpose Services model and achievement of the Multi-Purpose Services objectives in each site. iii. Identify barriers to successful implementation of the Multi-Purpose Services model: • in the developmental phase (prior to the signing of the Tripartite Agreement) • during the period of the first Tripartite Agreement (three years) • as an ongoing Multi-Purpose Services post the first Tripartite Agreement (second three years and beyond). iv. Review and assess the impact of the Multi-Purpose Services model on clients and on coordinated service delivery for clients, including the impact of more flexible funding on the nature of services available and whether they have appropriately addressed communities needs between each Multi-Purpose Service and sub-regional Services. v. Review and assess the nature and extent of change in service delivery within each site, comparing pre and post commencement date as an Multi-Purpose Service. This will include an analysis of the extent to which the pooling various Commonwealth and State funding streams has altered expenditure levels and patterns. It should also include an analysis of whether there has been an impact on services in surrounding locations. vi. Review and assess the issues associated with the implementation of multi-site Multi- Purpose Services, in comparison with those based at a single site. vii.Assess the likely impact of the introduction of current initiatives, including the Regional Health Services Program and the Primary Care Partnerships strategy.

The project was undertaken over a 16 week period. It commenced with a literature review, overview of the Multi-Purpose Services Program and its relationship to other flexible service models and examination of centrally held data. This was followed by field investigations at each site based on an intensive three to four day visit programs that included Board, management and staff presentations, reviews of services, data and reports. Over 180 people were directly consulted and participated actively in the Review and included Departmental Officers, MPS Boards of Management, MPS staff, general practitioners, a cross section of community members and others. The methodology was designed to cross check information and perceptions to achieve as accurate a reflection of the Multi-Purpose Services Program as

Multi-Purpose Services Program Evaluation, Victoria Preface possible and included community focus groups, meetings with MPS Board without the management or staff, individual interviews with those who may have wished to express an particular perspective (including opposing viewpoints), staff meetings and a series of separate interviews with Departmental Program officers. Following the field visits, preliminary reports on each MPS were forwarded to Chief Executives for factual review, but not for comment on interpretations or findings.

The project was managed by Jack Sach, Director of Sach & Associates, and the project team included Richard Clark (public health scientist), Dr Sharryn Lydall-Smith (psychologist) and Francis Lentini from Centre for Applied Gerontology, Bundoora (epidemiologist and statistician).

A Steering Committee was established to manage the Project Contract and a Reference Group contributed to the Review (Appendix 4).

Multi-Purpose Services Program Evaluation, Victoria Origins of the Multi-Purpose Services Program

1. Origins of the Multi-Purpose Services Program

1.1 Policy Precursors t certain times policy issues of national importance converge and a significant advance in meeting the needs of the community occurs. This situation arose in the 1990s when Athere was an increasing awareness of the health and community service needs of rural communities and a recognition that the multiplicity of programs funded by State and Commonwealth Governments needed reform. The Multi-Purpose Services Program was a pioneering response to the convergence of a community need with a policy reform agenda.

The difficulty in meeting the health needs of small rural communities had been acknowledged for an extended period, but the funding and organisation of services to support small communities had remained a major obstacle. In Victoria, the estimated resident population in rural and regional Victoria in June 1996 was 28 per cent of the total and while it is estimated to grow by 1 per cent a year to 2008, many small communities are ageing and declining, leading of to challenges for health and community service delivery.2

A 1997 study of rural and regional Victorians identified their differential health status. It found higher incidences of cardiovascular disease, cancer, injuries, diabetes, pneumonia and influenza and asthma. The study demonstrated that "residents of rural Victoria appear to have worse health status (measured by age- standardised annual death and hospitalisation rates) than residents of metropolitan Melbourne and Geelong"3. Overlying the view of health conditions was the issue of limited diversity and choice of health and community services in rural Victoria, with many communities unable to offer the range of services required of the community, and the possibility of losing the limited existing services due to their lack of viability both for financial and professional workforce availability reasons. These issues were (and continue to be) exacerbated by the wide diversity of rural communities. The National Rural Health Strategy in 1994 observed that "variations in the size, density and degree of isolation of rural populations result in considerable differences in the need for and ability of rural communities to sustain the range of health services"4.

There are also difficulties overcoming structural limitations in rural areas. These include sustaining a range of services, development costs, a lack of support services, difficulty in attracting qualified and skilled staff and isolation from mainstream services. Acute hospital viability, including their use for nursing home type patients, was a particular issues for many communities. These factors in combination demanded a more responsive approach to health and community service provision.

At the same time, there was an increasing recognition by the early 1990s that health and community programs were complex and overlapping and that this had implications for rural communities. Each small rural service had its own committee of management and program grants that required separate management and accountability. In particular there was no scope for service substitution, leading to sub optimal service arrangements, with limited choice and

2 Department of Infrastructure Victoria in Fact (1996) 3 Carson, N., Health Status of Rural Victorians . Presented at the 1997 National Rural Public Health Forum. cited in Department of Human Services, Rural Health Matters Strategic Directions 1999-2009 p 60 4 Australian Health Ministers Conference, 1994, National Rural Health. Australian Government Publishing Service

Multi-Purpose Services Program Evaluation, Victoria 1 Origins of the Multi-Purpose Services Program a high reliance on bed based services combined with limited home care and community services. The opportunity to develop individualised care plans was limited.

There was also a growing recognition of the population models that emphasise a social model of health. This approach seeks to improve population health by addressing the social and environmental determinants of ill-health in tandem with the biological and medical determinants. "A social view of health implies that we must intervene to change those aspects of the environment which are promoting ill health, rather than to continue to simply deal with illness after it appears, or continue too exhort individuals to change their attitudes and lifestyles when, in fact, the environment in which they live gives them little choice or support for making those changes."5

The Multi-Purpose Services Program emerged in this changing environment. Following the Australian Health Ministers' Conference in March 1991, the Overarching Committee of the Functional Reviews of Health and Aged Care established a Multi-Purpose Funding Task Force with representatives from the Commonwealth, State/Territories. The Multi-Purpose Services Task Force developed a proposal to establish a more flexible, coordinated and cost- effective framework for service delivery. Underlying this proposal was the premise that more flexible funding arrangements would maximise the value of current funding levels.

The Task Force found that, where individual programs cannot provide an appropriate level of aged care/health services for a rural community then consideration should be given to aggregate pooling of all or some of the existing funds. Broad consultation would be necessary to ensure agreement by the local community and to identify the most effective local administering entity. It was considered that, in time, this approach could be extended to other areas of community services support, including supported accommodation assistance, housing, child care and Aboriginal services.

In addition it was noted that if the proposal were to work, it would require strong commitment from both the Commonwealth and the States to relax specific program guidelines as well as statutory restrictions or limitations to allow negotiation of flexible work practices.6

1.2 Multi-Purpose Services Concept Multi-Purpose Services are legislated as flexible services under the (Commonwealth) Aged Care Act 1997. Flexible care is care provided in a residential or community setting through an aged care service that addresses the needs of care recipients in alternative ways to the care provided through residential care services or community care services (Division 49-3). A Multi-Purpose Service must provide an integrated service that includes residential care and at least one of the following: a health services provided by a State, a home and community care service, a dental or other health care service, a transport service, community care under the Act, a medical benefit service, a pharmaceutical benefits service or a service that the Minister nominates in an agreement with the responsible Minister of the State as an appropriate service.

5 Wass, Andrea, 1998, Promoting Health: The Primary Care Approach. South Australian Health Commission 1998 p 15. Quoted in Department of Human Services 1999 ibid. p26 6 Overview from the Multi-Purpose Services Task Force Final Report p2. Cited in, Andrews G., Dunn J., Hagger C., Sharp C., and Witham R., Pilot Multi-Purpose Services Program. Centre for Ageing Studies, Health Solutions and Consortium for Evaluation Research and Training, South Australia pp18-19

Multi-Purpose Services Program Evaluation, Victoria 2 Origins of the Multi-Purpose Services Program

The approved provider must also be able to: • provide the flexible care to people in rural and remote regions; and • target the care to meet the needs of people in rural and remote regions; and • improve access to the care; and • increase coordination, flexibility and innovation in the delivery of the care; and • ensure the care is cost-effective; and • ensure the care is culturally appropriate.

Other eligibility provisions also apply (Flexible Care Subsidy Principles 1997 (15.14 (5) -(7).

The Multi-Purpose Services concept essentially aims "to assist isolated, rural communities to deliver a range of relevant services according to community identified needs." 7 The philosophy and objectives underpinning the program are to: • improve the flexibility of programs • provide aged care and health services more cost effectively • enhance targeting of aged care and health services to community needs • improve the coordination of aged care and health services.8

The key principles of the Program include: • community involvement and ownership, • local determination of priorities, • a broader focus than physical facilities, and • targeting of local needs.

Multi-Purpose Services aim to improve the provision of aged, health and community care services and may include: • acute inpatient • residential care (high and/or low care) • Community Aged Care Packages • Commonwealth Respite for Carers • General practitioners • Home and Community Care • Community health services • Ambulance services • Volunteer services • Maternal and Child Health • Other Commonwealth community services • Medicare Benefits Scheme items9 • Pharmaceutical Benefits Scheme items

7 Department of Human Services¸ Multi-Purpose Services: An Innovative Aged and Health Care Model for Rural Victoria (brochure 1996) 8 Department of Human Services, The MPS Option: Health and Aged Care in Rural Communities 1996. p7. Sourced from: Multi-Purpose Services Task Force Final Report 1991 p5 9 Although permitted to include MPS and PBS items, no MPS includes these services in the funds pool.

Multi-Purpose Services Program Evaluation, Victoria 3 Origins of the Multi-Purpose Services Program

The concept has parameters common to all Multi-Purpose Services, although wide flexibility exists to arrange services according to local need. The defining characteristics of an Multi- Purpose Service include: • pooled funding. All funds contributed to the Program are pooled into a single budget. • cashed out program funds. Program funds are wholly or partly cashed out in accordance with Flexible Care Subsidy Principles (15.20). • flexible application of funds. Multi-Purpose Services are not subject to existing program or funding guidelines • staffing flexibility. Staff may be used flexibly across services according to need. • broad service range. Services can include any health, residential aged or community care service required by the community. • single Board of Management. • local accountability. Service accountability is to the Board of Management, which is responsible to local needs, and not centrally defined criteria. Reports are also provided to funding bodies.

Figure 1.1 The Multi-Purpose Services Program: A Structural Model

Needs identification

Commonwealth funds State funds

Pooled funding

PROVIDED TO

MPS Board

TO ACHIEVE

Objectives including: - program flexibility - cost effectiveness - improved targeting

- improved coordination

THROUGH

Local allocation of resources to meet identified needs

(After:Andrews et.al. ibid. p21)

Multi-Purpose Services Program Evaluation, Victoria 4 Origins of the Multi-Purpose Services Program

1.3 Funding In Victoria, funds may be provided to Multi-Purpose Services from the following recurrent budgets: • Commonwealth: Residential Aged Care Program, Community Aged Care Packages, Respite for Carers • State: Hospitals, Community Health, Residential Aged Care specified grants, Dental, Maternal and Child Health, Neighbourhood Houses. • Joint Commonwealth and State: Home and Community Care Program

The 1999-2000 combined Commonwealth-State Multi-Purpose Services Program budget was $19.9 million. The State contributes 77% of MPS Program funding in Victoria.

The Commonwealth Government is expanding its contribution to the Program and extending is support for rural services and these initiatives are examined in the following chapter. The Commonwealth budget nationally for Multi-Purpose Services will expand the funding by 23% over the next four years.

Recurrent Multi-Purpose Service funds are pooled and cashed on the following basis: Acute Review of WIES over prior 3 years. Reviewed triennially.

Residential Aged Care Cashed out at RCS 3 (high care) and RCS 7 (low care)

HACC Cashed out in accordance with unit cost base budgets for services. MPSs are eligible for growth funds, CPI adjustments etc.

Community Health Cashed out in accordance with base budgets for each service type. The base amount may vary according program due to factors such as salary differentials.

New capital funding is not necessarily linked to an Multi-Purpose Service. Capital works priorities are identified by Regional Offices of the Department of Human Services and often include new Multi-Purpose Services, but each case is considered on its merits. New capital works support the delivery of services made possible by the MPS model.

1.4 Chronology The Multi-Purpose Services Program emerged from the Multi-Purpose Centres Program of the 1980s which provides small grants to support existing health services. From those small beginnings grew a series of pilot projects targeted at a fully integrated, cashed out service model, which in turn developed into the recurrently funded Multi-Purpose Services Program that exists today.10

The increasing interest in coordinated care has continued to influence service planning and the introduction of new Commonwealth initiatives such as the Coordinated Care Trials in 1997 and Regional Health Services Program in 1999 and State initiatives such as Healthstreams in 1996, Primary Care Partnerships in 2000.

10 Department of Health and Aged Care, Commonwealth Regional Health Services Policy Framework, Commonwealth of Australia 2000 p.3

Multi-Purpose Services Program Evaluation, Victoria 5 Origins of the Multi-Purpose Services Program

As at November there are seven Multi-Purpose Services in Victoria: Upper Murray, Otway, Far East Gippsland, Mallee Track, Alpine, Timboon and Robinvale.

Table 1.1 Multi-Purpose Services Program Chronology Year Event 1989 Multipurpose Centre Program Federal Budget initiative.

1991 Australian Health Ministers Conference (AHMC) agrees to revise Multi-Purpose Centre guidelines to provide more flexibility. Overarching Committee of the Functional Reviews Health and Aged Care establishes Multipurpose Funding Task Force Multi-Purpose Services Task Force recommends the establishment a Multi- Purpose Services Program and pilot centres.

1991 Commonwealth and State Governments Task Force established to recommend new service structures for rural communities. Special Premier's Conference Aged Care Task force established to develop service delivery between levels of Government. Australian Health Ministers Conference (AHMC) agrees to revision of Multi- Purpose Centre guidelines to provide more flexibility. Overarching Committee of the Functional Reviews Health and Aged Care establishes Multipurpose Funding Task Force Multi-Purpose Services Task Force recommends the establishment a Multi- Purpose Services Program and pilot centres. Overarching Committee of the Functional Reviews Health and Aged Care confirms the establishment of the Multi-Purpose Service trials.

1992/93 Multi-Purpose Services Program commences. 17 approved.

1993 Three pilot projects commence: (Ceduna and Streaky Bay in South Australia and Dalwallinu in Western Australia). Four projects commence in NSW (Baradine, Braidwood, Urana and Urbenville). 1994 Additional 17 pilot projects approved. 1995 3 Multi-Purpose Services pilots established in Victoria (Upper Murray, Otway and Far East Gippsland). One site approved in Queensland (Clermont). Two sites in Western Australia (Boyup Brook, Northampton/Kalbarri). 1996 Mallee Track Multi-Purpose Services established in Victoria. 1997 Aged Care Act promulgated. Includes Flexible Services concept. 1997 Alpine Health established as a MPS in Victoria. 1998 Commonwealth budget initiative to expand Multi-Purpose Services Program. Additional 30 sited nationally. 1998 Timboon and District Healthcare established as a MPS. 1999 Commonwealth commitment to maintenance of program. Introduction of Commonwealth Regional Health Services Program. Robinvale and District Health Service gazetted as a MPS.

Multi-Purpose Services Program Evaluation, Victoria 6 Origins of the Multi-Purpose Services Program

1.5 Conclusions The Multi-Purpose Services Program represents a structural policy shift in the provision of services to small rural communities. It recognises the barriers to the provision of health and community services to rural communities and it has developed a coordinated controlled and innovative response by pooling program funds and supporting local communities to set their priorities and provide services in accordance with locally identified needs.

The Program has now evolved from its Multi-Purpose Centre origins and it can be expected to remain available as a service model option for rural communities to consider. With the introduction of the Commonwealth Regional Health Services Program, Multi-Purpose Services can be expected to further evolve and innovate towards increasingly responsive services for small rural communities.

Multi-Purpose Services Program Evaluation, Victoria 7 Flexible Service Models in Context

2. Flexible Service Models in Context

n this chapter, the range of flexible programs is reviewed, including an overview of ICommonwealth and State programs and Australian and international literature. It is demonstrated that there is an increasing convergence of health and community service delivery themes ranging from single programs to integrated, community and client centred systems of care, and that this trend can be expected to continue and develop, particularly in line with the increasing sophistication of information technology systems.

These developments provide indications for future policy directions for the Multi-Purpose Services Program. The policy development trend suggests that the Multi-Purpose Services will increasingly become one option amongst many approaches seeking to provide an improved service to rural communities and that the program itself is likely to adapt and integrate with components of related funding sources. Whilst each Multi-Purpose Service is underpinned by common principles they each produce unique service models and it is likely that the future will see increasing model diversity as each community shapes its services to reflect their priorities. As such the Multi- Purpose Services Program and other emerging flexible service initiatives may be understood to have been assisted by increasing information technology sophistication that has facilitated both client centred planning and overall program accountability.

2.1 Flexible programs chronology The programs under consideration in this report operate under a series of descriptors ranging from coordinated care, partnerships, multi-purpose services and others. Whilst each has characteristic differences, they each share the common objectives of providing a flexible, more integrated approach to health and community services based on identified client and community needs. For this report the term "flexible programs" is used as the generic term for this approach.

Table 2.1 provides a chronology of the flexible services programs applicable to rural regions under consideration in this review.

Table 2.1 Flexible Services Programs Chronology Year Program 1989 Multipurpose Centre (MPC) Program Federal Budget initiative. (Commonwealth) 1991 Multi-Purpose Services (MPS) (pilot) (Commonwealth/States) 1993 Multi-Purpose Services Program (Commonwealth/States) 1994 Rural Healthstreams Program (State) 1997 Coordinated Care Trials (Commonwealth) 1998/99 Rural Multipurpose Health and Family Services Network Program (Commonwealth) 1999/2000 Regional Health Services Program (Commonwealth) 2000 Primary Care Partnerships Strategy (State)

All of these programs operate today and represent an emphasis on increasing flexibility, innovation and responsiveness to community need. Programs options provided by the Victorian Government, the Commonwealth Government and jointly are reviewed below.

Multi-Purpose Services Program Evaluation, Victoria 8 Flexible Service Models in Context

2.2 State flexible care service initiatives

2.2.1 Rural Healthstreams Acute hospital casemix funding, introduced in 1993, provided for case payments to match the medical and surgical services provided to patients plus fixed and variable payments and this system had particular implications for many Group E (less than 500 patients per annum) hospitals. Also in 1994-95 small rural hospitals became subject to the mainstream residential aged care funding (CAM/SAM) which placed further pressures on service viability. Thus in 1994 a Victorian Small Rural Hospitals Task Force was commissioned to examine and report on issues affecting 55 small rural hospitals in the State.

The Task Force found that: • small rural hospitals were financially vulnerable, • recruitment and retention of general practitioners and other medical and allied health staff was a significant problem, • hospitals were experiencing extended lengths of stay from aged patients, • small rural hospitals were socially and economically important to rural communities, • a range of payment issues existed, • management structure duplication for small services was widespread, and • a number of detailed funding issues also required consideration.11

The Task Force, inter alia, recommended that the consideration of an integrated services model to include a range of providers including the local hospital and local government and the development of area/sub regional health services.

In 1996 the Victorian Government responded with the Rural Healthstreams Program and other initiatives to encourage greater flexibility in funding and service delivery in small rural agencies. As at August 2000 there were 12 Rural Healthstreams agencies in Victoria plus a further 10 with Approval In Principle.

The Rural Healthstreams Program is ensuring that health agencies in small rural communities are able to provide a broader range of services in community-based and home-based settings12. It provides an incentive to rural health services to rely less on bed based services and encourage a service configuration that best meets identified community needs.

The objectives of Rural Healthstreams are to encourage and provide: • improved service access • increased services integration • more coordinated health care • improved patient/client management systems • health promotion and education • a more diverse range of services which emphasise community and home based care • development of traditional bed based hospital services.13

The Rural Healthstreams model is not prescriptive and does not work to a formula. Agencies wishing to participate make their own decision to apply, and submit to the Department of Human Services regional office for inclusion in the program. Rural health services continue to provide bed-

11 Department of Human Services, Small rural Hospitals Task Force Report 1994 12 Department of Human Services Annual Report 1998-99 13 Healthstreams Quality Assurance Task Group, Recruitment and Retention of Skilled Health Professional in Rural Victoria. Discussion paper (April 1997) p2

Multi-Purpose Services Program Evaluation, Victoria 9 Flexible Service Models in Context based services but they have the option of trading some funding to facilitate the provision of community based services.14. A substitution guideline of 15% WIES funding for community health service alternatives has been adopted to date, but the aim is to provide service development according to needs, with trends towards increased program flexibility and higher levels of service substitution. It is to be noted that Heathstreams agencies require approval for WIES substitution each year.

Each agency develops its approach to service substitution and enhancement. Examples of the types of substitution may include a reduction in hospital bed utilisation and a transfer of funds to employ an allied health professional; or a service contracting with the local community health service, domiciliary nursing service, home care and visiting medical offices to provide coordinated services. It is possible that these types of services and others will not be financially accountable to each other. They may agree to participate in a Healthstream Network but the nature of the relationship and management structures may vary15.

The Program is administratively simple, with a minium of procedural requirements. Negotiation occurs between agencies and their regional office and central office endorses the Agreements.

The program is not dependent on vertical integration and does not require a single Board of Management but the program encourages co-operative approaches to service delivery. Nor does it use funds pooling, although there is no barrier to adopting that approach if a community considered it appropriate. Participation in Healthstreams does not limit the opportunity to also participate in other approaches to coordinated care and population health models, such as Primary Care Partnerships.

Agencies are eligible for two forms of grant: • Implementation Grant: $30,000 for planning, information technology required for reporting, training and development and set up costs. • Specified Grants: Service Agreements between the agency and the Department of Human Services Regional Office may be varied to permit interchanged or substitution services. There is no limit on the transferred amount.

Capital redevelopment is separately considered and participation in Rural Healthstreams is not linked to facility redevelopment funding.

Overall, Healthstreams encourages service flexibility based on community needs without the necessity to holistically reconfigure the acute, residential care, community health and community service system as occurs in Multi-Purpose Services. It is one service option that may particularly suit small rural communities with an existing narrow service base. It could also function as a stepping stone to the Multi-Purpose Service Program.

2.2.2 Primary Care Partnerships Primary Care Partnerships (PCPs) were introduced into Victoria in 2000 as a means of creating "a genuine primary care service system."16 The Partnerships may be formed in any part of the State and are not a rural initiative.

The Primary Care Partnerships strategy consists of voluntary alliances of primary health care providers aimed at improving the health and well-being of their catchment's population by better coordination of planning and services delivery in response to identified needs. The model is not

14 Department of Human Services - Rural Health Services Unit, Rural Healthstreams Program (Oct. 1999) 15 Department of Human Services The Implications of Healthstreams for Accredited Programs (no date) 16 Department of Human Services, Primary Care Partnerships: Going Forward April 2000

Multi-Purpose Services Program Evaluation, Victoria 10 Flexible Service Models in Context strictly a flexible care approach, but rather a service integration and coordination initiative. The strategy is underpinned by a social model of health that takes account of the full range of societal, economic, environmental and biomedical factors that influence people's health and well-being.17 There are 32 Primary Care Partnerships, with catchments covering all of the State, although all service providers within any one catchment may not necessarily elect to participate.

Primary Care Partnerships are a horizontal coordinating mechanism to achieve primary care system service development compared to Multi-Purpose Services which are a service reconfiguration model under a single governance and budget structure. Four of the five Multi-Purpose Services included in this Evaluation also participate in Primary Care Partnership alliances and their relationship is examined in the final chapter of this report.

The main objectives of the Primary Care Partnerships reform are to improve the experience and outcomes for people who use primary care services, and to reduce the preventable use of hospital, medical and residential services through a greater emphasis on health promotion programs and responding to the early signs of disease and/or people's need for support. There is no single Primary Care Partnership model. Each Partnership develops a Community Health Plan as a basis for service provision.

The criteria for Primary Care Partnerships catchments include: • A core services group of community health, local government, Division of General Practice, Aged Care Assessment Services (ACAS), Royal District Nursing Services or its rural or regional equivalent, plus, • Two of the following specialist services: psychiatric disability support service, drug treatment service, ethno-specific services, women's health services, sexual assault service. • The development of Community Health Plans is usually across two to three municipalities, with three based on four municipalities. There are also five Partnerships based on a single municipality.

The defining characteristics of the model include: • A social health emphasis that includes health promotion, illness and injury prevention, early detection • A coordinated primary care service system • Service provision in accordance with a local Community Health Plan. • A consolidated point of contact in the primary care sector. • Coordinated access to services. People can contact any one service in the Primary Care Partnership to obtain information about all health and support services. • Coordinated assessment. Assessment is managed to reduce assessment duplication. • Streamlined information management. Integrated information systems assist with care management and streamlined performance measures, and integrated data collection. • Community management of conditions, including chronic conditions.

Accountability occurs for each alliance as a whole for activities funded at the alliance level. Each member remains individually accountable for programs and services in accordance with Service Agreements. Partnership development plans are used to identify actions to be undertaken and also include common requirements for Primary Care Partnerships and locally determined initiatives.

Funding is available for the preparation of Community Health Plans, data base development, promotional activities to local communities, a statewide 24 hour health information referral services, Better Access to Services initiative, four disease management pilot projects and health

17 ibid p4

Multi-Purpose Services Program Evaluation, Victoria 11 Flexible Service Models in Context promotional initiatives. Currently each alliance receives the same funding level irrespective of size, although this funding model is under review. Additional funds for specific initiatives are available to some alliances. Funding for individual services is not pooled or cashed out.

Primary Care Partnerships are essentially a systems based population health approach to service planning and delivery.

2.3 Commonwealth flexible care service initiatives

2.3.1 Coordinated Care Trials The February 1994 the Council of Australian Governments (COAG) "determined that the health and community services system needed to be reformed in order to more appropriately meet people's care needs and more efficiently manage the health dollar" and in 1995 COAG endorsed a reform agenda.

The purpose of the Coordinated Care Trials is to test whether multi-disciplinary care planning and service coordination leads to improved health and well-being for people with chronic health conditions or complex care needs18.

Twelve first round trials commenced in 1997 and operated until 1999 (and were subsequently extended for a year). Expanded second round trials will commence in 2000. The aims of the trials is to develop and test different service delivery and funding arrangements to see the extent to which they contribute to: • improved client outcomes (measured in terms of health and well being) • better delivery of services which are individually and collectively more responsive to client assessed needs than the current arrangements and • more efficient ways of funding and delivering services.

The second round trials will also enhance and extend the initiatives currently being applied. In particular the aim will be: • further integration of holistic care for clients with chronic conditions and complex care needs • building on single point of entry • enhanced information technology applications • expansion of services contributing to the funds pool and more programs.

There is no single Coordinated Care model, but the Trials respond to a common framework that consists of: • Funds pooling. The funds linked to all participating Commonwealth and State Programs are pooled and cashed out. This may include acute hospital, Medicare Benefits Scheme, Pharmaceutical Benefits Scheme, residential, community health, community care, assessment and related services (such as Linkages). The cashed out value is determined by detailed modelling of the actual cost structures for every participating service. Services provided to clients are paid from the Trial funds pool managed by each Trial. • Randomised trial procedures. Trial participants are recruited and randomised to a Control Group or Intervention Group and their service expenditures are closely monitored. • Care coordination. Each Trial participant has a Care Coordinator (usually the General Practitioner) who works with a service coordinator to ensure that an individually package of services is provided according to continuously assessed need.

18 Dr Michael Wooldridge Coordinated Care Trials Get the Green Light Media Release 20 Sept 1996

Multi-Purpose Services Program Evaluation, Victoria 12 Flexible Service Models in Context

• Formal evaluation. Each Trial has an independent Local Evaluation organisation to continuously and formally evaluate the Trial. There is also a National Evaluator who examines data across all Trials and reports on Trial effectiveness. • Trial management. Commonwealth additional funding is provided to services to employ staff and establish sophisticated electronic systems to track all components of the Trial including client outcomes and expenditure.

Coordinated Care Trials are the most comprehensive approach to coordinated care undertaken to date in Australia.

2.3.2 Regional Health Services Program The Australian Health Ministers' Conference of 1994 issued the National Rural Health Strategy (NRHS)19. It was updated in 1999 and provides the context for small rural health service initiatives. The NRHS aims to provide a coordinated framework to ensure equitable access to effective health care for rural and remote communities through the provision of appropriate health services, the promotion of measures designed to maximise the health status of rural and remote residents, and the adoption of strategies that minimise the barriers and problems which currently impede the delivery of effective health care20. The National Rural Health Strategy provides a broad macro framework for health services throughout rural and remote Australia and encourages the development of flexible service models of service delivery.

The Commonwealth Regional Health Services (RHS) Program, introduced in 1999/2000 occurs within this national rural health strategic context. It incorporates three existing programs and extends the overall program reach by improving access to a mix of services for rural communities21. Component parts of the Program include Multi-Purpose Centres, Multi-Purpose Services (a Commonwealth and States funded initiative), Rural Multipurpose Health and Family Services Networks and Regional Health Services.

Multi-Purpose Centres Multi-Purpose Centres (MPC) were a 1989 Commonwealth Budget initiative that is ongoing but not expanding. There are 11 MPCs in Victoria.

A Multi-Purpose Services Centre is "a collection of services which are coordinated to meet the needs of the community" with three main objectives: • greater coordination of assessment, planning and approval processes across individual program boundaries • coordinated establishment and/or expansion of a range of mainstream health and community services with a MPC grant to supplement mainstream program funding • improved cooperation between Commonwealth, State and Local Government.

A Multi-Purpose Centre must involve a minimum of three service types, one of which must be funded by the Commonwealth. MPCs are expected to be 50 kilometres from the nearest equivalent services or 100km from a major provincial centre with a population greater than 50,000.

A $35,000 standard grant per annum over two years is provided to coordinate services and $45,000 is payable in circumstances involving five or more services, extreme remoteness, or a high need client group such as Aboriginal people. The purpose of the grant is to supplement mainstream program funding and assist other costs, coordinate the general operation of the Centre and monitor

19 Australian Health Ministers Conference National Rural Health Strategy 20 Department of Human Services Annual Report 1998-99 21 Department of Health and Aged Care, Commonwealth Regional Health Services Program Policy Framework 2000

Multi-Purpose Services Program Evaluation, Victoria 13 Flexible Service Models in Context the need for and provision of individual services and cost sharing resources. Program funding is not cashed out or pooled. MPC status, in some instances, can operate as a transition towards an Multi- Purpose Service, as is the case with Omeo which has applied to become a Multi-Purpose Service.

Multi-Purpose Services The Multi-Purpose Services is profiled in a previous section of this report. It is a Commonwealth and States initiative, each contributing funding according to the pooled services. As at August 2000 there were 36 Multi-Purpose Services in Australia, including 7 in Victoria.

Rural Multipurpose Health and Family Services Network The Rural Multipurpose Health and Family Services Network is a 1998/99 Federal Budget initiative that includes extra funding for aged care places and funds for planning, information technology and quality assurance. The Program does not operate within formal guidelines and there are few services under this banner, and none in Victoria. Unexpended funds have been rolled into the RHS Program budget.

Regional Health Services Regional Health Services build on the Rural Multipurpose Health and Family Services Network by providing a Commonwealth allocation for primary health care. Regional Health Services priorities identified by each rural community are met through a flexible mix and range of Commonwealth and State/Territory services. 22.

Regional Health Services is a Commonwealth primary health initiative (and does not include acute care) that has access to a broader range of Commonwealth funds than Multi-Purpose Services, particularly primary health care funding. It does not include State funds, although there may be a service relationship. Targeted regions are identified as areas of need for a Regional Health Service through State/Territory planning processes. Non targeted regions may gain approval for an innovative proposal.

RHS Development Grants may be used for planning, establishment and delivery of new services, particularly expanded or better coordinated primary health care services, and may be used for to support the planning and community consultation required to support the possible establishment of a Multi-Purpose Service. Service Delivery funds are available for a wide range of primary care services according to identified community need.

Regional Health Service auspices may include Non Government Organisations, local government, residential aged care providers and State/Territory Government agencies. Existing services are eligible to apply (including Multi-Purpose Services) provided they can demonstrate a broadened scope of service leading to improved access and better health outcomes. RHS services are often small rural service providers who require funds to meet specific service gaps.

Characteristics of Regional Health Services include: • Commonwealth funding only • Commonwealth primary care funding. Introduction of Commonwealth funds for primary care services not previously funded by this level of Government, if the need is established by a small rural community • No specified model of care. A single management restructure is not required, funds are not pooled or cashed out and acute service substitution is not sought as part of the program. • Faster establishment time. Regional Health Services are not subject to the same formal and legal service development requirements that apply to a Multi-Purpose Service in Victoria.

22 ibid., p12

Multi-Purpose Services Program Evaluation, Victoria 14 Flexible Service Models in Context

There is expected to be 85 Regional Health Services in Australia by 2003. In Victoria it is likely that the number of Regional Health Services will exceed Multi-Purpose Services.

2.4 Flexible Service models compared The broad parameters of the flexible service models that are available to rural communities are profiled in Table 2.3.

Rural communities may choose the most appropriate model for their community. In Victoria the choices are: • Rural Healthstreams: a service model that encourages service substitution and linkage to provide a more responsive health and community service for a rural community. It does not require the same extent of service reconfiguration as a Multi-Purpose Service. • Multi-Purpose Services: a vertically integrated service model with maximum flexibility for service configuration according to community need. • Regional Health Services: an initiative that incorporates existing programs and extends the program reach by providing Commonwealth funds for primary health service initiatives according to identified rural community needs. Multi-Purpose Services are eligible to apply. • Coordinated Care Trials are of a larger scale than the above programs. They mainly apply to urban communities and involve total funds pooling, including the Medicare Benefits Scheme and Pharmaceutical Benefits Scheme. • Primary Care Partnerships are complementary to other programs. Primary Care Partnerships are a horizontally integrated to provide a systems approach to primary care service delivery. Multi-Purpose Services are often a part of Primary Care Partnerships and gain advantages from additional funding available for population health initiatives, such as health promotion programs.

2.5 Australian and international trends A limited review of the international literature indicates that there are trends towards more integrated, flexible and particularly client centred approaches to care in several countries. There is an increasing emphasis on the application of linked and integrated information technology to develop individualised care plans. Approaches to common core assessment and client information exchange are developing with increasing sophistication, particularly in the USA. 23 However, in Australia the geography, small populations of rural communities and political structures has lead to the development of service initiatives that appear to be unique.

Three themes may identified from the literature: • trends towards increased consumer focus24 • aligning services to needs25 and • increasing focus on home and community based care.26 One report that provides international comparisons of flexible care approaches in the United States, New Zealand, Australia, Singapore, The Netherlands, Germany and Sweden is Minford M., The

23 See for example, Resident Assessment Instrument–Home Care (RAI-HC) and the development of an individualised care plan using the electronic care planning software e.CARe used by Coordinated Health Care, Melbourne. 24 See, Developing A Consumer Focus for Coordinated Care Health Issues Centre 1996 25 Bowman C, Johnson M,. Venables D, Foote C, Kane R, Geriatric Care in the United Kingdom: aligning services to needs British Medical Journal 45:8 pp990-993 Leutz W, Five Laws for Integrating Medical and Social Services: Lessons from the United States and Kingdom The Millbank Quarterly 77-105s 26 Many examples. Landi F, Gambassi M, Pola R, Tabaccanti S, Cavinto T, Carbonin and Bernabei R, Impact of Integrated Home Care Services on Homel Use JAGS 47:1430-1434, 1999

Multi-Purpose Services Program Evaluation, Victoria 15 Flexible Service Models in Context

Boundaries Between Health and Social Care for Older People in Developed Countries. It includes a best practice checklist that encompass the following processes: • a clear national strategy for delivering chronic/long term care, • good information ie up to date records, pooled data sets and trackable patient/client data, • early intervention ideally based on an individual wellness program, • multidisciplinary assessment which assists patient centred care, and • integrated funding streams.

The best practice service delivery principles included: • a clear geographic area, • multiple entry points into the health/social care system, • education, assistance and prevention, • holistic care, and • general practitioner involvement. The report also includes an overview of international experience and analysis of policy trends.

The international review indicates that health and community service conceptual frameworks are more advanced than in most Western nations. Whilst this is assisted by the geopolitical structure in Australia, there is clear evidence of advanced policy and systems development. The emerging population health focus, flexible funding and coordinated care approaches are consistent with, and in many cases leading, international best practice.

In Australia the Aged Care Act 1997 may be considered as a formal signpost for the commencement of flexible care approaches, although there are also examples of earlier initiatives. As national law, the Act formalised and legislated the concept of "flexible care." It defines flexible care" as alternative care to that provided through residential care", and it is limited to aged care and as such is exclusive rather than definitive. The Act also includes and defines several examples of types of flexible care.

It is of particular significance that the flexible care concept has developed and changed significantly in the three years since the promulgation of the Aged Care Act. Coordinated Care Trials, Primary Care Partnerships and Multi-Purpose Services are pushing the policy frontiers, and Regional Health Services can expect to build on the increasing momentum of policy change.

As at mid 2000 Multi-Purpose Services and other programs have demonstrated the feasibility of change from policy silos to integrated, flexible service systems. Australian society is only seeing the start of this shift towards integrated policy platforms and integrated, personalised care systems based on population health principles.

The future rate of change is likely to be dependent on the development of integrated reporting software and management information reporting systems to assess performance and ensure fiscal accountability whilst devolving decision making to the local level.

The current rate of change suggests that the program that is currently called the Multi-Purpose Services may increasingly diversify as each community grafts new initiatives onto their original models which in time may become increasingly unrecognisable.

Multi-Purpose Services Program Evaluation, Victoria 16 Flexible Service Models in Context

Table 2.3 Flexible Service Programs Comparative Analysis Multi-Purpose Services Coordinated Care Trials Rural Healthstreams Regional HealthServices Primary Care Partnerships Commencement year 1993 1997 1996 2000 2000 Jurisdiction Commonwealth program State Program Commonwealth/State program

Program size (number of auspices in year 2000) Victoria 7 2 12 2 32 National 36 9~ 32

Service mix MBS/PBS/acute/aged/residential/primary care Acute/aged/residential/ primary care Acute/primary care Primary care

Catchment Several local government areas Rural catchment (variable size)

Funding structure Pooled funds/programs cashed out Some service substitution (acute to community care) No pooled funds/additional funds for designated activities*

Governance Vertical integration: single Board Horizontal linking: no specified governance requirement

Program base Legislation (Aged Care Act 1997) and program guideline Program Guideline * Example: health promotion ~ Excluding indigenous trials MBS = Medical Benefits Scheme. PBS = Pharmaceutical Benefits Scheme

The significance of the Multi-Purpose Services Program is as an operationalisation marker of the flexible care concept. This program has implemented the flexible care concepts of the early 1990s and demonstrated how flexible care can be provided to rural communities. The policy challenge for the future is to maintain the broad policy perspective and not to compare and compete between the range of flexible programs that are now on offer.

Multi-Purpose Services Program Evaluation, Victoria 17 Otway Multi-Purpose Service

3. Otway Multi-Purpose Service - demonstrated service integration

3.1 Service catchment pollo Bay and the Otway area is located in the Colac-Otway South sub region of the Colac Otway Shire within the Barwon-South Western Region 190 kilometres from AMelbourne. The area, formerly known as the Otway Shire, is an extensive municipality dominated by the Otway Ranges which comprise 55% of the area as Crown Land and State Forest27.

The east-west mountain spine is a barrier to service access and those living on the inland side tend to access services in Colac. Apollo Bay is a one hour drive to Colac and two hours to Geelong.

Major industries in the area are dairying, timber production, potato growing and fishing and in holiday seasons tourists swell the local population from approximately 3,000 to 15-20,000.

Figure 3.1 Otway Health and Community Services Catchment Area

In 1996 the population of the Colac-Otway South Region was 3,225 and is expected to be 4,438 by 2001, a 38% increase. Preliminary projections indicate a population of 6,000 by 2011.28

27 Holl, K., Towards 2001: A Health Assessment of Apollo Bay and the Otway Area 1998 28 Department of Management and Budget, Demographic Information Papers

Multi-Purpose Services Program Evaluation, Victoria 18 Otway Multi-Purpose Service

Apollo Bay is becoming increasingly attractive as a retirement location, with 9% of the population over 70 years, compared to 7.5% for Victoria. . Future population increases are expected to occur in the 10-29 years, 40-49 years and 75-85 years age groups.

20 18 16 14 12 10 8 Local Pop% 6 Vic Pop % 4 2 0 s s s s s s s s s + r r r r r r r r r 0 y y y y y y y y y 9 -9 9 9 9 9 9 9 9 9 0 -1 -2 -3 -4 -5 -6 -7 -8 0 0 0 0 0 0 0 0 1 2 3 4 5 6 7 8

Figure 3.2 Catchment population, aged distribution

The population distribution also has implications for health and community services delivery. Apollo Bay accounts for 46% of the total, followed by the Wye River and Kennett River area 25%, Lavers Hill 17%, Beech Forest 8% and Forrest 4%. Nearly all communities other than Apollo Bay have less than 500 people and there are also widely relatively isolated households throughout the rural hinterlands.

The socio economic profile of the community adds a further dimension to the health and community services setting. Otway represents a wide range of educational and income groupings, with relative wealth of the area being lower than for Victoria, 47% having an individual income of less than $12,000.29 Sixteen percent of the population is separated, divorced or widowed and 11% of households are sole parent families. Educational qualifications overall suggest, however, a significant grouping of higher socio economic status, and possible high awareness of the needs of health and community service.

3.2 History 30 Prior to the establishment of Otway Health and Community Services a number of independent organisations had provided a range of services to the area. These included: • Apollo Bay and District Memorial Hospital • Laura Pengilley Hostel for Frail Aged • Shire of Otway • Apollo Bay Community Health Centre • Apollo Bay Community Centre • Ambulance Service of Victoria

29 Otway Health and Community Services: Services Plan 1997 30 ibid.

Multi-Purpose Services Program Evaluation, Victoria 19 Otway Multi-Purpose Service

The Community Health Centre had been governed by the Hospital Board, as was the Apollo Bay Hostel and Nursing Home Society, and some services were purchased from other providers, such as the Lorne physiotherapist two days a week. The Hospital was managed by a Matron, with the Hospital Secretary shared with the Lorne & District Hospital.

Services were also physically separated. The Community Centre operated from a church hall, HACC services were delivered from the Council Offices and the hospital and hostel were in separate parts of the site.

Services were small and uncoordinated, and gaps and service imbalance existed due to the emphasis on inpatient care and limited range of community services. Services were primarily directed towards interventions and health maintenance, with limited resources directed to health promotion and organisational insularity of the multiple service arrangements limited opportunities for the introduction of coordinated, client centred care planning. In addition, clients and families had to travel considerable distances to access basic services such as nursing home care.

Also at this time several services were provided by organisations external to the district. These included pays and medical records (Colac hospital), linen services (Barwon Linen), acute patient referrals (Geelong Hospital and Colac Hospital), Aged Care Assessment Team (Geelong), palliative care (Geelong), employment and welfare services (Colac) and workforce training (Geelong).

In January 1995, following an intense period of needs identification and community consultation, Otway Health and Community Services was incorporated as a Multi-Purpose Service and Gazetted. It consisted of the amalgamation of the following services: • Apollo Bay and District Memorial Hospital (12 beds) • Laura Pengilley Hostel for Frail Aged (15 beds) • Apollo Bay Community Health Centre • Apollo Bay Community Centre • Otway Shire's Home and Community Services

The Rural Ambulance Victoria at Apollo Bay and Council's Maternal & Child Health decided to remain independent but it is located on the Multi-Purpose Service site. Later, in 1997 Otways Telecentre amalgamated with the Multi-Purpose Service.

3.3 The Otway Health & Community Services Model 3.3.1 The model The Otway Health & Community Services represents an excellent case study of a fully integrated service. Previous service demarcations have been replaced by a single governance and management model, with all services functioning in accordance with a Strategic Framework and a three year Service Plan. Any former service demarcations have completely disappeared and been replaced by a coordinated service, and this characteristic is an outstanding feature of the model.

The relatively flat organisational structure has a Chief Executive Officer working with a Manager for Community Services and a Manager for Health and Aged Care, but the most impressive feature of the model is the non hierarchical, team based approach to care (Figure 3.3). All staff are aware of the multi-dimensional nature of the service and there is an absence of program boundaries, even though most staff work within specific service areas.

Multi-Purpose Services Program Evaluation, Victoria 20 Otway Multi-Purpose Service OHCS Organisational Chart

Board of Management

Chief Executive Officer

Executive Assistant

Maintenance Manager Accountant Chef Manager Officer Community Health & Services Aged Care

Handyperson Customer Community Finance Cook Division 1 Service Development Assistant Nurses Officers Worker

Adult Childrens Administration Apprentice Division 2 Education Services Assistant Cook Nurses Facilitator Team Leader

Child Care Food Personal Staff Services Care Assistant Assistants

Occupational Project Therapist Workers Community Nurses

Day Centre Physiotherapist Assistant

HACC Neighbourhood Coordinator House Administration Coordinator Assistant

Home Carers Personal Care Staff Figure 3.3 Otway Health and Community Services Organisational Chart

All services are centred on a Coordinated Care Unit that provides a single phone number. The Unit, staffed by community nurses, arranges assessment, care plan development and service delivery. Consumers have only one assessment, one collection of information and links to a care manager (Figure 3.4).

3.3.2 Services The service profile is now integrated and has expanded include a wider range of services, with over 37 services available to a community of 3,225 people (Table 3.1). The service span encompasses acute, aged care, community health, community care, education and community development. In addition there are no significant service gaps which is a major achievement for a small rural community.

Multi-Purpose Services Program Evaluation, Victoria 21 Otway Multi-Purpose Service

Figure 3.4 Otways Health & Community Services Coordinated Care Unit

Table 3.1 Otway Health & Community Services Service Profile Acute care Post surgical care Administrative support Property maintenance Adult day care Renal dialysis Adult education Residential aged care Aged & disability care Residential respite Ante natal/post natal groups Resource library Breast screening bus Room hire Child care Student support Community nursing Tutor bank Community transport Well women's clinic Critical incident stress debriefing Delivered meals Emergency medical Equipment hire Family support General medicine Health promotion Home care Needle exchange Neighbourhood House Occupational therapy Palliative care Parent support groups Personal care Post natal residential care

Multi-Purpose Services Program Evaluation, Victoria 22 Otway Multi-Purpose Service

The essential changes to the pre-MPS and post-MPS service arrangements are summarised in Table 3.2. The model demonstrates that total service coordination involves both the elimination of service duplication and the integration of services into a single management structure.

The model has moved the service focus from a health and community care model to an integrated population health emphasis. Community education with computer banks, community tutors and trainers, health promotion and child care and community transport take equal place beside care services. Services are established according to local community need and not program funding availability and broad planning guidelines.

Table 3.2 Characteristics of Pre-MPS and Post MPS model Pre MPS Post MPS Service duplication Service rationalisation Separate locations Single service location Different assessments Single assessment No coordination Coordinated services Limited services Wide service range Clients had to fit service criteria Client focussed service Competition between services Team structure

3.3.3 Staff Otway Health & Community Services is the largest employer in Apollo Bay, with 64 staff and 35.20 EFT positions. Total workforce has increased by 7.31EFT since 1992/93, with reductions in nursing and hostel staff and increases in community services, HACC, child care and administration/management (Table 3.3). The profile indicates a service shift towards community care, consistent with acute bed reductions and the development of a population health perspective.

Table 3.3 Otway Health and Community Services Pre and Post MPS Workforce Staff 1992/93 1999/2000 Change Number % Number % Number % Nursing 13.18 47.311.00 31.3 -2.18 -16.0 Health professionals 0.69 2.5 1.30 3.7 +0.61 +1.2 Personal care 3.39 12.2 3.00 8.5 -0.39 -3.7 Hostel and allied 5.77 20.6 3.40 9.7 -2.37 -10.9 Community services 0.50 1.8 4.35 12.4 +3.85 +10.6 HACC 2.78 10.04.00 11.4 +1.22 +1.4 Childcare 0.10 0.43.95 11.2 +3.85 +10.8 Admin/management 1.48 5.3 4.20 11.9 +2.72 +6.6 Total 27.89 10035.20 100 +7.31 +26.2

3.3.4 Financial performance The Otway Health & Community Service has achieved financial security within its operating period.

Average annual financial indicators over the period 1994/95 to 1999/2000 include: Expenses +6.9% Revenue +6.6% Operating surplus +1.9% Total equity +21.9%

The service has returned an operating surplus each year, except 1998/99 when a building depreciation adjustment was built into the operating performance.

Multi-Purpose Services Program Evaluation, Victoria 23 Otway Multi-Purpose Service

The operating budget in 1999/00 was $2.8mil. compared to $1.9 mil in 1994/95. Total revenues have increased by 6.9% per annum over the period, representing a real growth of approximately 3% per annum. Within this modest growth of base funds, Otway Health & Community Services has achieved significant service diversification and expansion.

3.4 Service effectiveness 3.4.1 Service targeting Otway Health & Community Services has adopted a strategic planning approach that includes cyclical needs analysis leading to service plan development and performance monitoring against set objectives. Whilst many non MPS services are also based on a similar structure, in this case it is possible to clearly identify the path used since the inception of the service, with reports and documentation supporting each step. It clearly delineates how the process works in practice, and the organisation is able to assess its performance continuously and precisely against its service plan.

In 1998 a consultant completed a health needs assessment using focus groups and personal interviews as the information base31. Needs were grouped into nine categories and analysed according to each community of interest. That report assisted both service planning and provided a resource for the organisation to use when making funding submissions. The report is a sound example of how a service can respond to funding opportunities by drawing on a sound information resource.

The Board has also developed a Community Consultation Policy to ensure a systematic framework for an ongoing participatory process. That policy provides for community as a central element of all proposed service developments. For example, a Child Care Review included community meetings during the development phase and community discussion of the proposals, which were subsequently modified as a result.

Otway Health & Community Services also has a number of standing focus groups within key areas of the service. These groups can be activated as a need arises.

A Health Promotion Advisory Committee has also been established with meetings held bi-monthly. The Summer of Safety was one initiative that emerged. There is also a Residents' Advocate for all aged care facility residents and meetings are held bi-monthly to address identified issues.

Community surveys are also undertaken as opportunities arise. For example, Otway Health & Community Services participated in the Community and Client Healthcare Service Client Satisfaction Survey as part of a National Benchmarking Study. Other surveys in which Otway Health & Community Services has participated include the Regional Effective Discharge Survey and Patient Satisfaction Monitor.

All programs complete an annual program evaluation. Formal staff self assessments are undertaken and clients surveyed. On completion, a Program Plan must be developed and the results may be reflected in the organisation's Service Plan.

A range of client satisfaction surveys are undertaken from time to time. These have included a meals on wheels survey, acute client survey, women's wellness survey and child care parents (surveyed every six months).

31 Holl K., Towards 2001: A Health Needs Assessment of Apollo Bay and the Otway Area. 1998.

Multi-Purpose Services Program Evaluation, Victoria 24 Otway Multi-Purpose Service

3.4.2 Access and cost effectiveness Access to Otway Health & Community Services contrasts significantly to that of the pre-MPS model (Table 3.3). The process is based on a community nurse assessment, discussion of service options and client choice of preferred service. Permission is obtained to share client information across the service as required. This process optimises ease of access to all services.

Table 3.3 Pre and post MPS Access Process Pre 1998 Post 1998

Referral from GP or other service provider to an Self referral, carer referral or referral from other individual program area service providers

Each service provides own assessment and Referral directed to Community Nurse for independently arranges service delivery assessment and service coordination

Links to other providers only if issues arise at Communication with other service providers by assessment internal referral form.

Two record systems: Community Service record Single Healthcare record, with dividers for different and Acute Medical record program areas

Dual point filing Single point filing

Service access has improved across the service spectrum. Acute separations declined by an average 8.5% between 1992/93 and 1999/2000 commensurate with a reduction in beds from 12 beds in 1992/93 to 8 beds in 1998 and 5 beds in 2000. Acute bed occupancy had been particularly low in previous years including for example, 31.3% in 1992/93 but increased to 55% by 1999/2000.

There is no available evidence of acute service substitution. The range of acute services remains unchanged (uncomplicated medical, post surgical and post natal care), and although the number of acute beds has been reduced the bed occupancy remains relatively low, with all appropriate cases able to receive acute care. There is no need or reason for patients to go to another hospital for the same level of care that is available at Apollo Bay. The reasons for acute service access in other hospitals relate to case complexity, as occurred prior to the introduction of the Multi-Purpose Service.

Examples of community service expansion include 140% increase in delivered meals between 1994 and 1999 and expansion of Home Care services by 28% (Figure 3.5). Physiotherapy occasions of service had declined in 1998 and 1999 but this was due to improved service targeting by identifying clients who could participate in group sessions, thereby improving overall physiotherapy service efficiency. Prior to that time there had been a steady increase in service.

A Colac Otway Shire PADP Survey (1999) did, however, identify that 41% of the sampled population believed that clients were not accessing all available services because they were unaware of them. Otway Health & Community Services responded by preparing new brochures that include the full range of available services.

Multi-Purpose Services Program Evaluation, Victoria 25 Otway Multi-Purpose Service

7000 6000 5000 1994 4000 1995 3000 1996 1997 2000 1998 1000 1999 0 Acute A&E Meals Home Physio Sep. Care

Figure 3.5 Otway Health & Community Services Service Utilisation

Improved cost effectiveness has also occurred since the advent of the Multi-Purpose Service. This has achieved by improved service targeting by, for example, the substitution, where appropriate, of community nurses with Personal Care Attendants.

Table 3.4 provides an overview of service utilisation improvements between 1992/93 and 1999/2000.

Table 3.4 Otway Health and Community Services, Pre and Post MPS Service comparisons Services 1992/1993 1999/2000 Acute care Beds 15 5 Inpatients treated 276 183 Same day establishment 0 103 Occupied bed days 1810 1000 % occupancy 32 55 Accident and emergency 2228 1478 Residential care - High No. of places 0 6-7 Occupied bed days 0 2132 Low No. of places 15 15 Occupied bed days 4478 5510 Delivered meals 1592 4798 Home care/property maintenance 5510 6107 District nursing occasions 0 1449 Day Centre 2 days pw 3 days pw Physiotherapy 2 days pw 5 days pw Occupational therapy 0.5 days p/month 3 days pw

Although there have been baseline budget changes in program areas, such as residential aged care, most improvements have been achieved within the same budget. Related services have also increased over the period including the addition of three high care places, a dialysis service, chemotherapy on occasions and palliative care.

Multi-Purpose Services Program Evaluation, Victoria 26 Otway Multi-Purpose Service

An internal review of aged residential care established that Resident Classification Scale (RCS) profiles for the high and low care residents are mostly below the cashed out values of RCS 3 for High Care residents and RCS 7 for Low Care residents, although the classifications upon which this conclusion is based have not been independently validated by the Commonwealth. No high care residents are above RCS3, but 6 low care residents are above RCS 7, and 4 are below RCS 7. However, whilst the funding is currently working slightly in favour of Otway Health & Community Services the trend is towards higher care, with three of the six high care residents increasing one or two levels over the past year. The relatively high number of low care residents at RCS 8 is a reflection of former admission policies and the lack of Community Care Packages in the area and it could be expected that people with greater dependencies will occupy those places in the future.

3.4.3 Coordination, flexibility and innovation Service innovations are adopted where appropriate. For example, the Community Antenatal Care Service has been devised to support women during and after pregnancy. Families in Apollo Bay and the Otways area continuously reported the need for local obstetric care for pregnant women and because the Acute Care Wing does not provide birthing services, an alternative service for women has now been developed as a 12-month pilot funded from the MPS budget.

The Community Antenatal Service (CAS) includes the following services: • A brochure is widely distributed to explain CAS and profile the five midwives employed at Otway Health & Community Services. • Pregnant women advise their GP that they intend to utilise CAS and request a referral to CAS. • The woman identifies which midwife she prefers to use throughout her pregnancy and telephones OHCS to make her booking. • The midwife visits the woman at her home and conducts the antenatal check as well as answering any questions the woman may have. • The midwife utilises the protocols for care developed by the CAS Team and documents the visit on the Antenatal Record, which is left with the woman for presentation to her GP. • The GP also records any antenatal checks on this record that remains in the home. • The midwife continues support to the woman until the birth and then provides a post natal visit on the mother’s return home.

CAS provides excellent support and assistance for pregnant women in their own community and enables them to return home after the birth feeling confident that the MPS has supported them throughout the pregnancy. Although local women have to travel to other communities to give birth, they can quickly return home knowing that support is available.

As an adjunct to CAS, Otway Health & Community Services through its Neighbourhood House Program, arranges for one week's supply of prepared meals to be delivered to the family when the woman returns home with the new baby. 3.4.5 Cultural appropriateness There are very few clients of diverse ethnic or cultural backgrounds in the Otway region. Each client is individually assessed and services provided accordingly.

3.5 Client impacts

3.5.1 Perceptions of service availability A well attended focus group meeting was held to discuss the performance of the service since its inception. The meeting included consumers, representatives of external service providers (such as Community Options) and other community organisations (Apollo Bay P-12 College). Consumers were represented by mothers with children in the child care centre, community program users and older people with experiences relating to acute, community and home based care.

Multi-Purpose Services Program Evaluation, Victoria 27 Otway Multi-Purpose Service

It is to be noted that the following results are the opinions of one focus group and not a sample survey of the community. The findings are of value in identifying broad perceptions of the service only.

The group considered the "availability of health and community services" to be "high" to "very high" (Figure 3.6). It was considered that the range of available services for this small community is exceptional, with very few service gaps. Some participants did not know of external services, such as Community Options, and there was an exchange of information within the group on these services.

For one group participant there was concern for the limited availability of residential high care due to the low resident turnover. Others considered that the demand for residential care would increase and that this needed to be included in future planning. The perceived limited availability of respite and community transport options were also cited as issues by some participants. The absence of a public dental service was of concern to some. However, the group concluded that the main issue was not the availability of services but the need to regularly remind the community that the services existed.

Perceptions of service responsiveness to health/community needs The group rated service responsiveness to community needs by responding to the question "How well met are the health/community needs in this community?" Most rated service responsiveness as "moderate" or higher (Figure 3.7). The needs of particular groups was separately considered, including babies health, youth health, women's health, men's health, families health, older people health and support, people with special needs and people from ethnic and cultural backgrounds.

How would you rate the availability of health and How well met are the health/community needs in this community services in this community? community?

40.00% 50.00% 35.00% 40.00% 30.00% 30.00% 25.00% 20.00% 20.00% 15.00% 10.00% 10.00% 5.00% 0.00% VERY LOW LOW M ODERATE HIGH VERY HIGH DON'T 0.00% KNOW VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW

Figure 3.6 Perceived service availability Figure 3.7 Extent to which health/community needs met

How easy is it to obtain the following services in this How would you rate the change in health and community community? services in this community today, compared to about five years ago? 50.00% 70.00% 40.00% 60.00% 30.00% 50.00% 40.00% 20.00% 30.00% 20.00% 10.00% 10.00% 0.00% 0.00% SIGNIFICANT MINOR DECLINE NO CHANGE IMPROVED SIGNIFICANT DON'T KNOW VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW DECLINE IMPROVEMENT

Figure 3.8 Perceived ease of access Figure 3.9 Rated change between current services and five years previously

Multi-Purpose Services Program Evaluation, Victoria 28 Otway Multi-Purpose Service

The meeting considered that the needs of most groups were "well met", except those of youth which required further development and discussion focussed on the need for further program developments with the school and the community. The group, however, was generally unaware of the range of preventative health programs conducted by OHCS in association with the school, and most discussion centred on the need for the Council and other organisations to develop activity programs for young people.

Access The focus group was in agreement that services were either "easy" or "very easy" to access (Figure 3.8). Most people considered that they received high quality support when accessing services and that they were supported according to their individual needs. One participant noted her experience following the birth of her child to have included excellent post-natal inpatient care with midwives rostered over the period, followed by community nursing care at home and volunteers support, including provisioning of her refrigerator for the first few days. The care was clearly appropriate, seamless and well coordinated, and this may have been more difficult to achieve under the pre-MPS service structure.

Concerns were expressed for the future of the volunteer service because most volunteers are older people and they are not being replaced. Suggestions were made to further develop a culture of volunteerism within the schools.

Consultation The availability of information about services was considered to be "high" or "very high". (Otway Health & Community Services has produced a booklet of all available services and over 20 specific service brochures). The group concluded that most members of the community only want to know about a service when they need it, and the best form of service promotion is the single telephone number to the main service centre.

Service improvements Participants were also asked to rate the change in health and community services in this community today, compared to about five years ago. Overall, the group considered that there had been a "significant improvement".

Discussion focussed on each of the following services: • acute health care. It was considered that the care of a high quality both before and after the introduction of the MPS and that access was the same. It is to be noted that acute beds have declined from 12 to 5 over the period. • general practitioners. Opinions varied about this issue depending on each persons experience, but over 80% of the group considered that it had improved to some degree. • allied health service. Opinions varied according to each allied health service. Physiotherapy was considered to have considerably improved, with opinions on other services varying according to service availability. • home based nursing. Most participants considered that it had improved. • residential aged care: The quality and number of places of service was considered to have improved, but for some participants access had declined. This response was particularly reflective of one group participant's current experience in seeking a high care placement for a relative, but several people in the group were concerned that there may be insufficient places for the future. • health and fitness programs and classes: All agreed that the availability of these programs had improved. • home based services: All agreed that the availability of these programs had improved.

Multi-Purpose Services Program Evaluation, Victoria 29 Otway Multi-Purpose Service

• community development programs: All agreed that the availability of these programs had improved. . Multi-Purpose Services Model Several dimensions of the MPS model were explored. It was considered that the single management structure linked to the MPS was sensible and effective.

However, most considered that there had been little or no change in the flexibility of the model to address the priorities of the community. (This response is counter to available evidence, with a wide range of programs being added to the service since the commencement of the MPS).

Several instances of service innovation were cited. In particular there was a perceived improvement in personal care, such as a patient admitted to hospital following an accident and nurses providing soft music, lighting an oil burner and placing lavender on her pillow. A farmer person spoke of his heart attack and excellent treatment in hospital followed by home nursing, meals on wheels, home help and hydrotherapy. Others cited examples of service adaptations to ensure that their needs and those of their families were met.

Community control over services was considered to have improved or significantly improved by most participants. It appeared that the group interpreted this question to mean ease of access to services, and no examples were cited from this group of the community influencing service priorities or service delivery. Many felt that community involvement was difficult to achieve and that the service providers were offering an excellent service.

3.5.2 Other evidence of client satisfaction The range of surveys undertaken by Otway & Community Health Services indicate high levels of consumer satisfaction with the services.

A Well Women's Clinic Client Survey found that: • 66% of clients identified the service from a local news sheet, 23% from a friend and 23% had previously used the service. This result indicates the effectiveness of Otway Health & Community Services health promotion strategy. • 65% of clients attended the clinic for pap smears, breast examination, pregnancy advice and related issues because they wished to consult a female clinician. This result indicates the appropriateness of service to the community. • 100% of respondents positively ranked service quality and responsiveness

An Acute Health Consumer survey in March 2000 also demonstrates high levels of client satisfaction: • all clients were an unplanned admission • 83% chose the hospital due to its location • over 80% rated the quality of care as "satisfied" or "very satisfied" across nine service dimensions including nursing care, cleaning, food services, support for carer/family, admission procedures and related issues • 100% said they would return to this hospital • 67% had received a brochure about their rights and responsibilities as a patient

A third example relates to a Children's Centre Parent Survey. It asked how the staff interacted with their children, how parents related with the staff, satisfaction with food, information provided, levels of supervision and related questions. This survey, which achieved high positive responses across all questions, is a sound example of detailed consumer attitude monitoring to ensure that

Multi-Purpose Services Program Evaluation, Victoria 30 Otway Multi-Purpose Service service standards are maintained. It also represents an effective method of consumer participation in service provision.

3.6 Barriers to implementation 3.6.1 Development phase It is of particular interest to observe that whilst the Otway Multi-Purpose Service is a resounding success for its community today, that it experienced considerable challenges during its formative years. A meeting was held with Board members to consider these issues and identify both the factors and their reasons.

Prior to the commencement of the Multi-Purpose Service, a group within the community considered that change was essential and the model offered a positive future. The hospital, which was operating at a deficit, was in danger of closing and it was in poor physical condition. Also hospital administration had increased in complexity following the introduction of case mix funding, with some Board members reported to require additional skills. The small stand alone services were meeting community needs but they were uncoordinated.

The hospital Secretary, shared with Lorne, was opposed to the change because it was a pilot project and the Maternal and Child Health Nurse saw few benefits, and others were insecure about the future of the program.

In particular there was strong opposition from the General Practitioner practice based at the hospital for nearly 20 years. Issues related to attaining VMO status under a new structure, the purchase of goodwill in the business and vehement opposition between the parties. Issues developed into a complex set of legal, personal and related issues that were eventually resolved, although not to the satisfaction of the general practitioner. Whilst the details of the disputes are not at issue in this evaluation, the issue for change management demonstrates the difficulties of modifying existing structures in small rural communities.

The Otway experience also indicates the need to negotiate a practical outcome that is sensitive to existing structures in that community. It was finally resolved that the Community Centre would join the service but retain its separate legal entity, the community nurses would join but they were opposed to vehicle pooling and the Shire's Maternal and Child Health Service and the Victorian Ambulance Service would not join.

3.6.2 First triennium The Multi-Purpose Service was established in 1995 and proceeded to implement the new framework. Several considerable additional challenges arose during this period. The new Board included two members from each of the former services and this assisted organisational unity.

The selection of a Chief Executive Officer to lead the change process was central to the implementation success and the Board made three changes during this period, until it found a manager with the appropriate combination of skills and leadership. They had initially sought clinical expertise, followed by management expertise and finally appointed a CEO with strong community service management skills, with a clear understanding of management practice. The Board also found that it had to move through a steep learning curve and it took some time for it to understand the balance of skills required to govern this service model.

It is reported that the "glass walls" based on former program boundaries remained within the service during the initial years of service development, but these have since been eliminated.

Multi-Purpose Services Program Evaluation, Victoria 31 Otway Multi-Purpose Service

Several attempts were made to introduce an accreditation process during the period, initially without success. "The reason may be related to the unsettling period normally associated with the creation of a new service and the fact of letting go of the historical context from which the various services came together."32

Pre-MPS problems were progressively resolved with the Community Centre disincorporated as a legal entity and fully incorporated into the Multi-Purpose Service. The Local Government Maternal and Child Health Service remains legally separate from the Otway Health & Community Service but now rents office space within the building and is linked to service delivery practices. The general practitioner dispute remained unresolved and Otway Health & Community Services appointed another VMO and provided consulting rooms in the facility, with the disaffected medical practice establishing independent consulting rooms in the town.

The Board also reported a range of issues related to inter organisational relationships, particularly with the Department of Human Services. Financial negotiations were initially an on-going issue requiring clarification, the identification of an accreditation framework suited to an Multi-Purpose Service model also needed to be addressed and establishing a single point of accountability and decision making for Multi-Purpose Services within Government created issues for the organisation.

3.6.3 On going barriers Otway Health & Community Services has very successfully navigated through its development phase and the Board feels confident of the service structure and its operations. The only identified on-going issue of significance is the need for a simpler accountability framework that meets the needs of both the Board and Government.

The Board has placed considerable emphasis on its own role and development. A sound understanding exists of its governance role, a comprehensive management information system has been developed, performance measures have been clearly defined and monitored, recruitment is now based on attracting applicants that relate to the organisational vision ("recruiting for excellence"), interdisciplinary skilling has been introduced (eg community/acute nursing, home carers/personal care assistants, personal care assistance/food services, child care worker/receptionist) and a flatter organisational structure has been adopted. The organisational structure has matured into an outstanding example of rural community services governance and management. It is to be noted. however, that over five years were taken to reach this point, but it is difficult to determine whether the change could have been made in a shorter time had optimal executive management been in place from the outset.

3.7 Key factors for success 3.7.1 Otway Health & Community Services Although there are many contributory factors to the success of the Otway Health & Community Service Multi-Purpose Service model, organisational vision and strategic planning stands out as the key factor for success.

Otway Health & Community Services provides a clear, traceable process that links all parts of its service commencing with the development of an organisational vision and leading to service monitoring and reassessment of priorities. The process is a sound case study of governance and management with application to other services. Whilst the process is familiar, Otway Health & Community Services demonstrates its practical implementation.

32 Otway Health & Community Services Keys Factors for Success. Internal paper prepared for Multi-Purpose Services Program Evaluation. August 2000

Multi-Purpose Services Program Evaluation, Victoria 32 Otway Multi-Purpose Service

The system uses three interlinked reports as its base: a) Strategic Directions document. The process commences with the development of an organisational vision. Whilst the vision is important the process of close relationships between the Board and staff is central to development of a unified organisational culture. The vision is the strategic framework for the organisation (Figure 3.10). The framework includes both an organisational vision and specifies key seven interrelated organisational goals.

The next step is to define a set of strategic drivers. This is a set of practice statements that define how the goals will be achieved. eg "by taking decision making closer to the consumer through planning and undertaking the way we provide our services in consultation with local communities on an ongoing basis."

An accountability framework has been devised. This structure specifies what form of reporting will be provided and to whom (Figure 3.11).

Next, strategic relationships are specified. This most important step, involves the specification of the roles of the Board, Chief Executive Officer and staff. This structure is of major benefit for role delineation, effective governance and accountability of all organisational components. b) Service Plan The next plank in the system is the three year Service Plan. The Service Plan is based on five programs: governance, corporate services, health & aged care, community services and business units.

Each program has a number of Sub Programs with associated objective and a set of strategies.

For example, the Governance Program has the following components: • strategic goal • goal • six performance indicators, each with a specified method of performance measurement.

Examples of Governance Performance indicators include: • level of organisational financial viability • Service Plan reflects current priorities and identifies clear direction for the future

In addition three year objectives and strategies are defined for a range of governance issues.

The Service Plan sets a clear, accountable reference point for all parts of the organisation. c) Annual Report The Annual Report directly relates to the Service Plan. It reports progress in a systematic manner and enables all parts of the organisation, the community and funders to gauge progress over the previous year. Statistical and qualitative indicators are provided for every program.

The only suggested improvement to this system might be the inclusion of simple bar charts comparing service performance to previous years and a an organisational performance indicator summary based on a small number (around 10) key organisational indicators

Multi-Purpose Services Program Evaluation, Victoria 33 Otway Multi-Purpose Service

Figure 3.10 Otway Health & Community Services Strategic Framework

Th e m ai nt enan ce of a range of statistical data enabling the service to moni t or i t s capaci t y i n m eet i n g i dent i f i ed needs within our community.

Reporting to the The production of an Com monw eal t h and Annual Plan, identifying Victorian Government on service provision, a quarterly basis in respect objectives and performance of financial performance indicators based on an and providing a 6-monthly assessment of Service Activity Report. communit y need.

Reporting to the The product i on of an Victorian Government Annual Report, identifying on a monthly basis outcomes of planned in respect of the objectives, attainment of provision of Performance Measures acut e care. and Financial Report.

Operat ing wit hin Annual Financial an Annual Budget and Report audited by reviewing income and t he St at e Government expen di t ur e on a Auditor General. monthly basis.

Reporting to our community through the Annual M eet i ng i n respect of our Annual Report and Annual Plan and reporting on service provision, general operations and financial statements. Figure 3.11 Otway Health &Community Services Accountability Framework

Multi-Purpose Services Program Evaluation, Victoria 34 Otway Multi-Purpose Service

3.7.2 Quality Assurance Otway Health & Community Services maintains a Quality Improvement Committee (monthly meetings), as one of five standing committees. Quality Improvement Activity Reports are prepared and quality improvement is an agenda item on Management Team meetings, Board meetings and Team meetings throughout the organisation.

The service has achieved three year QICSA Accreditation from the National Quality Improvement Council and this single system is accepted as appropriate to all programs, including acute health.

The Quality Assurance is facilitated by a contract staff member who works designated days with the organisation. The Board reports that this arrangement has provided an efficient method of addressing this need.

3.8 Overview of findings Otway Health & Community Services represents the potential of the Multi-Purpose Service model which provides the flexibility of local communities to operate their services according to their identified needs. This case study also, however, realistically indicates that the model in its own right does not necessarily guarantee substantive improvements. The success of the Otway service has been mainly due to the combination of three main factors - a model that provided flexibility to mould services around community needs, a Board with vision and commitment to sound governance and sound managerial strategic management. The service outcomes may well have differed if any one of these factors had varied.

The Otway Multi-Purpose Service further demonstrates the challenge and difficulty of introducing change in small communities, particularly to a hospital which is the largest employer in the district and upon which many families are dependent. All services were not amalgamated from the outset, and service integration has developed progressively according to the acceptance of the service model and demonstration of its success.

It is clear that the availability of capital redevelopment funding was a major incentive to change. The community needed to offset the insecurity related to the pilot status of the Multi-Purpose Service Program at the time against the risks of not changing. The commitment to the potential of the model was grasped and implemented.

Many benefits have emerged from the change process for this community of little over 3,000 people. The range of services is impressive, the balance between acute, residential aged care, community health and community care is sound and the method of managing and responding to community needs exemplary.

Multi-Purpose Services Program Evaluation, Victoria 35 Mallee Track Multi-Purpose Service

4. Mallee Track Multi-Purpose Service - a service, not necessarily a centre

4.1 Service catchment allee Track Health & Community Service (MTH&CS) is located in an isolated wheat/sheep region of north west Victoria. Ouyen, the largest town the main centre Mis 104 kilometres from Mildura, 468 kilometres from Melbourne and 380 kilometres from Adelaide.

The service area extends 150 kilometres east from Ouyen to Murrayville near the South Australian border and encompasses small rural hamlets in an area of 11,757 square kilometres of Mallee scrub and broad acre farms separated by significant distances in an area renown for its searing summer climate, droughts and resilient communities. The catchment is equivalent to that of enclosed by Melbourne to Seymour to Ballarat and Geelong. It is bordered by semi arid nature parks and concentrated mainly along the "Mallee Track" of east-west road arteries.

Figure 4.1 Mallee Track Health and Community Service Catchment Area

Multi-Purpose Services Program Evaluation, Victoria 36

Mallee Track Multi-Purpose Service

The 1996 population of the area was 3,21233. Ouyen has a population of 1400, followed by the Underbool/Walpeup area with 450, Murrayville area 350 and Patchewollock area 200. The remaining 25% of the population live in widely distributed small hamlets or on farms.

The population is slowly declining as younger people migrate to larger centres for employment, farm holding sizes increase and older people die. Many of the small towns exhibit clear evidence of rural decline, with many old, dilapidated and abandoned buildings reflective of a former era based on smaller land holdings and more intensive labour practices. Today the average viable wheat/sheep property is 1200 hectares (3,000 acres) with some holdings in excess of 2500 hectares (6,000 acres), managed by an increasingly smaller workforce. Many of the very old farmers have retired into small rural hamlets, with younger farmers moving outside the district to retire. Many houses are of a very basic construction with opportunities to support frail older people to remain at home being limited by the building fabric.

These small communities have a traditional farming social infrastructure, including a heavy reliance on neighbourliness, strong traditional ownership of community assets (such as hospitals, ambulances and halls), a resistance to loss of services and a strong desire for each community to be self reliant.

Over 96% of the population was born in Australia and most families in the district are inter generational. Only 12.8% have a skilled vocational qualification or higher (compared to 29% for Victoria). Households are mainly consist of two parent families (56% compared to 36% for Victoria) and 85% own their own homes (Victoria 73%), although some those houses may be worth little.

Rural poverty is a significant issue that places further pressure on service delivery. Fifty six per cent of the population have an income of less than $10,000 per annum, with significant numbers in receipt of welfare benefits. Emotional and financial stress, depression are significant issues, as is alcohol dependence for some. Travel distances often exacerbate problems, with some families dependent on one vehicle, many being unable to afford the high costs of fuel and the need to always travel long distances to access services. Children may also be isolated by the limited transport options, or by both parents working away from home.

Mallee Track operates within this established traditional environment that has proven to function effectively over the generations but increasingly faces new pressures as the population declines, leaving many older people with low incomes and poor housing to be supported.

4.2 History By late 1993 the Ouyen and District Hospital was experiencing viability pressures resulting from the impact of case mix funding. Soon after, local government amalgamations created further threats to the communities as they adjusted to unfamiliar administrative alignments. The Murrayville Hospital, 110 kilometres to the east had closed in 1990 and many of the existing small and under resourced community services were struggling.

33 The MTHCS is within the Mildura SLA Part B population 4,495.

Multi-Purpose Services Program Evaluation, Victoria 37

Mallee Track Multi-Purpose Service

At about this time, the Multi-Purpose Services Program emerged as an option and the (then) Shire of Walpeup hosted a meeting of the 13 main services providers from the surrounding Mallee Region and six months later in March 1995 a declaration to support a new model of health service delivery was made. There was limited appreciation of the full implications of a Multi-Purpose Service but the community had successfully negotiated a State commitment to a hospital (Ouyen) and three bush nursing centres redevelopment (Patchewollock, Underbool and Murrayville) and it was clearly understood that change was needed if services were to survive.

The former MPS administrative structure is shown in Figure 4.2. In the case of Murrayville hospital and Murrayville Bush Nursing Centre, there were two Boards, with similar membership. There was single Board for Ouyen & District Hospital and Pattinson House hostel. It can be seen that there were nine Committees of Management supporting services for a population of 3,212. Following the introduction of the MPS, this was reduced to one Board.

Murrayville Murrayville Hospital Murrayville Bush Nursing Centre Board of Management Board of Management

Murrayville Community Awareness Group Committee

Patchewollock

Patchewollock Bush Nursing Centre Committee of Management

Underbool

Underbool Bush Nursing Centre Committee of Management

Ouyen

Ouyen Hospital Board of Pattinson House Hostel Management Board of Management

Community Link Committee of Management

Ouyen Neighbourhood House Management Committee

Figure 4.2 Pre-MPS Management Structures

Multi-Purpose Services Program Evaluation, Victoria 38

Mallee Track Multi-Purpose Service

However, it is of particular interest to note that the sense of individual community ownership lead to each service retaining its own assets, except for the Ouyen Hospital. Thus, for example, the Murrayville Hospital Board remained in existence as the guardian of the facility, with Mallee Track as a tenant. The same arrangement applied to all other significant assets and continues to the present. The Boards of Management meet infrequently but have no function other than to protect their asset. This compromise was a necessary part of gaining support for the new service model.

The Mallee Track Health & Community Service was gazetted as a Multi-Purpose Service in January 1997. However, due to the introduction of HACC service tendering these services remained with the Rural City of Mildura, as did the Maternal and Child Health Service. All other services were amalgamated into the new structure. Agreement to the new service concept was based on the undertaking of a significant grant for capital redevelopment at the four towns in the service area.

4.3 The Mallee Track MPS model 4.3.1 Management Structure Mallee Track Health & Community Service has a single Board of Management based on a representative locality model. Each of the three rural centres has two representatives and Ouyen and district had six members. Whilst most Board meetings are held in Ouyen, some meetings are also held at Murrayville, Underbool and Patchewollock. The organisational structure has been significantly redesigned. The previous overlapping disaggregated model has been replaced with a flat structure based on a combined Chief Executive Officer/Director of Nursing position and two senior managers (Figure 4.3).

Board of Management

Dental Officer

CEO/DON

VMOs

Project Officer

Clinical & Business Manager Residential Care Manager

Acute Residential Community service services based

Admin. Dental Community Hotel Maintenance Purchasing services

Figure 4.3 Mallee Track Health & Community Service Organisational Structure

Multi-Purpose Services Program Evaluation, Victoria 39

Mallee Track Multi-Purpose Service

Each of the three main small communities has at least a community nurse, supported by visiting services from Ouyen. This arrangement allows every community to obtain the same range of community services, including allied health services which were previously less accessible.

4.3.2 Services The Mallee Track Health & Community Service profile has the following characteristics: a) Bed based services: Fifty "flexi beds" consisting of a nominal 10 acute beds and 20 high care beds in the same building complex and a 20 bed hostel on another site. These beds are substituted according to need, with currently one place for high care respite and a permanent palliative care unit nearing completion. All bed based services are managed according to demand, with most flexibility occurring in the acute and high care places. b) Allied health Ouyen had previously provided allied health services from the hospital. With the advent of the Multi-Purpose Service it has been able to attract and retain equivalent full time physiotherapy, occupational therapy and podiatry staff and make the services available throughout the service catchment. However, there have been major difficulties in attracting general practitioners and this remains the case. c) Community health and community care Community health/community care services include visiting dental (limited), community nursing in all main towns, adult day care in all main towns, a significant volunteer community transport and friendly visiting service throughout the service area, neighbourhood houses in Ouyen and Murrayville and a health promotion program that includes the Better Health Channel and an active education program based at district events throughout the year. d) Brokered and networked services Mallee Track Health & Community Service seeks to provide core services based on identified needs. In cases where there is a need but limited demand due to service specialities, arrangements are made for regional services to provide clinics or home visits if required. These include psychogeriatric assessment, counselling, disability services and others. Mallee Track also provides delivered meals on behalf of the Mildura Rural City Council.

Relationships are also maintained with related services. These include HACC services provided by Council, Community Care Options, ambulance services throughout the area and others.

The range of service options is shown in Table 4.1

4.4. Service Effectiveness 4.4.1 Service targeting The Multi-Purpose Services model introduced a coordinated approach to service targeting. In 1998 Mallee Track Health and Community Service engaged a research consultant to undertake a needs analysis. The methodology reflected consultation practices familiar in the Mallee consisting of a series of community meetings in Ouyen, Patchewollock, Underbool and Murrayville and surveys of existing service users. It is of interest that attendance at the community meetings was low (between 6 and 16) and this was considered to be reflective of

Multi-Purpose Services Program Evaluation, Victoria 40

Mallee Track Multi-Purpose Service community life in the area, whereby people are less likely to participate unless there is direct threat to an existing service. One hundred and seventeen service users also completed survey returns. These consultations were complemented by meetings with service providers throughout the district.

The Needs Analysis was followed by the development of the MTHACS Service Plan 1997- 2000.

Table 4.1 Mallee Track Health and Community Services Service Profile Operational support Preventive Community and Emergency Training & Health & management independent & bed development promotion & living based education services Polices Dental Care coordination Emergency Accreditation Diabetes care Capital redevelopment Screenings Transport Clinic T& D program Asthma 4 services (14 programs) Quality management Community Acute beds Arthritis activities Service planning Friendly visiting Residential Smoking Business services Group activities Respite care Counselling Financial planning Volunteers Dementia D&A OH&S Neighbourhood Day clients Emotional health house Communication ADASS HITH Injury prevention Residential First aide Respite care Men's health Maternal & child Women's health Nursing Healthy life style Palliative care Personal care Allied health Delivered meals Rehabilitation Brokered services: Farm safety, Kids on farms, counselling, D&A, Ambulance, Psychiatric services (aged, adult, child), disability services Networking: Links maintained to 29 area and regional services

In May 1999 Mallee Track Health & Community Service took advantage of a Commonwealth funded Rural Health Support Education and Training (RHSET) project grant to La Trobe University Bendigo to investigate health services in small rural and remote communities. Every household in the area was forwarded a questionnaire (431 responses) and health diaries were completed by doctors (735 entries) and nurses (578 entries). The survey profiled medical conditions of the population, identified community responses to the value of existing health improvement/illness prevention programs, services most valued by the community and service gaps.

The highest priority health services were identified as: • doctors - a major challenge for the Mallee community due to the difficulty in attracting and retaining general practitioners • hospital services • 24 hour ambulance and emergency services: a significant local issue, with each community having its own ambulance (except Underbool), several with volunteer drivers • aged care

Multi-Purpose Services Program Evaluation, Victoria 41

Mallee Track Multi-Purpose Service

• nursing services: a traditional service closely associated with former Bush Nursing Centres which have now been incorporated into the Multi-Purpose Service • support for the dying: A palliative care unit has been incorporated into the Ouyen Hospital as a result. • health screening: an increasingly important issue as awareness grows in the community.

Low cost methods of needs identification have been adopted and a baseline established for future comparative health and community service monitoring.

4.4.2 Access Service expansion at Mallee Track has been constrained by an attenuated facility redevelopment program. Building renovations and redevelopment was required at four sites (Ouyen, Murrayville, Underbool and Patchewollock) over two years, with reconstruction not due for completion at the Ouyen site until late 2000. Despite this limitation the Mallee Track can demonstrate improved access to a range of services.

Since the introduction of the model there has a progressive realignment of services, with increased emphasis on health promotion and community based services. Table 4.2 indicates expansion of community nursing, adult day activity programs, neighbourhood house programs and delivered meals (Figure 4.4). Community visiting and transport services have also expanded, with over 200 volunteers currently involved in a wide range of programs in including client transport involving 81,500 kilometres of assisted travel in 1999-2000 at an average of 48 kilometres per trip. Health promotion is now a major activity program with Mallee Track Health & Community Service presenting displays and demonstrations at most community events and field days.

700

600

500

400 1998 / 1999 1999 / 2000

300 NO. OF CLIENTS NO.

200

100

0 JULY AUG SEPT OCT NOV DEC JAN FEB MARCH APRIL MAY JUNE MONTH Figure 4.4 Meals on Wheels Service Growth

Table 4.2

Multi-Purpose Services Program Evaluation, Victoria 42

Mallee Track Multi-Purpose Service

Mallee Track Health and Community Services Year 1 compared to Year 3 1996/97 1999/2000 District Hospital Beds 15 15 Separations Acute 512 273 Non acute 15 5 Same day 78 37 Occupied bed days Acute 2346 2032 Occupancy rate 43% 57% Non acute 519 112 Same day 78 37 Non admitted (Accident & Emergency) 499 1402 Outpatient clinics (occasions of service) n/a 1585 Residential care High care (places) 30 20 Occupied bed days 9939 6267 Low care (places) (Pattinson House) 20 20 Occupied bed days 6774 6185 Respite (occupied bed days) High care 0 393 Low care 166 964 Allied Health Physiotherapy (occasions of service) 888 745 Occupational therapy (occasions of service) 529 284 Podiatry (occasions of service) 1585 1196 Community services Dental (public) (occasions of service) 1796 1783 District nursing (occasions of service) Ouyen 1237 2309 Adult Day Care (person hours) 13893 19377 (occasions of service 705 980 Delivered meals 5331 6976 Community Link Transport (occasions of service) n/a 1872* Friendly visiting n/a 1051 Neighbourhood house, Ouyen (occasions of service) 790 8721 (groups) 81 89 Health promotion (group session attendances) n/a 861

UNDERBOOL Bush Nursing Centre (occasions of service) 4071 4705

MURRAYVILLE Bush Nursing Centre 2463 2603 Neighbourhood house (occasions of service) 4281 2050 (groups) n/a 201 PATCHEWOLLOCK Bush Nursing Centre (occasions of service) 2607 2603 n/a not available

* 81,500 kilometres

Multi-Purpose Services Program Evaluation, Victoria 43

Mallee Track Multi-Purpose Service

Allied health services and dental services have experienced periods where service availability has been constrained by the viability of professional staff

Service substitution has also been applied to provide a more appropriate alignment of service to community needs. Acute bed numbers are managed conjointly as flexi beds with the high care beds, with their use varying according to the demand at the time. Average length of stay in acute beds declined from 6.3 to 5.6 days, even though construction work presented considerable limitations.

There has been no waiting list for residential high care until recent times and the adoption of an ageing in place philosophy has facilitated the care of a small number of high care residents in the hostel.

Evidence also exists of improved access to services for people living in outlying rural communities. Both Murrayville and Underbool have expanded their reach with more clients increased occasions of service (Table 4.2). The average number of individuals assisted over the past two years has remained relatively constant (Figure 4.5).

200.00

180.00

160.00

140.00

120.00

100.00

80.00

60.00 NO. INDIVIDUALS ASSISTED

40.00

20.00

0.00 JULY AUG SEPT OCT NOV DEC JAN FEB MARCH APRIL MAY JUNE MONTH

1998 / 1999 1999 / 2000 Figure 4.5 Underbool Community Nursing Performance

4.4.3 Coordination, flexibility and innovation Mallee Track Health & Community Service at Murrayville is one sound example of the benefits of the Multi-Purpose Service model to a small community. Murrayville Hospital, closed since 1990, was a large, mostly unused asset. With the advent of the Multi-Purpose Service, the hospital was renovated and developed as a multi-use health and community centre. It now includes a base for the community nursing service, a resource centre including the Better Health computer access, general practitioner consulting rooms, podiatry consulting room, neighbourhood house facilities, rooms for the visiting Land Care Service, offices for a private visiting Accounting practice, video conferencing facilities for CES and a community meeting room. This facility has provided Murrayville with a new community focus.

Of further interest is the relationship developed with South Australian health services. Murrayville being 30 kilometres from the border is closer to Pinnaroo than Ouyen. Visiting

Multi-Purpose Services Program Evaluation, Victoria 44

Mallee Track Multi-Purpose Service medical services come from Mallee Medical Practice in Pinnaroo/Lameroo, and aged residential care is accessed through the Pinnaroo Hospital, thereby optimising access for families. The relationship developed between Mallee Track Health & Community Service with a range of other service providers, including those across the border has lead to better use of resources and improved services for the community.

A second innovative example of service development relates to residential aged care. In 1993 the Ouyen & District Hospital took advantage of the availability of a motel which came on the market. In cooperation with the Commonwealth $1.1 was made available for the purchase and modification of the motel into a 20 place residential care facility. The motel had included ensuite bathrooms and was readily adaptable by extending and enclosing the area infront of the units where cars had previously parked. The design provided for private bedrooms and bathrooms, plus semi-private sitting area outside each unit. This clever adaptation enabled a small rural community to provide an ageing in place facility which may have been otherwise difficult to provide. Some limitations apply due to the unit's location 1 kilometre from the main service campus in Ouyen where meals are prepared, but this is offset by the availability of 40 low care and high care places for an aged community of an estimated 350 persons aged over 70 years.

Service flexibility exists within all parts of the service. Some examples include: • the ability to manage the 50 beds according to need for acute, interim care, post natal care, respite, residential aged care or palliative care. • resource sharing, including the use of vehicles. For example Community Link friendly visiting and transport service was previously limited to one vehicle and now has access to a vehicle pool. • the development of co-operative professional arrangements. With the extreme difficulty of recruiting allied health professionals to rural communities, Mallee Track is fortunate in having equivalent full time access to physiotherapy, occupational therapy and podiatry services. It is planned to share these services with Robinvale Multi-Purpose Service.

4.4.4. Improved cost effectiveness Mallee Track Health & Community Service has achieved service growth (Table 4.2). Acute bed occupancy has increased from 43% in 1996/97 to 57% in 1998-99, early discharge to home with community services has been expanded and fewer people are admitted to acute care due to a more extensive outpatient and home based supports.

Clear trends are also apparent in the expansion of community services within the base budget allocation. Figure 4.6 indicates a significant growth in adult day care and community nursing across all sites. Other services such as health promotion and community transport have also experienced significant growth but data is not available to quantify the change. Some services, such as dental services and some allied health services experienced declines across the three year period due to difficulties in attracting professional staff.

Workforce adjustments have also been made in response to the shift towards community care. Nursing staff have been reduced and staff in most other service areas increased. The available data is too limited to establish a clear trend given the workforce adjustments that occur from year to year in remote rural areas, but there is a trend towards increased acute care efficiency through higher bed occupancies without the need for additional staff and expansion of community services (Table 4.3).

Multi-Purpose Services Program Evaluation, Victoria 45

Mallee Track Multi-Purpose Service

100

90

80

70

60

50

40

per cent increase 30

20

10

0 ADASS Ouyen Underbool Murrayville Patchewollock Meals on community community community community wheels nursing nursing nursing nursing

Figure 4.6 Mallee Track Service Growth between 1996/77 and 1998/99

Table 4.3 Mallee Track Health and Community Services Workforce Adjustments Staff 1997/98 1998/99 Change Number % Number %Number % Nursing 28.26 44.5 27.27 39.1 -0.99 -5.4 Allied health 5.22 8.2 6.13 8.8 +0.91 +0.6 Hostel 6.46 10.1 6.34 9.1 -0.12 -1.0 Neighbourhood houses 0.65 1.0 0.86 1.2 +0.21 +0.2 Community link 0.53 0.8 1.06 1.5 +0.7 +0.7 Food services 7.44 11.7 7.91 11.3 +-0.57 +0.4 ADASS 1.91 3.0 3.06 4.4 +1.15 +1.4 Administration 7.26 11.4 9.68 13.9 +2.42 +2.5 Environmental services 3.43 5.4 4.27 6.1 +0.84 +0.7 Engineering & maintenance 2.31 3.6 3.23 4.6 +0.92 +1.0 Total 63.47 100 69.81 100 +6.34 +10.0

It is to be noted, however, that significant workforce reductions occurred at Ouyen & District Hospital immediately prior to the formation of the Multi-Purpose Service. Preliminary data suggests that administrative staff positions have expanded since the introduction of the Multi- Purpose Services and this may be reflective of increased accountability and multi-site management requirements. Due acknowledgment also needs to be given to the place of the Mallee Track Health & Community Service as the largest employer in the district, with many families reliant on it as a source of employment. Under these circumstances sensitivity and community responsibility is required when reviewing workforce requirements and optimal efficiency may not be achievable under all circumstances.

In addition the 200 volunteers who participate in service delivery produce cost savings and contribute to community ownership of the service. For example, the hostel does not have a

Multi-Purpose Services Program Evaluation, Victoria 46

Mallee Track Multi-Purpose Service bus and any resident requiring transport calls the Community Support Service and residents collected.

4.5. Client impacts 4.5.1 Client feedback The focus group session was represented by community members from each of the towns in the Mallee Track service.

Perceptions of service availability Overall the group considered that the availability of services across the wide geographic catchment was "high" to "very high" (Figure 4.7). It was widely recognised that small rural communities would never have local access specialist services, but the availability of other services was considered "very good" or even "fabulous", and this was attributed to the Multi- Purpose Service model.

The availability of general practitioners was identified as an on-going problem, although satisfactory at present. General practitioner home visits to outlying rural areas were also reported to rarely occur, but this was not considered a significant issue.

Most praise was reserved for the community nurses. Representatives from the rural communities considered the community nursing service to a fundamental element of the service system. They are accessible and provide the link to other service options according to need. They provide the community with reassurance that their primary health care needs can be met in the first instance and their retention in small communities was considered to be "one of the big bonuses" of the Multi-Purpose Service model.

One of the former problems of stand alone community nursing services related to back fill due to sick leave or annual leave. Whilst this issue remains, the Multi-Purpose Service does provide the opportunity to establish temporary cover from community nurses in other towns, or in cases of high need the Mallee Track CEO/DON will provide a service to Patchewollock if other options are not available. It was reported that every community can be assured of community nursing cover at this time.

There was also considerable support for the well established Community Link service which provides volunteer transport services to all parts of the service catchment. If a car is not available in a small community, another vehicle can be sent out from Ouyen, thereby providing flexibility that had not previously existed. Apart from transport to medical appointments in Mildura and other cities, Community Link was also transports older people into Ouyen for shopping and banking each week.

The Multi-Purpose Service was also recognised for the allied health continuity of care. Monthly visits are made to the smaller communities by the physiotherapist and podiatrist, with the occupational therapist undertaking home based assessments as required. This service had previously been spasmodic.

Some services have not joined the Multi-Purpose Service program in the Mallee including Home Care and Home Maintenance and the Women's Health Centre funded through the Loddon-Mallee regional office at Bendigo. Working relationships between the services is sound and it was considered important that time be given to any service to determine whether or not join Mallee Track.

Multi-Purpose Services Program Evaluation, Victoria 47

Mallee Track Multi-Purpose Service

How would you rate the availability of health and How well met are the health/community needs in this community services in this community? community?

60.00% 60.00%

50.00% 50.00%

40.00% 40.00% 30.00% 30.00% 20.00% 20.00% 10.00% 10.00% 0.00% 0.00% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW

Figure 4.7 Perceived service availability Figure 4.8 Extent to which health/community needs met

Perceptions of service responsiveness to health/community needs It was considered overall that the health and community needs of the community were "moderately" to well met (Figure 4.8). Youth health was the main area identified as requiring additional support. It was also considered by some participants that whilst men's health had been addressed through a very successful community forum, this needed to be reinforced with programs aimed at addressing the identified issues. Such programs were developed and provided throughout the Mallee Track communities.

How easy is it to obtain the following services in this How would you rate the change in health and community community? services in this community today, compared to about five years ago? 60.00% 80.00% 50.00% 70.00% 60.00% 40.00% 50.00% 30.00% 40.00% 20.00% 30.00% 20.00% 10.00% 10.00% 0.00% 0.00% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW SIGNIFICANT MINOR DECLINE NO CHANGE IMPROVED SIGNIFICANT DON'T KNOW DECLINE IMPROVEMENT

Figure 4.9 Perceived ease of access to Mallee Figure 4.10 Rated change between current services Track Services and five years previously

Access Most services were considered to "easy" to access (Figure 4.9). High residential age care is experiencing some waiting for the first time, but there are vacancies in the low care facility which was attributed to the improvement in home and community based services. Specialist care was recognised as only "moderately" accessible, as was home based care in some outlying communities. Thee focus group considered that the Multi-Purpose Service "provides communication and links between services" and even though many people are unaware of their availability, the community nurse can arrange of an appropriate service if required.

Multi-Purpose Services Program Evaluation, Victoria 48

Mallee Track Multi-Purpose Service

Consultation

All focus group participants agreed that there had been extensive consultation prior The Age. 22 August 2000 to the introduction of the Multi-Purpose

Service. Meetings were well attended in the smaller communities but less so in Ouyen. Issues had been well considered and the smaller communities in particular had recognised the Multi-Purpose Service model was an opportunity to preserve and improve services which might otherwise be lost. The success of the process was attributed to the potential benefits exceeding the risks and the representative structure of the proposed Board. In addition, the Board decided to refurbish communities in the three small communities prior to Ouyen and this provided reassurance to those areas. It was reported that there had been some concern about the possible power relationships between the amalgamated services but this was offset by the benefits that became readily apparent

The effectiveness of existing consultative arrangements within the Mallee Track Health & Community Service was an issue of difference within the focus group. Some considered that there was a need for a structure to assist community members to be kept informed of Board decisions and to influence decisions. It was suggested that the community might be invited to meet the Board as it moved between community locations for meetings. . Service improvements It was widely agreed that services has greatly improved in Mallee Track compared to five years ago and that this could be attributed to the Multi-Purpose Service model (Figure 4.10). Acute care was considered to have experienced "no change" because it had been functioning at a similar level over the period and staff were "very good" throughout the period.

Multi-Purpose Services Program Evaluation, Victoria 49

Mallee Track Multi-Purpose Service

Most other services were considered to have "improved" or "significantly improved". It was considered by some that health and fitness information and classes could be further developed in the future.

Multi-Purpose Services Model The focus group also considered the extent to which the Multi-Purpose Service model had made a noticeable difference to health and community services in this part of the Mallee. All considered that the following issues had either "improved" or "significantly improved": • service management structures • flexibility in addressing priorities in the community • ability to innovate in the way services are provided • community control over services.

It was considered that "services have improved out of sight in every field." There is improved service cohesion, more information sharing, service segregation has been eliminated" and "we are all pulling together in the one direction" rather than competing and struggling to survive. The Board feels "in control, to a degree" and it was considered that the full benefits of the model have still to be seen due to the delay in facility redevelopment.

The group considered that information technology developments should be part of the next phase of development. This would reduce the time currently devoted to meetings whereby travel time usually exceeded the duration of the meeting and provide for more integrated health and community care. In particular it would assist with service monitoring, quality control and accountability.

4.5.2 Other evidence of client satisfaction The La Trobe University Health Services Survey established that the most common treatment provided by community nurses was general care monitoring (31.5%), including the monitoring of existing conditions and general support. Given the limited access of many remote area residents, the community nurses reported that many clients seek on-going support as a form of reinforcement and support.

Initial assessments were also significant (15.6%), followed by medication administration and dosette box management (15.6%) (there being no pharmacy in the small townships) and 8.7% sought counselling. This pattern of use clearly demonstrates an important preventative and support role for community health and care throughout the Mallee Track service area.

The 735 Doctor diary entries indicate a similar level of community support. Forty per cent of patients had travelled between 3 kilometres and more than 50 kilometres to access the doctor.

Service users also completed 431 survey forms. The main outcomes of the project include: (per cent very satisfied or satisfied) (a) satisfaction with general practitioner services • travel time 67% • waiting time 71% • continuity of care 72% • access to specialist 60% • emergency care 67% • choice 61% • quality of service 72% • referral by GP 72% • bulk billing 68%

Multi-Purpose Services Program Evaluation, Victoria 50

Mallee Track Multi-Purpose Service

(b) satisfaction with community nursing services • health needs met locally 72% • travel time 79% • waiting time 74% • continuity of care 66% • emergency care 71% • choice 51% • quality of service 79% • information about other services 72% • bulk billing 75%

(c) responsiveness of services to individual health needs • immediate/urgent 57% • long term/ongoing 52% • day to day 56%

The main issues of client dissatisfaction include: (dissatisfied or very dissatisfied) • access to medical specialists 24% • choice of doctor 21% • provision of long term/on-going care 19% • access to health services locally 10%

Interpretation of the results is difficult. The results appear low relative to urban community attitude survey results34, but given the isolation, long distances from services and difficulty in providing services, these results may be optimal for this community. Future surveys are required to determine service effectiveness.

Qualitative judgement would suggest that with the increase in community services, the redevelopment of facilities in all communities and the expansion of residential care since the commencement of the Multi-Purpose Service, these survey results may be approaching optimal levels and some levels of community dissatisfaction may be unavoidable.

4.6 Client impacts linked to service model There is no evidence of consumers from Mallee Track communities seeking the same acute services in other towns that are available in Ouyen. The same range of acute procedures is available to the community in 2000 compared to the pre-MPS service profile. The reasons residents are accessing acute services in large towns (mainly Mildura) include the need for surgery or specialist consultations and to give birth.

Overall, the expansion of community services has provided improved access to a wider range of services than previously.

4.7 Barriers to implementation 4.7.1 Development phase The development phase prior to the introduction of the Mallee Track Health & Community Service presented challenges that required specific management. From the community perspective, it was found necessary to hasten slowly. Attenuated capital redevelopment funding negotiations slowed the process and whilst this was frustrating for the Board and management, it did provide an opportunity too reassure the community that the proposed changes would be beneficial.

34 For example, average levels of satisfaction over 90% for HACC services for Yarra, Greater Dandenong, Maroondah. Multi-Purpose Services Program Evaluation, Victoria 51

Mallee Track Multi-Purpose Service

For staff there were threats of loss of employment. Workforce downsizing had been introduced immediately prior to the introduction of the MPS and any further loss of jobs to the largest employer in Ouyen was a threat to the entire community. It was therefore necessary to ensure that service realignments were matched with expanded community and residential aged care developments. Staff were invited to embrace the concept and develop a more flexible approach by working across different service types according to identified priorities at the time. The outcome has been an acceptance of the model and a recognition by staff of expanded work opportunities.

Insecurity also existed concerning the long term future of the program. Whilst there were guarantees of funding over the first triennium, the community had some concerns about major system changes in the long term. It was recognised that once the change was made it would be impossible to return to the former program funded model, especially for residential aged care where unit sizes and cost structures would be unviable under a non MPS model.

The major issue in this period, however, related to the adequacy of capital redevelopment funds. An initial grant of $1million was insufficient to achieve the objectives and the final grants to date of $3.1 million remains approximately $600,000 short of current commitments. It was also recognised that with rural drought and increasing community indebtedness that there was very limited opportunity to raise community funds.

4.7.2 First triennium Delays in the commencement of the service redevelopment and a construction program extending over two and a half years and continuing, caused disruptions during the first three years of MPS redevelopment. However, renovations at Murrayville, Underbool and Patchewollock sites were successfully completed with minimal disruption to service.

Many of the remaining issues in the first three years of operation related to long term structural issues for rural communities. General practitioner recruitment, managing an integrated system when staff need to travel long distances to attend meetings, providing services to very small remote communities, introducing contemporary management practices and the cost of staff training remain as continuing challenges.

Several Departmental regional office and central office issues were identified. These include a perceived need for more comprehensive program guidelines, Program Officer continuity and a clearer method of program accountability.

4.7.3 On-going barriers Two main on-going barriers were identified by Mallee Track Health & Community Service. First, it was considered that greater clarity of MPS funding conditions is required. Whilst the existing method of calculating the base line budget is considered reasonable, guidelines are needed to specify the extent to which service substitution may occur. Secondly, there is a perceived need for a Multi-Purpose Services minimum data set. It is unclear to whom the service is accountable and it is considered that whilst the Program represents a pooling of funds to create a unique response to the community, this contrasts to accountability requirements linked to former program based service systems.

Other more specific on-going issues include: • Award requirements limiting opportunities for flexible workforce adjustments based on need. • budget security in instances when deficits occur for reasons relating to service provision in remote areas • the cost of IT hardware, software and particularly training

Multi-Purpose Services Program Evaluation, Victoria 52

Mallee Track Multi-Purpose Service

• the high cost of travel to Melbourne for meetings (12 hours return trip) • pressures on management and staff.

4.8 Issues for a multi site model The multi-site model adopted by the Mallee Track Health & Community Service was the only reasonable way of introducing a vertically integrated service model into this community. Due recognition was given to the pre-MPS service structure and any threat of loss of community control was eliminated by the introduction of by-laws that required representation from each of the four main communities on the Board of Management.

The process was also assisted by the avoidance of facility closures. Had a hospital in one of the smaller communities been closed to accommodate the model, the likelihood of community acceptance of the change would have been in doubt. Circumstances in the Mallee Track service area were such that an existing hospital in Murrayville has been closed for six years prior to the introduction of the Multi-Purpose Service model and the other smaller towns had small struggling Bush Nursing Centres in need of renovation and support. Hence an environment existed for the introduction of a service model that had no significant threats.

Furthermore a natural hierarchy of service centres existed prior to the Multi-Purpose Service, thus avoiding the necessity of significant resource redistribution between the sites. Ouyen is the major centre and Murrayville has a sound basic infrastructure including links to services across the border into South Australia, and Patchewollock and Underbool were very small communities that could only benefit from the model.

Governance issues also existed at the time. The seven separate Boards of Management were supported by ageing members and generational change was not occurring. The Multi-Purpose Services model offered an acceptable alternative to a problem of governance entropy.

It was therefore fortunate that the pre-conditions for a multi-site model were reinforced by the introduction of the Mallee Track Health & Community Service.

The only significant remaining issue affecting the multi-site service is the travel distance and travel time between sites. This mainly affects community nurses who lose significant time in attending meetings, but this factor is generally accepted as a normal part of service delivery in this community.

Management suggests that the main advantage of the multi-site model is its ability to adjust resources as demand changes.

4.9 Key Factors for Success Prior to the introduction of the Multi-Purpose Services Program, Boards and Managers of health and community services recognised that the viability of rural services was threatened by case mix funding and Residential Aged Care program requirements. The conventional service system depended on a relatively large population base and the Mallee with its many small communities, long distances and declining populations did not fit that model. The Mallee community suggests that they had little choice other than to embrace the Multi-Purpose Service model, even though concerns existed about its long term security were not guaranteed at that time.

Hence the key factor for success of the model in the Mallee has been identified as the trust placed in its potential and the willingness of the community to move towards a population health model. It was accepted that tertiary level acute services would never be possible in this rural community and that benefits could be obtained by expanding home and community based services.

Multi-Purpose Services Program Evaluation, Victoria 53

Mallee Track Multi-Purpose Service

4.10 Quality Assurance Mallee Track Health & Community Service has selected ISO9002 for its quality assurance and is working towards an accreditation survey in 2001.

4.11 Overview The Mallee Track Health & Community Service exhibits the strengths of other Multi-Purpose Services. It also demonstrates particular features that are unique to this community.

Mallee Track Health & Community Service needs to be understood within the cultural context of the Mallee farming community which has developed processes and problem solving methods that adapt to the issues of distance, isolation, professional staff retention and achieving optimal efficiency within the resources available to it. The fact that the Chief Executive Officer is also the Director of Nursing and fulfils roles as varied as community nurse backfill in small communities and other similar roles is but one example the way in which this community functions. Service reporting systems are not as sophisticated as in other services but informal support services that adapt to individual needs are particularly strong.

A significant feature of Multi-Purpose Service implementation was the process used to introduce the model. By involving all communities and progressing slowly, it was possible to reach consensus and support for this significant change. The Board of Management model based on area representation reduced local insecurities and bound the community together as a stronger entity.

The Multi-Purpose Service has also introduced more tangible benefits and efficiencies. The range of services has markedly expanded, acute bed efficiency has improved and the occasions of service have increased. In particular there has been a shift towards a more balanced service system that includes acute, residential aged care, community health and community care.

Perhaps the greatest benefits from the Multi-Purpose Service are most apparent in the smaller communities. Faced with threat of a loss of service, these communities each have access to well established multi-purpose community centre, a stable community nursing service and access to visiting medical and allied health services. The interstate cooperation between Murrayville and Pinnaroo/Lameroo works effectively for both communities and is a sound example of inter-service relationships, facilitated by the flexibility of the Multi-Purpose Service model.

Particular components of the Mallee Track service also warrant recognition. Community Link volunteer transport and community visiting service has become an integral part of the Multi- Purpose Service model and has proved vital in reducing social isolation throughout the largest municipality in Victoria. Similarly, the community nurses in Patchewollock, Underbool and Murrayville provide the foundation for the health and community services to these distant rural communities.

Furthermore the Multi-Purpose Service model has facilitated flexibility and innovation. The concept of "flexi beds" has positioned the Board to respond well to community needs as they change. Also the conversion of a motel into a low care aged residential care facility has been a positive adaptation that may have been more difficult had the service been subject to Residential Aged Care Program requirements.

Areas for the Board to consider for possible future service improvement have also been identified. Management systems could be further developed to provide improved care plan management, service delivery development and performance monitoring. This is dependent on the development

Multi-Purpose Services Program Evaluation, Victoria 54

Mallee Track Multi-Purpose Service of a fully integrated and networked information technology system, and consideration could be given to the introduction of a staged development program. Further consideration might also be given to service plan development and monitoring. A three year Service Plan has been developed and this would benefit from an integrated reporting system to monitor performance. Over time, the existing relatively informal monitoring approaches should be expanded into more formal systems.

It is well recognised by the Board and management that delays in facility redevelopment has impacted on the full realisation of the service model. Once this has been completed the opportunity exists to focus on quality assurance and systems development to take Mallee Track Health & Community Service to its next stage of development.

Multi-Purpose Services Program Evaluation, Victoria 55

Alpine Health Multi-Purpose Service

5. Alpine Health Multi-Purpose Service - linking across communities

5.1 Service catchment lpine Health is a multi site MPS based in Myrtleford, Bright and Mt Beauty in North East Victoria. Mt Beauty in the Kiewa Valley is 84 kilometres from Albury and a one Ahour drive from the Albury Base Hospital. Myrtleford in the Ovens Valley is 45 kilometres from Wangaratta. Bright is a further 29 kilometres from Myrtleford one hour east of Wangaratta. There is limited natural connection between Bright/Myrtleford and Mt Beauty, each being located in separate valleys separated by a mountain range and relating to different regional centres, Wangaratta and Wodonga respectively. This geographic structure has lead to the development of town focussed services, each with a basic service infrastructure and limited economic, social, or health service interaction35.

Bright has a long tourist tradition, whereas Myrtleford has an industry workforce based on farming (including significant tobacco growing) and timber harvesting. Mt Beauty is the base for the Kiewa Hydroelectricity Scheme of the 1960s and the (then) State Electricity Commission contributed significantly to the community infrastructure, including the hospital. Today Mt Beauty is mainly a service centre for the Falls Creek Ski Resort and rural industries.

Gundowring Glen Creek ALPINEALPINE SHIRESHIRE

Dederang Mudgeegonga Gundowring Upper Gapsted Barwidgee Creek Merriang Myrtleford Running Creek Estimated Resident Population Merriang South Ovens Rosewhite ( 1996 ABS Census ) Coral Bank Buffalo River 12,180 Persons Eurobin Nug Nug

Porepunkah Tawonga Bright Federal Electorate of Germantown Mount Beauty Freeburgh INDI Wandiligong Dandongadale

Smoko Bogong

Falls Creek Harrietville Victorian State Electorates of BENALLA ( Central Highlands ) BENAMBRA ( North Eastern ) Hotham Heights Dinner Plain

Figure 5.1 Alpine Health Service Catchment

The entire area is one of high tourist value, having some of the best scenic attractions in Victoria and attracting significant numbers of visitors throughout the year. In 1998 there were 300,000 visits to Mount Hotham and Dinner Plain alone, with the Alpine Shire attracting an estimated 2 million visits a year. There is a significant retirement population.

35 Alpine Health Annual Report 1999 p32

Multi-Purpose Services Program Evaluation 56 Alpine Health Multi-Purpose Service

The combination of geographic division, individual communities focus and high visitor numbers make service planning complex.

The estimated year 2000 Alpine Shire population, which aligns with Alpine Health's service catchment, is 13,046, making it considerably larger than that of the other Victorian Multi- Purpose Service catchments with populations of approximately 4,000. The population is expected to increase by 9.8% between 2001 and 2011, with 40% of the increase being in the over 65 years age group which currently stands at 15.5%.

Eighty eight per cent of the population was born in Australia, New Zealand or the United Kingdom, and 5% of households speak Italian at home. Over half (52.3%) of the 1996 Census population was recorded as being in receipt of less than $15,558 per annum.

5.2 History Prior to the Alpine Multi-Purpose Service, there were three small rural facilities - Myrtleford District War Memorial Hospital (25 acute beds and Barwidgee Lodge 30 bed nursing home), Bright District Hospital (9 acute beds and Hawthorn Village 40 bed hostel) and Tawonga District General Hospital, Mt Beauty (15 acute beds and Kiewa Valley House 20 bed nursing home) (Table 5.1). Each hospital included a district nursing base and (formerly called) day hospitals. Thus there were three hospitals and three residential aged care facilities providing three towns with a relatively self sufficient health and aged care service. However, with the introduction of case mix funding the financial viability of the two smaller hospitals at Bright and Mt Beauty became tenuous and it was apparent that significant reform was essential.

Table 5.1 Pre MPS Bed-based Service Profile, Alpine Bright Mt Beauty* Myrtleford* Acute 9 Acute 15Acute 22 Aged residential Aged residential Aged residential - nursing home - nursing home 20 - nursing home 30 - hostel 40 - hostel - hostel A range of primary care services was also available at these locations including alcohol & drug services, post acute care, Hospital in the Home and the Maternity Services Enhancement Scheme.

All of the hospitals were reported to have "fine traditions" and strong local historical links36. They provided basic acute care (Service 2 level for most procedures)37 and day surgery (supported by visiting specialist services and local trauma services). Home and Community Care services were mainly provided by the Alpine Shire38 and community health services were delivered by two sub regional services - Ovens and King Community Health Service based in Wangaratta and Upper Hume Community Health Service based in Wodonga. Each community health services includes Rural Allied Health Teams which service the Ovens and Kiewa Valleys and related areas. Community Aged Care Packages were managed through Community Options Wodonga and Community Options Wangaratta.

Prior to amalgamation, each of the agencies had its own Board of Management and the three large hospital based agencies had their own executive and management structures headed by a

36 Alpine Health Annual Report 1997 p2 37 Service levels are defined in Alpine Health Service Plan and Evidence Based Health Needs Assessment 1998 Volume 1 Service Plan 38 Alpine Health receives HACC funding but the majority is provided to the Shire.

Multi-Purpose Services Program Evaluation 57 Alpine Health Multi-Purpose Service

Chief Executive Officer/Director of Nursing (Bright). In addition there were management structures to provide service coordination and management across the smaller communities39. As of November 1996 the hospitals and their associated residential aged care facilities amalgamated under the Multi-Purpose Services Program. Neither Council provided HACC services nor the two community health services joined the service.

Alpine Health experienced a difficult commencement. The financial problems facing each of the amalgamating entities were carried into the new organisation and perpetuated through its first years. Eighteen months after commencement, the Alpine Health Treasurer reported that of an Andersen Consulting report had found that expected efficiency gains had not occurred, management/and nursing position reviews had not been undertaken, Alpine Health had been left responsible for MPS establishment costs and that significant losses were likely to continue.40 The 1998 deficit was $1.4 mil. However, by June 1999 a surplus of $244,349 was reported, due to additional Department of Human Services funding and workforce downsizing. The 1999/2000 deficit was $87,000 and whilst a surplus will occur over the next two years, this will be generated from capital redevelopment grants arising from a health facilities construction program and Alpine Health estimates the underlying recurrent deficit to be approximately $344,000.

"Alpine Health's history has been of an organisation that had a very early enthusiasm for and commitment to significant organisational change with the support of its local community. It then suffered a process of rapid decline in community, organisational and staff confidence."41

In its three year life Alpine Health has experienced considerable instability including a turnover of 25 staff (but a minor net gain in total staffing), changes to Board membership (with only one original member remaining), four Chief Executive Officers and the retention of only one of the original senior managers. Relationships with the13 general practitioners have also been difficult due to concern over acute bed rationalisation and reduced access to hospital facilities.

The Alpine Health model is examined within the context of this complex set of circumstances to identify the contributing factors to Multi-Purpose Service development. In particular, consideration is given to the pre-requisites that need to be met to optimise the model's effectiveness.

5.3 The Alpine Health MPS model 5.3.1 Structure and services The Alpine Health model is the outcome of two significant contiguous change strategies. Amalgamation was seen to be necessary for future health service sustainability, whilst at the same time the Multi-Purpose Service option presented an opportunity for a needs based health service based on a flexible funding model, with opportunities for broadening the service base.

The resultant model is reflective of the amalgamation strategy but not the development of a broadly based service system. Hence the service regime includes acute, aged care and limited community service programs provided by Alpine Health, linked to Home and Community

39 Alpine Health Submission to Multi-Purpose Services Program Review. August 2000 40 Alpine Health Annual Report 1998 p 7. 41 Alpine Health Submission, op cit., p5

Multi-Purpose Services Program Evaluation 58 Alpine Health Multi-Purpose Service

Care services provided by Local Government and community health services provided by two sub regional services, plus a range of other programs delivered by specialist providers.

Alpine Health is not a fully developed Multi-Purpose Service model. This evaluation does not focus on the reasons for non-amalgamation of the acute and residential aged care services with community health and home and community care services but seeks to determine how the arrangements function and to determine the effectiveness of a co-operative model compared to an integrated service model.

The Alpine Health Multi-Purpose Service has the following characteristics: • Integrated governance. The Alpine Health Board of Management initially included representatives from across the catchment, but it did not legislate for this to occur. It is now moving towards a skills based composition rather than area based representation.

• A program structure. The organisation is arranged into three main service programs, each with a Program Manager, and includes Acute Care, Aged Care and Community Services. There is also two support programs - Finance and Corporate Services and Quality and Accreditation Manager. The Program structure has provided a coordinated structure across the organisation and introduced a service planning and management skills base into the organisation that was previously lacking.

• Acute bed base. Acute services are provided from three facilities in Myrtleford, Bright and Mt Beauty. There are 30 acute beds compared to 46 pre-MPS acute beds, with reductions introduced in response to budget pressures and to better relate staffing profiles to actual demand. Bright campus has reduced its acute bed base from 9 to 5 but provided 4 high care beds for nursing home care, Mt Beauty campus (currently under redevelopment) will have reduced its acute beds from 15 to 10 and Myrtleford campus reduced acute beds from 25 to 15.

• Community services base. A Community Services Program has been established. It is of similar scope to the pre-MPS community services provided by the three hospitals and in includes district nursing, an allied health team, a Lifestyle Activities Program (diversional therapy to support community and residential day activities services) and an Early Parenting Service which emerged from a one year State pilot Maternity Services Enhancement Strategy and has been continued by Alpine Health. Most other primary health and community care services are delivered by Local Government or Community Health Service providers. The Alpine Health Community Services Program is gradually establishing an identity and developing relationships with other community health and home based service providers.

The Alpine Health model is best understood as a cooperative relationship between four main service providers. Alpine Health is understood by the community as the health service identity, but as observed above, it does not control all services (Figure 5.3).

Multi-Purpose Services Program Evaluation 59 Alpine Health Multi-Purpose Service

BOARD OF MANAGEMENT

SUB CEO VMO’s COMMITTEES

AGED ACUTE FINANCE & CORPORATE CARE CARE COMMUNITY SERVICES SERVICES

In-patient Services FINANCE CORPORATE
District
Residential
Theatre & Day SERVICES Services Procedures Nursing
Contract
Day
Obstetrics Nursing &
Food Services Activities
Accident &
Finance Home Care
Environmental
Residential Emergency
Payroll
Respite Services Respite
Ancillary Clinical
Human
Palliative
Purchasing
Volunteer Services Resources Care
Fleet Program
Diagnostic &
Health
Allied Management
Quality Assessment Informatio
Infection Control Health
Workcover, Assurance n
Client Services
Day Centre Risk
Education Manageme
Quality Activities Management Assurance
Quality & Insurance
Education Assurance
Information
Education Technology
Asset Management Figure 5.3 Alpine Health Organisational Structure
Contract Management
Occupational Health & Safety

Multi-Purpose Services Program Evaluation, Victoria 60 Alpine Health Multi-Purpose Service

SHIRE • HACC • M&CH

ALPINE HEALTH • acute • aged residential • some community services

OVENS & KING CHS UPPER HUME CHS • community health • community health

Figure 5.3 Alpine Health Service Relationships

This model has two essential characteristics: a) health and community services are delivered by four main providers and not one as in other Multi-Purpose Services. Alpine Health provides one sector of the health market (acute health aged care and a limited community services program), two community health services provide community based allied health and related services and the Shire Council provides most HACC services. b) there has been minimal change to the pre-MPS span of services. Improved coordination has improved within the services provided by Alpine Health but the model relies upon the establishment of cooperative arrangements between the other main health and community services providers to Alpine Shire.

This includes a developing range of co-operative arrangements. These include: • a health promotion and education program supported by funding from Alpine Health, Ovens and King Community Health Service and Alpine Shire. • contracting of the Wodonga Regional Health Service speech pathologist to Alpine Health It took 6 months to recruit a speech pathologist to Alpine Health and given similar problems for other providers, it was appropriate to extend the service to clients of other providers. • conversely, the Alpine Diabetes Educator will soon provide services to Wodonga Regional Health Services under a contract arrangement.

This approach demonstrates that if the amalgamation of all significant health and community services does not occur, then coordinated service delivery arrangements need to rely on agreements between participating agencies to achieve continuity of care. The success of this arrangement relies on the development of mutual trust between service providers, and in the longer term service amalgamations may occur, or alternatively, the co-operative model may the best that be obtained.

The down side for Alpine Health was the fact that the Multi-Purpose Service model was promoted to the community as a service improvement, but facility redevelopment is only now commencing three years later and in the meantime the community and general practitioners experienced acute bed reductions without commensurate health or community service developments. The Multi-

Multi-Purpose Services Program Evaluation, Victoria 61 Alpine Health Multi-Purpose Service

Purpose Service model in Alpine was unable to deliver tangible benefits from its inception and this delayed community approval which is only developing now.

Despite the structural problems, several service improvements have occurred. They include: • Improved health service sustainability. The Multi-Purpose Service pooled budget has assisted in the retention of acute services on all three sites, and financially assisted residential aged care services. It may have been difficult to sustain hospital services at their current level in Mt Beauty and possibly Bright without the Multi-Purpose Service model and the associated capital redevelopment grants.

• Flexible use of beds at Bright for respite care. Whilst there has been community concern about the 34% acute bed reductions, there remains capacity within the system with 84% bed occupancy rates, and there is an increased ability to provide respite according to need.

• More efficient use of staff resources. An acute theatre team has been developed and it has the capacity to move between sites according to need.

• Introduction of uniform quality assurance across sites. Prior to Alpine Health, Tawonga Hospital (Mt Beauty) had not been accredited for 26 years and there was different approaches to service quality. This has been replaced with a more comprehensive and integrated approach to quality assurance.

• Administrative efficiencies. Some triplicated administrative practices have been eliminated, including single contract purchasing. Common reporting practices are also being developed.

It is difficult, however, to determine whether some service developments are directly attributable to the Multi-Purpose Service model or to hospital amalgamations which could have occurred without the model.

5.3.2 Staff structure Alpine Health has a significant workforce of 137.48 EFT positions and 250 persons, which is reflective of its multi-campus structure and its catchment population. It is double the size of Far East Gippsland MPS workforce which is the next largest Multi-Purpose Service under Review. Over half of the workforce is nursing staff, compared to approximately 30% in other Multi-Purpose Services, and this serves to illustrate Alpine Health as fundamentally a health service.

The overall staffing profile has remained relatively consistent since its commencement, although there has been significant change of personnel. Nursing staff reductions have occurred as result of acute bed closures and some efficiencies have been achieved in administration. The total workforce size 1998/99 is similar to that of 1996/97.

Table 5.3 Alpine Health Workforce Changes (FTE) Staff 1996/97 1997/98 1998/99 Change Number % Number % Number % Number % Nursing 76.19 57.4 82.20 62.7 74.87 54.5 -1.29 -1.7 Hotel and allied 43.18 32.5 37.00 28.2 42.58 30.1 +0.58 +1.4 Administration 13.34 10.1 12.00 9.1 12.48 9.1 -0.86 -6.4 Medical support 0 0 0 0 7.55 5.5 +5.5 +550.0 Total 132.71 100 131.2 100 137.48 100 +1.78 +3.6

Multi-Purpose Services Program Evaluation, Victoria 62 Alpine Health Multi-Purpose Service

5.4 Service Effectiveness 5.4.1 Service targeting Alpine Health is progressively refining its approaches to service targeting. Senior staff expertise has improved with clear reporting arrangements to Program Managers and a broader application of application of service standards was reported.

The data set for Alpine Health is limited, with standardised analysis difficult to undertake due changes in reporting methods and the absence of an integrated data system which is now in the process of being developed. It is reported that data was not retained in the earlier years and methods of reporting information have varied. Data for Table 5.4 was developed for this Review and indicates broad trends in the reduction of acute and a consistent use of residential care beds.

Table 5.4 Alpine Health Service Activity Measures, 1997/98 to 1999/2000 1997/98 1998/99 1999/2000 ACUTE District Hospital (Myrtleford) Beds 25 15 15 Separations 1964 1328 799 Day Cases 713 n/a n/a Occupied bed days 8288 n/a 3924 Non admitted (Accident & Emergency) 2324 1533 1753 District Hospital (Bright) Beds 9 9 5 Separations 978 615 574 Day cases 399 n/a n/a Occupied bed days 3689 n/a 1975 Non admitted (Accident & Emergency) 2677 1588 District Hospital (Mt Beauty) Beds 15 10 10 Separations 1146 721 588 Day cases 429 n/a n/a Occupied bed days 3853 n/a 2233 Non admitted (Accident & Emergency) 1356 886 n/a Alpine Health Totals Separations 4088 2664 2409 Day cases 1541 1229 897 Occupied Bed Days 15830 n/a 8132 RESIDENTIAL AGED CARE Hawthorn Village-Bright Beds 40 40 40 Occupied bed days n/a 12877 11856 Barwidgee Lodge-Myrtleford Beds 30 30 30 Occupied bed days n/a 10489 10558 Kiewa Valley House-Mt Beauty Beds 20 20 20 Occupied bed days n/a 7000 6921 Bright Hospital Beds 0 0 4 Occupied bed days 0 0 998 Total Beds Occupied bed days ALLIED HEALTH (Outpatients) Physiotherapy (occasions of service) n/a Occupational therapy (occasions of service) 412 Podiatry (occasions of service) n/a Diabetes educator (occasions of service) 1030 Speech pathology 214 Community based or home services Physiotherapy (occasions of service) n/a Occupational therapy (occasions of service) n/a Podiatry (occasions of service) n/a Diabetes educator (occasions of service) n/a Speech pathology n/a n/a No data

Multi-Purpose Services Program Evaluation, Victoria 63 Alpine Health Multi-Purpose Service

Multi-Purpose Services Program Evaluation, Victoria 64 Alpine Health Multi-Purpose Service

5.5 Client impacts 5.5.1 Focus group A focus group session to explore perceptions of the Alpine Health service was well attended by representatives members from each of the main towns in the catchment and included Board members, community members, community health service executives, Alpine Shire Council and Department of Human Services Regional Office. The Alpine Health Chief Executive and Community Services Manager also participated in the discussion. A frank exchange of views was expressed, with positive learning outcomes being experienced for the group.

Perceptions of service availability The group ranked the availability of health and community services in the Alpine Shire as "moderate" to "high" (Figure 5.4). There was a clear awareness that services are provided by a range of agencies, with Alpine Health providing a coordinating role and identified by the community as the "health badge". There is, however, a perceived limited supply of allied health and particularly mental health services. Neighbourhood house program activities (a volunteer based service) were considered to be "fragmented". The absence of rehabilitation services was also observed, given that early discharge from regional hospitals back to local communities often requires extended rehabilitation support that is difficult to supply.

The availability of general practitioners was extensively discussed, with supply problems occurring at Myrtleford (due to the recent closure of a general practice clinic). Whilst general practitioner recruitment is not the responsibility of Alpine Health, the group identified this an Alpine Health issue given its high profile health service status. Participants suggested that the service system is often finely balanced and can easily upset by small changes, which are then reflected as significant community issue and Alpine Health often is often held responsible, irrespective of its authority to act.

It was considered that perceptions of service availability differed between various groups in the community. Local, older people are likely to perceive the range of services as sound, whereas some early retirees from urban centres moving into the area without family networks may consider the range of services to be sub optimal.

The overall issue for small rural communities was considered to be both the availability of services and an ability to provide those services to people in 38 settlements across the area.

Perceptions of service responsiveness to health/community needs The health and community needs of this community were generally considered by this group to be "moderately" well met, trending towards "poorly" (Figure 5.5). The focus group suggested that basic health and community needs were reasonably well met, but this declines as specialisation increases, the size of the group needing the service declines and the distance from main towns increases.

The group considered that a basic problem for Alpine Shire communities is that they are effectively located in two "cul de sacs", with Myrtleford and Bright in one valley and Mt Beauty in another. This geographic configuration makes it difficult to provide equity of service access. It was felt that services meet basic need well within the available resources but more service development is required.. Youth health needs, men's health and the needs of people requiring mental health services were identified as services requiring further attention.

Multi-Purpose Services Program Evaluation, Victoria 65 Alpine Health Multi-Purpose Service

How would you rate the availability of health and How well met are the health/community needs in community services in this community? this community?

80.00% 80.00%

60.00% 60.00%

40.00% 40.00%

20.00% 20.00%

0.00% 0.00% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW

Figure 5.4 Perceived service availability Figure 5.5 Extent to which health/community needs met

How would you rate the change in health and How easy is it to obtain the following services in community services in this community today, this community? compared to about five years ago?

100.00% 100.0%

80.00% 80.0%

60.00% 60.0%

40.00% 40.0%

20.00% 20.0%

0.00% 0.0% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW SIGNIFICANT MINOR DECLINE NO CHANGE IMPROVED SIGNIFICANT DON'T KNOW DECLINE IMP ROVED

Figure 5.6 Perceived ease of access Figure 5.7 Rated change between current services and five years previously

Access The focus group considered that services in Alpine Shire are "moderately" easy to access, with difficulty increasing with service specialisation (Figure 5.6). It was generally perceived that whilst access to services is high, there is continuing concern if one community has greater advantage than another, and this makes service rationalisation difficult in circumstances where total service availability is limited.

Consultation The availability of information about health and community services was generally considered to be "moderate". Brochures on individual services have been available and work is proceeding on a consolidated service profile. Also an Alpine Health information section is reported in the local paper each month including a President's report and information on any service developments.

Discussion also focussed on the extent to which the community had been involved when decision making when services were to be redeveloped. It was widely argued that the change had been externally imposed on the community and this had caused considerable angst, due to perceived loss of acute services. Those supporting the Multi-Purpose Service concept found that "it was difficult to sell" and that the process was exacerbated by slow decision making and uncertainty. In particular, community expectations were raised but then not met by positive service developments.

The Board, staff and community consider that new Multi-Purpose Services need education, clear program guidelines and support for an extended period following the commencement of major health and community service reforms. The Alpine community acknowledge they were unskilled to deliver the MPS reform, and that initial senior executive appointments were inadequate for them to successfully negotiate this development phase. In particular, it was considered that the inherent

Multi-Purpose Services Program Evaluation, Victoria 66 Alpine Health Multi-Purpose Service risks of combining three organisations, two of which had financial problems, can have implications across all parts of the new organisation.

Further complications were experienced by the need to relate to two levels of Government and to a range of program managers within the Departments. The group felt that more clarity of Departmental contact points and responsibility for all aspects of Multi-Purpose Services is required.

On-going consultation with the community occurs through Alpine Health focus groups in each community and newspaper articles.

Service improvements Overall, it was considered that services have improved since the introduction of the Multi-Purpose Service. When individual services were examined, however, some participants considered that there has been no recognisable change to most pre-MPS services, but advances have occurred in allied health service provision and, particularly in the development of relationships between key health and community service providers.

It was considered that service amalgamations of health, residential aged care, community health and home and community care faced formidable barriers in Alpine Shire. These included: • deep seated community suspicion about loss of services • the hospital amalgamation issues dominating the agenda of the day • the restructure of community health services immediately prior to the introduction of the Multi- Purpose Service meant that there was little interest from those organisations to enter another restructure process • the tradition of Local Government as the provider of certain services was well established and there no motivation to change the status quo • regional service funding streams made it difficult to capture part of those funds for the Alpine Shire alone • governance and management expertise to guide a major reform process was limited.

Multi-Purpose Services Model The Multi-Purpose Service was discussed from several perspectives. Most of the group considered that the Multi-Purpose Service model has "improved" health and community services in the Alpine community on all dimensions, except community control over services.

Management structures have clearly improved, with closer working relationships and a broader vision having developed across the three main communities. The model was considered to offer flexibility to respond to identified local community needs, but it was suggested that transition funding is desirable to fund the initial establishment costs of a Multi-Purpose Service. Multi- Purpose Services were also recognised as a sound basis for service innovation and this had been reflected in several Alpine Health initiatives such as the continuation of the maternity service enhancement strategy following the cessation of Commonwealth pilot funding.

Community control over services, however, was considered to have not changed It was suggested that the Multi-Purpose Service process had never been community driven and that this remains the case. The focus group considered it to have been a "top down" response to an acute health financial problem, which caused considerable anxiety for the community, but was accepted as a way out of a difficult problem.

The general consensus was that Alpine Health is now approaching a stable period following a period of tortuous development. Relationships between services are maturing, cooperation between communities has developed and service management improvements are developing.

Multi-Purpose Services Program Evaluation, Victoria 67 Alpine Health Multi-Purpose Service

5.5.2 Other evidence of client satisfaction Alpine Health has yet to develop an integrated client satisfaction reporting system. Individual program evaluations have occurred and include client surveys and focus groups relating to the Early Parenting Program. Similarly, the development of the Occupational Therapist and Speech Service was proceeded with a needs analysis. Other activities to assess client satisfaction and inform the community include initiatives such as public forums occur as required, as applied to the launch of the Alpine Health Palliative Care Volunteer Service. However, there a structured approach to client satisfaction assessment has yet to be developed.

5.6 Barriers to implementation 5.6.1 Development phase Significant difficulties were experienced during the Alpine Health development phase. Strong differences existed between doctors and the new service, hospital deficits placed pressures on the newly formed Board and negotiations with Government were attenuated leading to uncertainty.

A due diligence review had established that the three hospitals faced an uncertain future and the Multi-Purpose Service offer from Government provided an opportunity resolve that issue whilst also offering an opportunity for a more integrated approach to service provision. However, the range of services willing to amalgamate was limited. Local Government, which had recently undergone amalgamation with resulting service realignments, had little interest devolving services and the two community health services served which included catchments beyond Alpine Shire and saw limited benefit from severing part of their organisations. The proposed change was threatening to the existing organisations rather than reinforcing.

Thus it appears that the main motivation for the Multi-Purpose Service was to resolve an acute and aged residential care financial need. There was a hope and intention to broaden the service over time but the MPS commenced with many unresolved issues and a narrow service base. Issues of the day dominated the agenda over this period, with protracted negotiations in establishing the new legal structures, and long delays lead to "loss of enthusiasm for the concept by some of the community and other stakeholders"42. A new CEO was also not appointed for four months after the Multi-Purpose Service was gazetted and this further delayed the commencement of organisational restructuring. During this development phase, Alpine Health was to have three Chief Executives.

In addition significant general practitioner issues existed from the outset. In contrast with other remote rural communities which struggle to attract a general practitioner, the Alpine area has 13 general practitioners and hence issues such as medical practice viability, access to operating theatres, hospital procedures and patient management became major points of contention.

Furthermore a significant barrier during the Development Phase was the linking of a community problem (the viability of the small rural hospitals ) with a new service initiative (the introduction of a Multi-Purpose Service). Both issues became intertwined and lead to community opposition to the new service model because of perceived loss of acute services. When combined with other complicating factors such as governance and management insecurity, the new service delivery concept was compromised from the outset.

5.6.2 First triennium Developmental problems have continued over the past three years, although stability has now been achieved.

42 Alpine Health Annual Report 1997 p4

Multi-Purpose Services Program Evaluation, Victoria 68 Alpine Health Multi-Purpose Service

In particular, significant organisational change had to managed simultaneously with unresolved problems from the development phase. Strategic planning was required as part of the Agreement with Government and this activity had to occur in parallel with service delivery. The organisation found that it needed additional resources to manage both sets of tasks, and also new senior management skills that did not exist.

The organisation considered that it did not have a clear contact point with government Departments. Broad guidelines existed but there was a need for more direction and support on the development process. In particular, Alpine Health needed clearer lines of accountability to Government and consistent policy direction. For example, it is unclear whether the Commonwealth Aged Care Program's Complaints Resolution Scheme can be accessed if required.

5.6.3 On-going barriers The experience of Alpine Health identified three sets of on-going barriers for Multi-Purpose Services.

Achievement of long term viability. Alpine Health is primarily concerned that the cash out rates for aged care do not match the costs of an integrated ageing in place service and that this will progressively impact on the ability of the organisation to operate within its financial limits, to introduce more cost effective services and expand community based services.

Alpine Health submits that it currently has 34% of its high care residents above the RCS3 funding base and 54% of its low care residents above RCS7, although these classifications have not been independently validated. Alpine Health submits that this issue is affecting its ability to achieve a balanced budget.

Infrastructure costs to establish integrated information systems. Multi-Purpose Services need to develop and manage integrated reporting systems that encompass a wide range of services. The Alpine experience suggests that IT development costs and the need to attract the appropriate expertise are challenges for Multi-Purpose Services.

Funding to grow the business The Alpine Health experience demonstrates the problem of funding new information systems, undertaking evidence based needs assessment and developing strategic plans may requires resources beyond those of available from amalgamating organisations, unless restructuring cost savings can be immediately achieved. It was suggested that Multi-Purpose Services require "hump funding" to support newly established Multi-Purpose Services. For Alpine Health the Multi- Purpose Service cost savings have been difficult to obtain due to the guarantee to the community of retaining the three hospitals.

5.7 Issues for a multi site model The Alpine Health model clearly demonstrates issues for multi- site management. Whereas Mallee Track Health & Community Services consists of a dominant service centre (Ouyen) and three very small communities separated by considerable distances, Alpine Health is based on three communities of relatively similar size, each having the same infrastructure base of a hospital and residential aged care facility.

Because all hospitals are of similar importance to their communities hospital rationalisation is not tenable without severe community dislocation. Alpine Health has introduced some efficiency initiatives such as a mobile theatre team which moves between the towns on designated surgery days. It has also been possible to introduce uniform standards across the three sites.

Multi-Purpose Services Program Evaluation, Victoria 69 Alpine Health Multi-Purpose Service

However, Alpine Health has found it necessary to retain three service systems and has been unable to make significant cost reductions. Experience has also demonstrated the difficulty of modifying one part of the service system to achieve overall cost efficiencies. This is amply demonstrated by the situation in Myrtleford. Myrtleford War Memorial Hospital had been operating in surplus prior to the formation of the Multi-Purpose Service, compared to Bright and Tawonga Hospitals (Mt Beauty) Hospitals which were in deficit, and there was strong Myrtleford community resentment to Alpine Health potentially using "Myrtleford's funds" to support acute health services across the new organisational structure.

Alpine Health has found that it has to manage two conflicting sets of objectives. On the one had, it is seeking to develop an integrated health system, but on the other it must ensure that no services are lost to any one of the three main communities.

Thus the Board is managing a model that includes some elements of commonality overlaying the former structure of local facility ownership and control. This has been a difficult process but community acceptance of Alpine Health appears to be growing as the organisation moves from through the development phase.

Alpine Health has sought to keep the community informed and has worked to present a unified approach. The attainment of ACHS Accreditation in August 2000 is direct benefit of the process and the development of new facilities in all three towns further reinforces the community.

Overall, the multi site structure of Alpine Health was essential to launch the model, but the retention of site specific services has been retained and opportunities for service rationalisation and economies have not been realised.

5.8 Key Factors for Success 5.8.1 Alpine Health's Key Factors for Success Alpine Health identified four key factors for success of a Multi-Purpose Service, not all of which were met in its case.

• Community desire to change. Ideally, community support for the concept should exist. Support was developing at Alpine Health despite a continuing number of unresolved issues, but slow decision making and the failure to deliver facility redevelopment changes prior to or soon after staff restructuring occurred, lead to a dissipation of community enthusiasm. The Alpine Health experience suggests that effective strategic planning, transparent decision making, community involvement followed by implementation of positive service redevelopments should occur.

• Board leadership. The Board needs to be able to clearly articulate the benefits of change to the community and this requires skill, commitment and the selection of a Chief Executive Officer with the appropriate skills.

• Capital redevelopment funds. The Department of Human Services has committed $8.9 mil. to facility redevelopment across all three Alpine health campuses and this "cannot be underestimated as a powerful tool in changing people's perceptions of organisational role and their expectations of organisation service delivery."43

43 Alpine Health Submission, op cit., p8

Multi-Purpose Services Program Evaluation, Victoria 70 Alpine Health Multi-Purpose Service

• Effective relations with funding agencies The Alpine Health experience indicates the needs for clear program guidelines to support Multi- Purpose Services through their development phase. Newly formed Boards require considerable support from funding agencies beyond the gazettal of an Multi-Purpose Service, including the need for clear program guidelines and reporting arrangements.

5.8.2 Quality Assurance Alpine Health received Australian Council on Healthcare Standards EQuIP Accreditation in August 2000.

The Surveyors found that "the first few years of the new organisation have been difficult and it has faced a huge number of teething difficulties. …..The current Senior Management team including the Board of Management has really been in place for less than 12 months and its focus has been primarily that of establishing the infrastructure necessary to run a new organisation. ….. It can be seen that the focus of the organisation has really been on the infrastructure necessary for a new and modern health care organisation to become established and to survive in the environment. Substantial progress has been made in developing and implementing this infrastructure. ….Because of the use of the organisation, Alpine Health still has great strides to be made, but change is occurring and this can be seen in every facet of the operation of Alpine Health."

The ACHSA ratings for the Alpine Health services indicate "moderate achievement" on a 5 point scale that includes "little achievement", "some achievement", "moderate achievement", "extensive achievement", and "achievement with commendation." (Table 5.5).

Table 5.5 Alpine Health EQuIP Overview Function summary Rating Surveyors' Comments Continuum of care Moderate Achievement Operational and strategic plans have been developed to guide service delivery. Leadership and management Moderate Achievement Rating of MA is well deserved. Human resource management Moderate Achievement Staff orientations programs, job descriptions and policy and documentation guide in place. Information management Moderate Achievement Information technology is expanding rapidly. Safe practice and environment Moderate Achievement The surveyors were impressed with the high standard of commitment and professionalism. Improving performance Moderate Achievement The quality improvement program is achieving significant improvements. Source: Report of the Organisation- wide Survey for the ACHS Evaluation and Quality Improvement Program, Alpine Health 11-14 July 2000

5.9 Overview Alpine Health represents a most important case study for the Multi-Purpose Service Program Evaluation.

The main conclusion is that Alpine Health is not a Multi-Purpose Service within the concept of the model, but this finding ought not to be interpreted in terms of failure or inappropriateness. It means that the service needs to be evaluated within its own cultural context and it has emerged as a hybrid model including some Multi-Purpose Service features but retaining the dimensions of an amalgamated generic service. To understand the influences that lead to the formation of the Alpine Health service, consideration needs to be given to the pre-conditions that existed in the other Multi-Purpose Services under Review but did not fully apply to Alpine.

First, the model works best in small communities where service structures are relatively simple and individual services have difficulty in optimising their roles as stand alone operations. Secondly, a primary prerequisite for an effective Multi-Purpose Service is the existence of a single set of health

Multi-Purpose Services Program Evaluation, Victoria 71 Alpine Health Multi-Purpose Service and community services prior to the reform process. The catchment area should include a core set of services that includes a hospital, residential aged care facility (low and high), community health service and Home and Community Care services. Thirdly, service delivery boundaries should ideally coincide as this provides a common focus and facilitates amalgamation.. Fourthly, the potential should exist to deliver improved services for a common community.

The Alpine Shire catchment did not meet most these pre-conditions. Certainly, the area is rural and it is remote from main service providers. The existing services were also small, there were multiple management committees, service budgets offered limited opportunity for service development and the opportunities for population based planning were limited due to the multiple funding arrangements linked to individual programs.

However, other key pre-conditions either did not exist or were in conflict with the Multi-Purpose Service model.

These include the following: • Relatively large and heterogeneous catchment The total population base was relatively large and this created complexities that do not occur elsewhere. While the overall population is relatively small in a regional sense, the Alpine catchment is approximately four times larger than the other MPS catchments under review. There are also other complicating features such as a large transient population, including the State's most popular attractions for winter sports, attracting an estimated 2 million people per year. The area is also a major tourist destination over autumn spring, and summer for people attracted by its high scenic values. Thus Alpine Shire is a both a dormitory area plus a major tourist destination and has the characteristics of both a rural community and a major holiday destination. This brings with it a range of transient populations, high service expectations, retirement households used to urban service regimes and significant commercial enterprises requiring a sound community infrastructure of which health services are a key component.

• Multiple communities There is also considerable variation within the configuration of the catchment. The Alpine Shire contains three separate communities each of which have developed their own services and distinct characteristics. Myrtleford is the commercial centre based on a tobacco farming, other intensive agriculture and timber milling Bright is the local government, tourist accommodation and restaurant centre, and Mt Beauty has a history of a company town based on hydroelectricity generation and as a service centre for Falls Creek Ski Resort. In addition these communities were previously located within two Local Government Areas and had developed identities, loyalties and community networks related to their municipalities. They are located in two separate valleys and their transport networks link to different regional cities. These differences developed distinct community identities and ownership of community services (particularly the hospitals) which were threatened, rather than supported by a model based on service amalgamation.

• Multiple health services of the same kind existed. There were three substantial hospitals, compared to other Multi-Purpose Services that have either one hospital or where there is one hospital and related bush nursing centres. In Alpine Shire each hospital had its own VMOs and nursing staff living in the town and Ladies Auxiliaries and other support structures . They provided stable employment opportunities to over 200 people and attracted intense community loyalties. It is very challenging to introduce a redistributive model into such an environment. Guarantees were made to retain the three hospitals and related residential aged care facilities but this limited the capacity of the combined service to achieve cost savings that otherwise can be achieved in areas where the service regime is less complex.

Multi-Purpose Services Program Evaluation, Victoria 72 Alpine Health Multi-Purpose Service

• Discontiguous service catchment The absence of this fundamental pre-condition has been a major barrier to the realisation of the Multi-Purpose Service model in Alpine Shire. There is alignment between the Alpine Health catchment and the Local Government boundary (and this offers considerable potential for future service amalgamation between health and community services). However, community health service catchments are not common with the two community health services based at Wangaratta and Wodonga linked to the Ovens and Kiewa Valleys respectively. In addition each community health service has catchments extending beyond parts of the Alpine Shire. This meant that the Alpine Health Multi-Purpose Service model had to be built as a co-operative model rather than an integrated service.

• Community benefit not easily achieved For the Multi-Purpose Service model to be successful basic community support should exist. At minimum the community needs to see the potential for improvement to services. In the case of Alpine a base acceptance for the change was tolerated given the promise of the retention of the three hospitals, new buildings and service developments. However, the community believes that the process was driven by external pressures to change, or lose the community may have lost its hospital services. In addition any early enthusiasm for the MPS model was dissipated due the complexities and debates surrounding financial issues leading (after 18 months) to an external financial review with consequent staff reductions and bed closures and no tangible evidence of service expansion. For Multi-Purpose Services to be successful benefits or the potential for service improvements need to be delivered as soon as possible. After three years of operation at Alpine Health the community is only now seeing benefits with facility redevelopments occurring at Myrtleford and Mt Beauty.

• General practitioner support The role of general practitioners must be given due consideration. Whilst Alpine Health experienced similar problems to that of other Multi-Purpose Services, it was further complicated by the number of general practitioners (13 compared to 2 or 3 in other Multi-Purpose Services) linked to the three hospitals. Bed reductions and reduced access to facilities to perform procedures has been a significant factor for doctors, who have reported no basic change in the health service system.

• Management expertise Management expertise during the development phase of a Multi-Purpose Service is also a desirable pre-condition for Multi-Purpose Service implementation. Alpine Health shares this limitation with other Multi-Purpose Services. There were changes to the Board, four Chief Executive Officers and a change of nearly all senior staff positions in the period following the initiation of the MPS and this contributed to instability. The Multi-Purpose Service model is based on integrated needs based planning, strategic plans and service plans, accompanied by an effective management information system and requires skilled executive management expertise and a supportive Board.

This combination of factors has resulted in Alpine Health being a hybrid model. Alpine Health is the key provider in Alpine Shire but it is uses a horizontal structure to link across Council services, two community health services and Division of General Practice, rather than the vertically integrated model of fully developed Multi-Purpose Services.

The future of Alpine Health relies on acceptance and further understanding of the service system that exists in the Alpine Shire. In the 1999 Alpine Health Annual Report the Chief Executive Officer noted observed that "Alpine Health is now back at the starting gate in respect to MPS development." and this Review finds that this is the case.

Multi-Purpose Services Program Evaluation, Victoria 73 Alpine Health Multi-Purpose Service

The following developments are required for Alpine Health to realise its full potential:

1. A stable recurrent funding environment must be established. The problem of continuing operational deficits suggests that strategic intervention may be required, including further consideration of the method of funding. It will not be possible to realise service development objectives unless a secure long-term financial base is established.

2. A service planning framework that links all services within Alpine Shire needs to be formalised. Protocol developments has commenced between Alpine Health and other service providers and this process needs to be expanded to include a mapping of all service provider roles and the development of an integrated service system with its associated control mechanisms and management information system.

3. Facility redevelopment should proceed as soon as practicable in all three towns. The community needs to see tangible benefits of health and community services, following this extended period of uncertainty. The commencement of facility redevelopment Myrtleford, Mt Beauty and Bright offers an opportunity to firmly establish Alpine Health and the opportunity to link facility developments to systems development needs to be taken.

4. The community services base of Alpine Health needs to be broadened. The pre and post MPS service structures have not fundamentally changed mainly due to the inability to fund service diversifications and unclear service regimes between providers. In particular there is a need to develop an integrated community health services plan between Alpine Health, Ovens & King Community Health Service and Upper Hume Community Health Service. Specific issues for Alpine Health to consider include expansion of its District Nursing service and attention to significant service gaps, particularly mental health services.

5. Medium term consideration should be given to bringing HACC services under the Alpine Health. Given the past experience of territoriality and suspicion associated with service change, there is a need for a positive change strategy to be developed, commencing with dialogue, clear service planning and the identification of the benefits, including demonstration of integrated individual care planning. Consideration should be given to developing a district nursing service development and HACC service integration at the same time. There are signs that the conditions for such developments may be favourable in the very near future.

6. Priority needs to be given to the development of planning, reporting and accountability systems to underpin the service system. Further work is required to develop these processes into a fully operational system. Work is commencing on electronic tracking of medical records, more sophisticated data and activity monitoring and reporting and the development of communication links with general practitioners and community service providers. It would be highly desirable to have a comprehensive information system established by June 2001.

There is limited benefit in comparing Alpine Health to other Multi-Purpose Services at this time as it has been established under different conditions. The future of Alpine Health will be different to that of other Multi-Purpose Services and needs to be understood within its own community parameters. The short term challenge for Alpine Health is to establish systems that are capable of delivering and measuring effective outcomes and in the medium term to develop seamless, but formal service relationships with complementary service providers. A vertically integrated Multi- Purpose Service is unlikely to be achievable, but an effective horizontally integrated service is a reasonable objective.

Multi-Purpose Services Program Evaluation, Victoria 74 Alpine Health Multi-Purpose Service

Alpine Health is an instructive case study for the Multi-Purpose Service Program evaluation. It claries the principles for Multi-Purpose Service model application and in particular the pre- conditions that should be met for when a new Multi-Purpose Service is established.

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6. Upper Murray Multi-Purpose Service - integration with a population health focus

6.1 Service catchment pper Murray Health & Community Services is located at Corryong in north west Victoria 140 kilometres from the nearest regional centre at Albury-Wodonga. The main centres are U Corryong, Walwa, Khancoban (NSW) and Cudgewa, in an area bordered by the Kosciusko National Park and incorporating the Wabba Wilderness area and Burrowa Mountain Pine National Park. It is an isolated area of high scenic value, the main activities are rural production.

The regional population is 3,264, with the estimated population of Walwa being 150, and Jingellic across the border in NSW has a population of 100. Khancoban has approximately 500 residents and is a town based largely on several facilities developed by the Snowy Mountains Authority. A further 1200 people live within 5 kilometres of Corryong. (The local catchment is now part of the larger Shire of Towong which includes both Corryong and Tallangatta 82 kilometres to the west and has a population of 6,103).

Figure 6.1 Upper Murray Health & Community Services Catchment

The population of the Upper Murray catchment declined by 130 between 1991 and 1996. Upper Murray is considered to be an older community, relative to surrounding municipalities. Fourteen per cent of the population is over 65 years compared to 11.7% for the State.

A high proportion (87.8%) of the population is Australian born and 93.8% have Australian citizenship. Ninety five per cent of the population speak English at home compared to 72.2% for the State.

Multi-Purpose Services Program Evaluation, Victoria 76 Upper Murray Multi-Purpose Service

Based on the Socio-economic Indices, Corryong is the most disadvantaged area in the Upper Murray catchment.

6.2 History The Victorian Cottage Hospital was established in Corryong in 1916, with beds numbers increasing to 42 in the 1960s and then declining to 15 immediately prior to the formation of the Upper Murray Multi-Purpose Service.

The Upper Murray Nursing Home, opened in 1983, and immediately prior to the introduction of the Multi-Purpose Service it included 20 high care places and an Adult Day Therapy Centre (full time physiotherapy, part time occupational therapy). Allied health staff from the hospital only visited community clients upon a doctor's or ACAT referral. Other allied health services (podiatry, dietician and psychiatric nurses) regularly visited the area. District nurses had provided general nursing care and home based palliative care five days a week. Corryong Ambulance also provided a 24 hour emergency transport service to and from hospitals and operated with three staff.

The Walwa Bush Nursing Hospital also provided 9 private beds and 24 hour emergency care for the Walwa and Jingellic (NSW) communities. The community centre/neighbourhood house supported a coordinator 20 hours a week to provide community development activities including women's health camps, holiday programs and other activities.

In addition there was a significant number of regional services visiting the area on a regular or as needed basis. There was no locally based Community Health Centre, with the nearest services being available through Wodonga. Corryong Community Centre did, however, provide a local community education focus.

HACC services and the Maternal and Child Health service were provided by Council.

The Upper Murray Health & Community Services Multi-Purpose Service commenced in July 1995 and by November 1996, a new 15 bed hostel and 20 bed nursing home had been developed and the west wing of the hospital refurbished. In December 1996 HACC services transferred from the Shire of Towong.

This service profile included all of the significant health and community services. Within one year of commencement of the Multi-Purpose Service the following services were delivered by the Upper Murray Health & Community Services: acute care (including surgical and maternity), residential aged care, allied health, district nursing, health promotion (diabetic education, asthma education), day care, palliative care (coordinator 4 hours per fortnight) and HACC services, community transport.

Partnerships were developed with other services (such as Upper Hume Family Care which provided a counselling service) and coordination arrangements were made with 12 visiting services ranging from dietetics, podiatry, psychiatric services to Aged Care Assessment Service, Rural Allied Health Team and others.

6.3 The Upper Murray Health & Community Services MPS model The Upper Murray Health & Community Services approach is not fundamentally different to that of other well developed Multi-Purpose Services. It has a population health focus, it is based on consumer participation strategies, point of entry advocacy, continuing care and multidisciplinary/multiservice assessment and care planning. But it differs in the extent to which the concepts have been operationalised and integrated.

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Upper Murray Health & Community Services approach represents a high level of sophistication.

This outcome is due to three main factors: • the extent of adherence to a population health model. The Multi-Purpose Service Program facilitates a population health approach and Upper Murray Health & Community Services has sought to fully incorporate all of the principles into its practices.

• catchment size and characteristics. This isolated rural area located in a geographic cul de sac included all of the components needed for an integrated service including acute, residential aged care and HACC, and access to a community health service. It is a self contained area, without overlapping service catchments. It also has a small population, with one significant township (Corryong). The one additional factor is the town of Walwa where there is a Bush Nursing Hospital and its own general practitioner, but the Multi-Purpose Service has been a benefit rather than in conflict with this structure..

• management vision. The Upper Murray Health & Community Services Board and management have been able to progressively understand the potential of the model and develop its full potential.

This combination of factors has provided a comprehensive demonstration of one approach to implementing a Multi-Purpose Service for the benefit of rural communities.

Whilst it is possible to identify the main components of the Upper Murray approach, it is important to also appreciate how these translate into benefits for each member of the community, and these are more difficult to fully appreciate. Nevertheless, it is appropriate with three brief case studies of the benefits of the integrated and flexible care approach for consumers as a basis for understanding the model developed by Upper Murray Health & Community Services.

Case 1* Mrs X, an 85 year old frail person was admitted to acute care with a bleeding bowel and following assessment was transferred to Albury Base Hospital where she underwent abdominal surgery, and during her hospital admission suffered a CVA. Whilst in hospital, the Multi-Purpose Service outlined the services that were available in the local community and developed a plan for on-going support. Mrs X was returned to Corryong as a bed fast, frail person, with limited confidence. Using the Continuum of Care program approach, a team meeting identified possible supports and the service commenced physiotherapy and also commenced counselling work with the grieving family. Assessments and interventions were taken to address issues related to wound infection and continence. Mrs X was transferred to the low care aged residential unit and continued with occasional day care. Occasional day leave to home was also provided as a means of building the confidence of Mrs X and her family. Later, Mrs X returned home and visits were made by the occupational therapist and district nurse. Mrs X's was also supported with shopping and transport to day care. Later her elderly husband was offered respite and taken on a fishing day whilst his wife was supported at home. Mrs X is now relatively active and a part of the community.

Whilst many elements of this case study are common to other services, it demonstrates how an integrated approach is facilitated by the Multi-Purpose Service model and more particularly by an extension of the chain of support beyond residential care. A more conventional approach may have concluded with Mrs X remaining in residential care.

* An abbreviated version of the case, only.

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This case study demonstrates the following elements: - consistency of approach at any point of entry to the service - an integrated service approach - service flexibility - timely services - an ability to respond with all appropriate services - a commitment to home based care of that is the consumer's wish

Case 2: A resident of the nursing home required dentures which the family could not afford. Upper Murray Health & Community Services arranged and paid for that service from its pooled service budget.

This minor example, demonstrates the ability of the model to respond to individual needs without significant administrative complexities or referral to other services.

Case 3 The nursing home residents have recently been asked if they would like to go away for a holiday, and investigations are currently underway to determine how this might be arranged. This case also illustrates how a flexible service can focus more on outcomes than arranging on sources of funding.

The model that facilitates these responses includes the following elements44:

Population health perspective The Upper Murray model demonstrates an understanding and commitment to population health planning. It both recognises and operationalises the Ottawa Charter which identifies health promotion to include building health public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services. The model also adopts a comprehensive primary health care system approach as reinforced by the 1990 AHMAC Rural Health Care Taskforce report in Australia to include treatment, preventative services, health promotion, rehabilitation and local community needs based service development. The Upper Murray Health & Community Services also reflects primary health principles of the Health Horizons report of the Commonwealth Department of Health and Community Services45. In particular Upper Murray Health & Community Services has a commitment to local democracy, which seeks to respond to the individual and the community as the primary drivers of the service system. The adoption of a local democracy approach is defining element of the Upper Murray Health & Community Services approach.

Evidence Based Needs Assessment46 Upper Murray Health & Community Services uses an evidence based approach to identify the health needs of the community. The approach is as rigorously applied as possible and is being continually refined.

44 An introduction to the approach used by the Upper Murray Health & Community Services is included in: Hoodless M., and Evans F., The Multi-Purpose Service Program: the best health service option for rural Australia Primary Care 2000. Second International Conference Melbourne April 2000. This section draws from that paper and consultations with the author and other Upper Murray Health & Community Services staff and documentation. 45 Department of Health and Community Care, Healthy Horizon, a Health Framework for Rural Regional and Remote Australians, 1999-2003 46 The initial approach is fully described in, Evans F., Hoodless M., Dare L., and McGowan C., Upper Murray Health & Community Services Evidence Based Needs Assessment 1997. UMH&CS 1997 See also Upper Murray Health & Community Services - A Multi-Purpose Service Powerpoint presentation September 2000. (Source: Frank Evans CEO)

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This needs assessment conducted by UMH&CS between May and November 1997 was conducted in six stages and involved: 1. the development of a demographic profile of the UMH&CS catchment and identification of the relationships between demographics and health status; 2. an epidemiological study of the UMH&CS catchment focusing on the national priority areas of cancer, cardiovascular disease, injury and mental health and other areas of significance that relate to rural or local population characteristics or areas of state or national focus such as diabetes and asthma; 3. the identification and evidence of effective and cost effective services with the greatest potential to improve health; 4. community consultation providing a high level of information relating to the above and seeking feedback on local service priorities; 5. a comparison between current service programs and models of service delivery within programs and identified “best practice” models and services and community identified service priorities; and 6. a plan for future service provision based on the information obtained in stages one to five.

Evidence Based Epidemiological Practice High Prevention & Socio High Support Demographic Based Model Profile

Community Consultation

Figure 6.2 Upper Murray Health & Community Services Evidence Based Needs Assessment Model

In order to provide an evidence base, case studies were also undertaken into particular conditions that had been identified as high priority. For example a cardio-vascular case study found that compared to Victoria, 33% more males and 57% more females were admitted to hospital due to cardio-vascular disease and that 185% more females died prematurely from ischaemic heart disease. This form of evidence provides an effective basis for resource allocation and the establishment of health service priorities. It also provides a basis for proven effective health service delivery practice.

• Community consultation Community consultations included five community meetings, focus groups and individual interviews. Each community meeting included: - a survey of knowledge and perceptions of health - presentation of research evidence as it applied to the Upper Murray - facilitated discussions - service prioritising using a voting system.

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Using this process, the community developed its own priorities for the Upper Murray Multi- Purpose Service. The Board accepted the community's priorities and established a community reference group to advise on health projects

A second needs assessment is currently commencing and is introducing some changes based on learnings from the 1997 approach. It has been found that the most effective health promotion mode is key people involved in the community activities, as opposed to more conventional forms such as newspaper advertisements. To this end the community is now directly involved in the needs assessment process.

The organisation is increasingly committed to power sharing and responding to the community on its own terms. It is also learning how to undertake consultation without influencing the process or predetermining the outcomes. Hence, members of the Community Liaison Group (2 Board, 3 staff and 13 community members) are currently being trained in social research techniques, (supported by a $30,000 budget from the MPS pooled funds) and assisted by a La Trobe University researcher) and they will undertake much of the community needs identification. LaTrobe University staff will analyse the results and assist in the process. The objective is to ensure that the community maximises more control over its own health and community support services.

The outcomes of the needs assessment are directly and specifically linked to the Upper Murray Health & Community Services Corporate Plan. That plan identifies service delivery, financial, personnel and asset management performance measures for three forward years (and compares them to actual performance for the previous year). For example, a stated financial target for 2000/01 is less than 2% variance for the operating budget, and the Personnel measure there is to be >90% compliance with the Continuing Education Program. The Corporate Plan also includes strategies to achieve objectives in five key operational areas and separate Operational Plans for Services, Finance, Continuing Education, Quality Management and Support Services.

There is also a range of initiatives, processes and staff positions that elaborate on this summary overview of the model. Examples of these are provided to illustrate the breadth and depth of Upper Murray Health & Community Services.

The Upper Murray Health & Community Services now understands and can demonstrate that the high prevention, high support approach will make a difference to their community. This high support model provides options that are client focussed, acceptable, accessible and appropriate. To facilitate this process the staff member at the first point of entry to the service is an advocate for consumer and facilitates access to the person's assessed and preferred needs, and those of the carer and family, and ensures that services are coordinated, case managed, appropriately referred and sensitive to specific needs47. Previously qualitative needs assessment techniques of the type that asks the community "what do you need?" have been replaced with evidence based approach that provides an informed basis for service needs identification.

Staff development Upper Murray Health & Community Services places a major emphasis on team work and in the development of staff skills and staff initiative. Program Managers negotiate their budget and are given maximum responsibility to manage and make decisions relating to the service. This highly devolved structure empowers the entire workforce. Hierarchical structures have been reduced to an absolute minimum and staff operate across several program areas. Staff take responsibility across a wide range of functions and there are only 2.5 identified administrative positions in the workforce

47 Upper Murray Health & Community Services Powerpoint presentation, ibid.,

Multi-Purpose Services Program Evaluation, Victoria 81 Upper Murray Multi-Purpose Service of 63 EFT. This places additional pressures on staff but it reinforces equality, teamwork and individual responsibility.

All staff are encouraged to set their own continuous training objectives according to their own interests and needs and not those set by the organisation. These are complemented with compulsory/legislated training requirements to ensure legal conformance of services. These needs are translated into a three year Training & Development Plan which defines the number of staff to participate in each program. The interesting aspect of this program is its extent of application for a service of this size. It identifies 68 training and development activities and encompasses everyone from Board members to maintenance and grounds staff. A further interesting dimension is that staff are given the choice of developing skills outside their own roles, if they choose to do so.

The organisation develops staff skills and trust, but also seeks to provide direct benefit to staff members where possible. For example, financial accounting was primarily outsourced, but as a staff member increased her skills and tasks were transferred back to the organisation, part of the cost saving was passed onto the staff member in direct proportion to savings.

There is also a commitment to staff and community fitness and health. Upper Murray Health & Community Services has invested in gymnasium equipment and established a basic room for staff and some members of the public to use on a trust, self monitored basis. Currently there are 98 uses of the gym a week and it has provided to be of benefit to groups such as youth in this country town where there are limited health and fitness options. Staff have been offered one hour paid time a week to participate in personal exercise. Because some staff (such as acute nurses) are unable to find the time within work hours, preliminary investigation is being given to the concept of paying them for an additional hour per week so that they might also participate in a fitness program of their choice. This has a cost implication for the organisation but is an important part of the commitment to inclusive team work across the organisation and it reinforces the value that the organisation places in its staff. Without the Multi-Purpose Service model, such an initiative would not be possible.

6.3.2 Services Upper Murray Health & Community Services is based on 10 acute beds, 1 palliative care unit (used for a range of purposes according to need), 1 high dependency bed, 18 high care and 15 low care aged residential beds, all in the same facility complex, with adjoining doors to demarcate the uses. The pre and post MPS range of services is shown in Table 6.1. All community services are integrated into the service.

The community health service was previously a component of the Upper Hume Community Health Service but given that only 0.5EFT ($12,000) was allocated to the Corryong area, arrangements were made to transfer a proportion of the budget to Upper Murray Health & Community Services and guarantees of access to regional services be maintained.

The general practice service is integrated into the service with three salaried Medical Officers.

The only exceptions are the Ambulance Service which remains a part of the North Eastern Ambulance Service, but the staff participate in the Upper Murray programs and use the facilities as needed. Maternal and Child Health remains with the Shire of Towong.

Upper Murray Health & Community Services provides a one stop shop for all visiting services, thereby encouraging those services to come to Corryong and provide services at a known contact point.

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Table 6.1 Upper Murray Pre and Post MPS Service Profiles Pre MPS Post MPS (1999) Acute services: (18 beds) Acute services: (10 beds) - general medicine - general medicine - accident & emergency - accident & emergency - maternity - maternity - surgery - minor procedural, diagnostic and - surgery - minor procedural, diagnostic and intermediate intermediate level general surgery, gynaecology level general surgery and gynaecology Residential services: Residential services: - nursing home (20) - nursing home (20) - hostel (15) District nursing General practice medicine & nursing Women's health

Community services and allied health: Community services and allied health: - physiotherapy (inpatient and outpatient) - Physiotherapy (inpatient, outpatient, community) - occupational therapy (inpatient, outpatient) - Occupational therapy (inpatient, outpatient, community) - day care - Day care - Care coordination (inpatient and community) - Allied health assistant - Podiatry - Speech therapy - Dietetics - Family counselling/social work - Community transport - Palliative care Home and Community Care Home and Community Care (delivered by Council) - Home care - Home maintenance - Meals on wheels - Social support - Adult day activities - Senior citizens Health Promotion Community development Public Health Cardiac rehabilitation Childbirth education Asthma education Diabetes education VISITING COMMUNITY SERVICES Audiology, Optometry, Child and Adolescent Mental Health, Rural and Domestic Financial Counselling, Drug and Alcohol Withdrawal Service, Families with Dementia Counselling Service, (Brokerage Services - Community Options, Villa Maria, Carer’s Respite, CoNect), Maternal & Child Health, Rural Allied Health Team, Wodonga Psychiatric Services, drug & alcohol counselling, Aged Psychiatry Assessment and Treatment service, domestic violence support, remedial sports therapist, women's health nurse practitioner, ACAS, low vision clinic.

6.4 Service Effectiveness 6.4.1 Service targeting The targeting of services in the Upper Murray Health & Community Services is a foundational element of the Multi-Purpose Service model. The span of services has expanded since its inception and it is continuously expanding.

The salaried Medical Officer model used by Upper Murray Health & Community Services contributes to equity of access, although there remains community differences with the service due to a difficult change process in which the former private practice general practitioners decided not to participate in the service. The current model is based on bulk billing and permits members of the community to access general practitioner services, which is estimated to return cost savings of $150,000 per annum to the community. Other identified benefits from this arrangement include

Multi-Purpose Services Program Evaluation, Victoria 83 Upper Murray Multi-Purpose Service increased responsiveness to community needs, improved ability to care for the older people, increased accountability for health to the community and an improved opportunity to evaluate health outcomes48. It also expands opportunities for general practitioners to participate in public health and health promotion programs. The medical clinic is also supported by Clinical Nurse Practitioners which assists with the provision of appropriate support according to the needs of patients. Service access is reinforced by the highly consultative and local democracy model adopted by the Upper Murray Health & Community Services.

6.4.2 Access Improved access to services is demonstrated by the availability of an enviable range of services for a small, isolated rural community. Whilst the level of specialist service provision is not that of an urban centre, the primary health system is exceptional in its scope and depth. Access to specialist services is facilitated according to need. The Upper Murray Health & Community Services also has a well established volunteer program involving 150 community members across a wide range of services. This further assists service access. A community vehicle is also available to assist with the significant transport demand.

Table 6.2 Upper Murray Health & Community Services Service Indicators Services 1994/95 1995/96 1999/2000 Acute care Beds 18 15 10

Inpatients treated 674 760 474 Same day establishment Occupied bed days 4086 3046 1844 % occupancy 62.19 55.63 50.52 Accident and emergency 2336 2625 1122 Residential care - High 20 20 20 No. of places Occupied bed days 7220 6770 4486 Low No. of places Nil Nil 15 Occupied bed days - - 2986 General practice medicine & nursing (occasions) N/A N/A 12991 Women’s heath (occasions) N/A N/A Part of above Community services and allied health:* (occasions) - Physiotherapy - Occupational therapy 447 1321 - Care coordination see above 835 - District nursing 2027 see above - Podiatry 2582 - Speech therapy 187 - Dietetics 59 - Family counselling/social work 29 - Allied health assistant 650 - Community transport 1600 - Palliative care 271 387 - Health promotion 83 2266 Home and Community Care - home care 6790 - home maintenance see above - meals on wheels 2876 3830 - adult day activities 4076 4993 - senior citizens- 14 Health Promotion Officer (days per week) 0.0 0.5 5.5 Public Health Officer (days p.w) 0.0 0.0 1.67 Cardiac rehabilitation (occasions) 17 Child birth education (occasions) 14 Asthma education (groups) 8 Diabetes education (groups) 1 Total 10603 13708 34948 * inpatient, outpatient and community as appropriate

48 ibid.

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Appropriate service provision is a further dimension of the model and the use of bed based services clearly demonstrates this approach. Acute beds have been reduced and community services expanded significantly. Access to acute beds remains high with average occupancy being 50%, but with considerable fluctuations according to need. There is no readily available evidence of upstreaming acute services to other hospitals. The number of births at the Corryong facility has declined as more people choose to access larger hospitals and the birth rate declines, but conversely there is higher return of patients to the local hospital from case mix based acute providers.

Management of the aged care beds is a further demonstration of the flexibility of the Multi-Purpose Service model. Given that there is no financial necessity to maintain high occupancy (except to optimise resident fee levels), the Multi-Purpose Service model allows for the most appropriate service to be offered to a client without financial penalty to the service provider. Hence, Upper Murray Health & Community Services currently has 12 high care residents being supported at home and 8 high care residential aged care facility place vacancies in its 20 place facility. (The 15 place low care residential aged care facility places is currently occupied by 13 residents).

Table 6.3 demonstrates that actual performance has been met against 1999/00 targets.

Service utilisation over the past five years has reflected the outcomes and recommendations of the 1997 Evidence Based Needs Assessment, with the demand for primary health and community support services showing substantial growth.49 (Figure 6.3).

16000 14000 12000 10000 A&E 8000 UMHCS 6000 Comm 4000 Hlth 2000 0 HACC 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99 1999/00

Figure 6.3 Upper Murray Health & Community Services Service Utilisation 1994-2000

6.4.3 Improved cost effectiveness Achieving allocative efficiency is another central plank of the Upper Murray Health & Community Services. The evidence based needs assessment approach seeks to identify approaches and services that have the potential to produce the greatest health gains for the community50.

The Multi-Purpose Service model has provided the opportunity to achieve economies of scale that may have otherwise been difficult. The co-location of services in the one facility cluster facilitated a $250,000 salary cost saving by permitting staff utilisation across the different care settings. Other cost savings also have been assisted by the single budget feature of the Multi-Purpose Service.

49 See Upper Murray Health & Community Services Annual Report 1999/2000 for additional details 50 Evans F., et. al op cit 1999 p24

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Table 6.3 Upper Murray Health & Community Services Performance Measures Performance Measures 1998/99 1999/00 2000/01 2001/02 Service Delivery Target Target Target Target Increase in service utilisation reflects HACC: >1.1 HACC: >1.2 HACC: >1.25 HACC: >1.3 identified needs: Home care (H) Health Health Health Health Health Promotion (HP) Promotion: Promotion: Promotion: Promotion: >2.0 >2.0 >3.0 >4.0 Current Occasions of Service (OOS) / Actual Actual Actual Actual 1996 OOS H: 1.07 H: 1.54 H: H: HP: 5.2 HP: 2.6 HP HP: Improved service coordination Target Target Target Target Continuing Care Program (CCP) >80% referred >85% referred Number of Complex Clients (acute) Actual Actual Actual Actual referred to CCP / Number of clients with 71% 70% complex needs Increase in number of aged high needs Target Target Target Target clients supported in community >0.5 >0.5 >0.75 >0.8 Number of aged clients with high needs Actual Actual Actual Actual supported in community / Number of aged 0.58 0.91 clients with high needs supported in residential care ACCREDITATION Health Service Target Target Target Target Join program Accreditation Accreditation Accreditation achieved maintained maintained Actual Actual Actual Actual Joined QICSA Accreditation program Achieved Medical Centre Target Target Target Target Joined Accreditation RACGP Achieved Financial Operating budget variance compared to Target Target Target Target total expenditure. <2% <1% <1% <1% Actual Actual Actual Actual 1.6% 0.08% Appropriate mix of recurrent & capital Target Target Target Target expenditure. Budgeted capital expenditure <1.5% <1.5% <1.5% <1.5% for items <$50,000 >1.5% of total income. Actual Actual Actual Actual 2.6% 1.7% Personnel Workcover Premium as % of Salaries Target Target Target Target &Wages costs. <2% <2% <2% <2% Actual Actual Actual Actual 2.01% 2.2% Time lost injury: Frequency Rate Target Target Target Target (Frequency = No. of occurrences /100,000 <2.8% <2.2% <1.6% <1.0% person hrs) EFT Budget vs Actual Actual Actual Actual Actual 2.28% <2% Asset / Risk Management Five Star Risk Management Aggregate Target Target Target Target Score <3 stars <3.5 stars 3.7 stars 4.0 stars Actual Actual Actual Actual 2.9 stars

Overall, the application of an effective service mix into the Multi-Purpose Service is a cost effective measure. More people with high care needs are supported at home where they wish to be and additional options now exist for more targeted use of residential aged care facilities.

The budget for Upper Murray Health & Community Services has increased from $2.8mil. in 1995 to $4.3 mil in 1999/2000. This has been achieved by the integration of additional services, such as HACC services, and particularly through the astute use of service development opportunities arising from program funding opportunities.

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Staff positions have expanded from 47.9EFT in 1994/95 to 63.0 in 1999/2000 (Table 6.3). The service employs 101 people including 17 full time, 67 part time and 17 casual positions. They are assisted by a significant volunteer service. In 1999/2000 the service provided 1,844 bed days, and 38,167 occasions of service of which approximately one third were medical attendances, one third HACC services (including home care, meals ADASS and related services) and one third across a wide range of allied health, health education and related services.

Table 6.3 Upper Murray Health & Community Services Workforce (EFT) Staff 1994/95 1999/2000 Change Number %Number %Number Nursing, diagnostic, health professionals 28.18 58.8 28.10 44.6 -0.08 Medical support 2.18 4.5 3.00 4.8 +0.82 Personal care 8.51 13.5 +8.51 Hotel and allied (domestic) 13.12 27.4 16.71 26.5 +3.59 Administration 4.25 8.96.9 11.0+2.65 Total 47.93 10063.00 100+15.07

6.5 Client impacts 6.5.1 Focus group The focus group session was represented by a combination of Board, staff and community members. Additional focus group questionnaires were distributed to community members to extend the range of community opinion.

Perceptions of service availability There was a consensus that the availability of services in the Upper Murray catchment exceeds that which could be expected for a small rural community. All significant services were reported to be either directly available or provider by visiting regional services, and this contrasts significantly to the pre-MPS service profile. Of particular significance is the availability of choice for some services, such as counselling.

The availability of transport was cited as an issue for some people, although it would appear that the perception does not match the reality, with a number of cars being available.

The group also considered how the community knows what services are available. Upper Murray Health & Community Services has used a wide range of information distribution methods including letterbox drops, radio, advertising and brochures but it has found that point of contact advocacy is the most successful method of linking consumers to services, rather than information distribution. Nevertheless it does widely distribute information including support for the emergency services information update that involves personal delivery of information by the Police to all households outside of the township.

Perceptions of service responsiveness to health/community needs Whilst the availability of services was rated highly, the extent to which the health/community needs are met varies between user groups. Whilst the service emphasis is placed on quality, the focus group considered that the next phase of Multi-Purpose Service development will involve the further development of program components for youth, men's health and special needs groups (Figure 6.5).

Access Access to all primary care services was considered to be high, except for specialist services which require a significant population catchment to be justified (Figure 6.6).

Multi-Purpose Services Program Evaluation, Victoria 87 Upper Murray Multi-Purpose Service

How would you rate the availability of health and How well met are the health/community needs in this community services in this community? community?

80.00% 80.00%

60.00% 60.00%

40.00% 40.00%

20.00% 20.00%

0.00% 0.00% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW

Figure 6.4 Perceived service availability Figure 6.5 Extent to which health/community needs met

How would you rate the change in health and community How easy is it to obtain the following services in services in this community today, compared to about this community? five years ago?

100.00% 100.00%

80.00% 80.00%

60.00% 60.00%

40.00% 40.00%

20.00% 20.00%

0.00% 0.00% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW SIGNIFICANT MINOR NO CHANGE IMPROVED SIGNIFICANT DON'T KNOW DECLINE DECLINE IMP ROVEMENT

Figure 6.6 Perceived ease of access Figure 6.7 Rated change between current services and five years previously

Extensive discussion centred on emergency services, given the isolation of the area from specialised acute services. It was considered that Upper Murray Health & Community Services provides an effective response that includes emergency service training (First Line Emergency Care) of all acute nurses, First Aid training, the introduction of Advanced Life Support Protocols especially developed for this Multi-Purpose Service and general practitioners with appropriate skills. Doctors are supported to maintain their anaesthetic skills by rotation through regional services. Access is also maintained to the Critical Care Network based in Albury, with the maximum retrieval time in recent years reported to be four hours. In addition First Aid information support is provided to the other service providers, such as the Maternal and Child Health Service, with Red Cross and St John's retaining primary responsibility for this training.

Access to all services was reported to be high. It is facilitated by the entry point advocacy process and Continuity of Care Program.

Consultation A major effort has been directed at the development of consultative processes over the past three years. The group considered that meaningful consultation in the early years only occurred after the decision to have a Multi-Purpose Service had been made and that this created problems for developing an on-going dialogue. However, in recent years there is evidence of consultation occurring at several levels, ranging from discussion of major resources allocation issues through to specific developments for each service.

Multi-Purpose Services Program Evaluation, Victoria 88 Upper Murray Multi-Purpose Service

Service improvements There was common agreement that the services in the Upper Murray have "significantly improved" since the commencement of the Multi-Purpose Service (Figure 6.7). There was a perception some that bed based services had not improved, with this being due to staff restructuring that had shifted from an excessively high staff:consumer ratio of 1:2.7 (for 20 aged care residents) down to the existing ratio of 1:6, which compared to other services still provides a high level of support.

Multi-Purpose Services Model It was further considered that the Multi-Purpose Service model had made a "significant improvement" to health and community services in the community. Management structures are more accountable and responsive, there is improved flexibility for delivering services to meet community needs and several examples of service innovations for individuals were cited (such as arranging for wood to be delivered to a consumer who needed supplies for her stove).

6.5.2 Other evidence of client satisfaction The Upper Murray Health & Community Services does not implement broad based consumer satisfaction surveys, but it does extensively evaluate individual services and programs. Recent consumer evaluations have been completed for home maintenance, post discharge processes, day surgery pathway effectiveness, food services, meals on wheels survey, physiotherapy patient satisfaction, "front office" satisfaction and satisfaction of maintenance services by surveying the staff as the "clients" of the maintenance service.

As one example of this process, the Home Maintenance Evaluation included a survey of 72% of clients. The survey identified those parts of the service upon which consumers considered most important (lawn mowing, pruning etc) and prioritised the preferences. In further consultation with the consumers, an agreed position was established on the scope of the home maintenance service, including items such as lawn mowing, sweeping paths, cleaning gutters once a year, installation of rails, installation of smoke detectors and related items. An agreed position was also reached on service items to be excluded such as window cleaning, weeding, digging gardens and chopping wood on a regular basis. This consumer action evaluation, is a sound example of participation in service definition based on expressed community preferences.

6.6 Key Factors for Success A significant range of issues have resulted in the achievements of the Upper Murray Health & Community Services but the key factors for success have been identified to include:

• Primary health care philosophy. A primary health approach underpins the Multi-Purpose Service Program and provides the basis for each service to adopt that is responsive to their community's needs.

• Evidence based needs assessment. All Multi-Purpose Services undertake needs assessments, but application of an evidence based approach by Upper Murray Health & Community Services "is possibly the first of its type in rural Australia."51 All strategies and outcomes can be linked to this base for the services' practices and outcomes, which includes extensive community decision making. This approach has replaced a planning approach based on habit and tradition (and myth, in some instances) with evidence.

• Commitment to community democracy. The bottom up approach of this service enables this service to respond to the needs of each person and the community, as opposed to a service approach that develops a range of services and makes them available to the community. The

51 Evans et al. ibid. p29

Multi-Purpose Services Program Evaluation, Victoria 89 Upper Murray Multi-Purpose Service

Upper Murray service consciously encourages the community to set the direction and the health service to respond.

• Continuing care program. The Continuing Care Program developed by the Upper Murray Health & Community Services is based on a wellness paradigm. It seeks to integrate all aspects of health under a coordinated service structure. Territorial boundaries have been eliminated, service plans have been developed and implemented within a single organisational structure (thus avoiding the necessity for external case managers to broker across a range of discrete service providers), flexibility of response is maximised and all services work together as a single team

• Good governance model. A clear understanding has been developed of the respective roles the Board and the staff. There is an effective Board code of ethics and instrument of delegation. The Board understands its role well and exercises a high level of trust in the staff.

• Supportive Board. The Board of the Upper Murray Health & Community Services is enthusiastic about the benefits of the Multi-Purpose Service and seeks to fully exploit the benefits it offers. Board members suggest that its most significant challenge is communicating the benefits of the Program to the community, but they feel confident with the manner by which the organisation sets the priorities is based on a rigorous methodology, as opposed to the previous fragmented programmatic approach.

• Ability to recruit, retain and develop its staff. The success of the model for Upper Murray Health & Community Services is also linked to the team approach adopted to service development. Staff often have dual program and clinical service roles, and this broadens their approach and links individual staff members to wider organisational objectives. Other factors include above Award remuneration, flexible hours, staff training and development, professional networking.

• Leadership. The current senior management is a contributing factor to the success of this Multi- Purpose Service. They have been able to understand its potential, provide the vision and, importantly, translate it into results.

• Other. The QICSA accreditation identified the following standards as having been "exceeded" by the Upper Murray Health & Community Services, and they provide a further indicator to the key factors for success. The "exceeded" standards included: leadership, planning, quality improvement, support for participation, orientation to an integrated health care system, orientation to primary health care and multi disciplinary approaches. These factors in combination effectively summarise the strengths of this service.

6.7 Quality Assurance Upper Murray Health & Community Services adopts a Total Quality Management (TQM) approach to all dimensions of its service. It maintains a Quality Management Plan that includes performance measures and a quality strategic plan with 59 detailed and defined "action steps". It is a comprehensive approach based on community needs and continuous improvement and includes features such as Quality Teams, a multi disciplinary assessment instrument based on quality principles and consumer participation as part of the quality process.

Upper Murray Health & Community Services has a Quality Manager and uses the Quality Improvement & Community Services (QICSA) Accreditation approach as the most appropriate model due to its social view of health.

Multi-Purpose Services Program Evaluation, Victoria 90 Upper Murray Multi-Purpose Service

The December 1999 QICSA review found that: "The Chief Executive Officer and senior staff demonstrate leadership, enthusiasm and commitment to providing a quality service for their clients and a quality work environment for all that are employed by the service. This is demonstrated through high morale, low staff turnover, cohesion and a clear structure focused on quality Primary Health Care practice, staff trust and empowerment. All staff at every level of the service are able to clearly enunciate, using a common language, the organisational philosophy, the focus on health promotion, consumer involvement and integrated care. They understand the meaning of multidisciplinary care and are clearly focused in all areas of service provision. There are some gaps in the areas of Information Technology and Records management that require work on policy and procedure development. However, the majority of recommendations contained in this report do not relate to meeting the standards but more to providing the motivation for the service to continue to strive to be leaders in their field and exceed the standards."52 The QICSA ratings are summarised in Table 6.4.

Table 6.4 QICSA Rating of Upper Murray MPS (December 1999) CORE STANDARDS MODULE Management and Leadership Governing body Met Accountability Met Effective management Met Leadership Exceeded Efficient administration and personnel systems Met Planning, Quality Improvement And Evaluation Planning Exceeded Evaluation Met Quality improvement Exceeded Information technology infrastructure Meet in part Information management Met Training and Development Appropriate training and development Met Orientation Met Work and its Environment Work satisfaction Met Occupational health and safety Met Appropriate facilities Met Appropriate equipment Met Environmental responsibility Met in part Consumer rights Policy and resources Met Confidentiality and privacy Met Fair investigation of complaints Met Consumer And Community Satisfaction Understanding and informing the community of interest and other stakeholders Met Addressing barriers Met Support for participation Exceeded INTEGRATED HEALTH SERVICES MODULE Systems Integration Orientation to an integrated health care system Exceeded Orientation to primary health care Exceeded

Assessment & Care Intake/admission Met Accurate assessment Met Planning comprehensive care Met Continuity of care Met Residential aged care Met Hotel services Met Contracted out services Met Multi disciplinary approaches Exceeded

52 QICSA Upper Murray Health & Community Services Accreditation Review Report 1999 p7

Multi-Purpose Services Program Evaluation, Victoria 91 Upper Murray Multi-Purpose Service

Early Identification And Intervention Documentation and resources Met Comprehensive approach to early identification Met Accurate methods for early identification Met Prompt and appropriate intervention Met Promoting Population/Public Health An environment for health promotion Met Comprehensive approach to health promotion Met Coordinated approach to health promotion Met Records Client record system Met in part Content of client records Met in part Program record system Met in part

6.8 Barriers to implementation 6.8.1 Development phase The barriers to the implementation of the Multi-Purpose Service in the Upper Murray are mainly relate to the change process, with many issues being common to other Multi-Purpose Services.

The identified issues included: • the difficulty of operationalising broad based concepts and explaining these to the community. Although the Multi-Purpose Service concept had attractive features, the community did not fully understand its potential nor its method of operation in practice. The model was not articulated beyond the broad program principles.

• lack of support immediately following commencement. Although the Department of Human Services was closely involved in offering the concept to the community, it was perceived to be an imposed solution, and following commencement, little additional support was offered. A Board member suggested that "we didn't have a clue what to do and I don't think the CEO did either." The Board felt confused, unsupported by lack of guidelines and under pressure to redevelop services within an antagonistic community climate with general practitioner opposition and concern over the possible loss of acute services.

• commencement with a narrow operating service based. The Upper Murray Health & Community Services commenced with only the hospital and its associated residential aged care facility. It took over a year before Local Government HACC services were amalgamated and the intervening period was one of uncertainty and confusion.

• the value that rural communities place in traditional services was threatened. The district hospital is the central community facility in most rural communities, particularly in remote locations and any proposed changes need to change slowly. The Multi-Purpose Service, whilst being acknowledged as the only realistic option to the larger threat of case mix funding and possible loss of service, was a broad ranging restructure that destabilised the rural community.

These barriers illustrate several learnings for future service development. First, consideration needs to be given to a reasonably long period of planning and development prior to the commencement of the service. In the case of the Multi-Purpose Service program, organisational restructure occurs first and this is followed by needs assessment and service planning occurring in parallel with service restructure, on-going service delivery and pressures to undertake financial reform. This service and others found this change process confusing and destablising. It suggests the need for sound program guidelines and the continuing involvement of Government Departments to facilitate the change process, particularly in negotiations between potential future partners and in establishing a collaborative environment.

Multi-Purpose Services Program Evaluation, Victoria 92 Upper Murray Multi-Purpose Service

Secondly, organisational development of the model, which now exists, should be built into a common framework to assist all new Multi-Purpose Service applicants. The absence of guidelines on legal, governance, management, operational and reporting processes was significant barrier during the development phase.

6.9.2 First triennium The main barriers during the first three years of operation for Upper Murray Health & Community Services occurred in the following categories:

• translating the MPS objectives into practice with the same resources. The Multi-Purpose Service Program offers flexibility that previously did not exist, but it does not provide additional funds. Thus if a service commences with a financial deficit or if former organisational structures were inefficient, then significant reform involving some loss of services and/or staff restructuring is likely to be required. These requirements will be destabilising and may indicate the need for continuing support from Government to restructure the financial base.

• development of organisational structures and processes. The commencement of an integrated service requires the development of a planning and administrative framework that is suited to the new model. The development of these new structures takes considerable time and resources and the experience of Upper Murray Health & Community Services suggests that expectations of positive benefits from the new model cannot be expected until two to three years after its commencement.

• developing the needs based assessment as a basis for service redevelopment. The need to develop a well researched, community based Corporate Plan as the basis for facility and service restructure is in conflict with the objective of delivering benefits and cost savings resulting from service commencement. The risk associated with the commencement of service and facility redevelopment prior to sound needs based planning is that the services and facilities may not match the match the plan that is later developed.

These barriers suggest the need to undertake development phases in the right order and that this can take up to three years to achieve.

6.9.3 On-going barriers The main on-going barrier identified by the Upper Murray Health & Community Services relates to identifying the means of "growing the business" without additional resources. Once the model has stabilised and its potential is fully articulated, there is a need for a range of new initiatives to meet identified needs, but opportunities for efficiency restructuring are likely to have occurred during the first triennium. The service may not be able to achieve its full potential. Astute managers are learning to broaden the Multi-Purpose Service by taking advantage of new initiatives such as the Regional Health Service and the Primary Care Partnerships, but consideration may need to be given to broadening the base of the Multi-Purpose Service Program to include a wider range of services.

6.10 Overview In common with other Multi-Purpose Service, Upper Murray Health & Community Services, experienced significant difficulties during its establishment years. However, the services has now developed into an impressive demonstration of the potential that is possible within the Multi- Purpose Service Program.

Many of the reforms implemented at Upper Murray can also be seen in other Multi-Purpose Services, but this service demonstrates an advanced stage of conceptualisation and implementation. The primary features of Upper Murray Health & Community Services is the integration of needs

Multi-Purpose Services Program Evaluation, Victoria 93 Upper Murray Multi-Purpose Service assessment, service development, community control and outcomes measurement. The service is not only philosophically based on a population health model which includes a developing community democracy approach, but it also uses methodological rigour to optimise its cost and service effectiveness.

The following features of the services warrant particular acknowledgment:

Evidence Based Needs Assessment: Upper Murray Health & Community Services has developed a system that targets the needs of the community using evidence based practice, epidemiological and socio-demographic profiling and community consultation. The identified needs are substantiated and prioritised, and replace more conventional approaches based on service gap analysis and qualitative analysis. This impressive system is to be recognised as a best practice model for service planning. However, the rigour and conceptual skills required to develop and implement such an approach may be difficult for others to apply.

Community democracy. Community development concepts have been applied for some years in the community services field, but its application in the primary health field have not been widely applied. In the Upper Murray Health & Community Services, the system is designed not only to share power but to actively and specifically empower the community to set the priorities, using evidence based needs analysis. The Board facilitates this approach, financial resources are provided to ensure it can function, community members are being trained in social research techniques to act as the link to the wider community and the findings are translated into service developments.

Integrated planning. The Upper Murray Health & Community Services can demonstrate a comprehensive corporate planning and management approach. Whilst the structure of the Corporate Plan is similar to that of other services (mission, key action areas, strategies, action steps, target outcomes, timeframes and responsibilities), its Corporate Plan extends the process and includes specific operational plans for every part of its service, even down to maintenance and ground staff. It also identifies financial allocations for all identified items (if required), thereby providing the means of implementation. Key performance indicators are specific and measurable and report performance against targets across 11 selected items. Using this system, it is possible to precisely understand where the service is heading and the extent to which its objectives were achieved. A Total Quality Management Approach links across all parts of the system.

Continuum of care. The adopted continuum of care approach is central to the provision of seamless, individualistic service provision. Upper Murray Health & Community Services reduces hierarchical structures and programmatic divisions to a minimum. The service uses a well developed team based approach, with staff members adopting a range of roles. Staff interest, involvement and delegated responsibility have produced a well motivated organisation working towards common objectives.

Many other individual features of the service demonstrate a high level of practice, including quality management teams, service-specific consumer satisfaction surveys, flexible staffing arrangements to optimise cost effectiveness of bed based services, high level home based services, a significant health promotion program and a staff training program that is individually and organisationally responsive.

Given this record of achievement, a significant question is the extent to which the Multi-Purpose Service Program model has facilitated this process. Several features of the Program have been fundamental and include funds pooling, the breadth of service amalgamation possible under the Program, local control and flexibility. However, the success of Upper Murray Health &

Multi-Purpose Services Program Evaluation, Victoria 94 Upper Murray Multi-Purpose Service

Community Services has also been strongly influenced by the extent to which the Board and management have been able to fully understand and operationalise the model's potential.

Some of the positive outcomes extend beyond the Multi-Purpose Service Program. Whilst the Program provides the platform for service reform, it is not possible to grow the service from a $2.6 mil to a $4.2 mil operation without seeking external funds. The reason for successfully attracting those funds, however, is directly attributable to the evidence based needs assessment which can fully demonstrate and target new sources of funds to measurable objectives.

Furthermore, the existence of the Multi-Purpose Service Program has facilitated model service development for other rural service providers, whose existence may have been otherwise at risk. Upper Murray Health & Community Services and Walwa Bush Nursing Hospital have attracted Regional Health Service Program funding to redevelop the Walwa service for its community of 150 people. This association is a demonstration of how the Multi-Purpose Service Program can serve as launching pad to support other small, remote rural communities.

Upper Murray Health & Community Services is continually evolving. It has successfully navigated the service restructuring and development phases and is moving into a mature period which will exhibit stronger community control and health promotion benefits.

The Upper Murray Health experience now poses a challenge to the Multi-Purpose Service model to establish whether further advances could be made to rural health services by extending the concepts upon which it is based. Two possible developments may bear further consideration. First, is it possible to build residential care facility cost savings into community care? Secondly, what would be the benefits of cashing out Medical Benefits Scheme and Pharmaceutical Benefits Scheme payments?

In conclusion. the Upper Murray Health & Community Services is challenging its own community and that of the health and community care system as a whole to understand what a future rural health service should look like. The traditional view of a hospital as the centrepiece is being replaced by a systems approach focussed primarily on people at home supported by bed based services as required. It is taking time for the Upper Murray community to grasp this fundamental reorientation. Many signs of increased public confidence are apparent.

Short term issues often dominate the debate and its appears that resolution of those issues is often important to underpin community confidence in the model as a whole. For Upper Murray Health & Community Services, the further development of its general practitioner medical service is such an issue. Once it has been satisfactorily resolved this MPS will be well placed to further develop its potential.

The Upper Murray experience demonstrates that whilst the Multi-Purpose Service model provides a sound platform for rural, remote service development, there is a need to understand and exploit that potential for a community.

Multi-Purpose Services Program Evaluation, Victoria 95 Far East Gippsland Multi-Purpose Service

7. Far East Gippsland Multi-Purpose Service - optimising service range for rural communities

7.1 Service catchment he Far East Gippsland Health & Support Service is a Multi-Purpose Service based at Orbost in eastern Victoria, 380 kilometres from Melbourne and 123 kilometres from T the New South Wales border. The catchment is an isolated rural community based on the former Shire of Orbost and covers an area approximately 100 by 150 kilometres. The coastal plains include the Croajingalong National Park, and the inland segment is bordered by relatively inaccessible mountainous country that includes Snowy National Park and other parks. Far East Gippsland is recognised as a conservation area, an area of significant but declining logging and a beef and dairy farming area.

Orbost, the main town, is located on the Princes Highway, and whilst many pass through the area, the town acts as a rural service centre. The nearest hospital is at Bairnsdale 100 kilometres to the west. Other localities in the catchment are very small settlements mainly located along the Princes Highway, Cann Valley Highway and Bonang Highway

The 1996 population of the MPS catchment was estimated to be approximately 4,500 of which Orbost accounts for 2,150 (48.0%). The population over 60 years accounts for 18.9% of the population (including 8.7% over 70 years)53.

Figure 7.1 Far East Gippsland Support Service Catchment

53 Based on Orbost SLA

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The socio-economic profile indicates a community of high dependency. Unemployment is high with 14.0% of the Orbost Shire population registered as unemployed54, compared to 9.4% for Victoria. Seventy six per cent of the Orbost population earns less than $25,948 per annum55.

Far East Gippsland also includes an Aboriginal community and the Moogji Aboriginal Co- operative (a Community Controlled Health Organisation) is located in Orbost. In 1997, 341 Aboriginal people and 12 Torres Strait Islander people were recorded in the Shire of Orbost. They account for 4.27% of the population, compared to 2.7% for the East Gippsland Shire and 0.5% for Victoria.

7.2 History56 Prior to the formation of the Far East Gippsland Health & Support Service, services to the Shire of Orbost has been based on traditional health and community service program arrangements. The Orbost and District Hospital, hostel, community health centre, neighbourhood house and other services each had their own committees of management.

Orbost Shire Council administered and delivered Maternal and Child Health Services, the community immunisation program and HACC services. These services lacked policy development and appropriate client targeting and had little or no contact with other health care providers.57 The neighbourhood house which had initially received strong support had declining attendances and the facility was in poor condition. The Supported Accommodation Assistance Program (SAAP) was located in a shopfront which lacked confidentiality and often duplicated the service delivery of other agencies.

All of the health services were separate agencies, often with only one worker, and this produced poor service coordination, limited ability to be effective and poor financial viability.

Other health providers in the area at the time included Merindah Disability Training and Accommodation Service, Moogji Aboriginal Co-operative and Cann Valley Bush Nursing Centre.

Following a period of extensive community consultations, service amalgamations commenced in July 1994 and included the hospital, hostel, community health centre, HACC services, Maternal & Child Health Program and neighbourhood house. The new East Gippsland Shire had determined that HACC services were not part of its core business and this facilitated the process.

The Supported Accommodation Assistance Program (SAAP) and Regional Domestic Violence Information & Referral Service (a two year Commonwealth funded program) were auspiced by the Multi-Purpose Service, but their funds were not pooled. Disability services did not join the Multi-Purpose Service.

The Ambulance Service facility was incorporated into facility redevelopments and a close working relationship has been developed, although it retains its separate legal identity.

54 Australian Bureau of Statistics 1997 55 Australian Bureau of Statistics, Basic Community Profile 1997. 56 Department of Human Services, Multi-Purpose Services: Development and Design Guidelines 1996 pp14-16

57 Far East Gippsland Health & Support Service Annual Report 1994-95

Multi-Purpose Services Program Evaluation, Victoria 97 Far East Gippsland Multi-Purpose Service

The Far East Gippsland Health & Support Service was gazetted in September 1994 and commenced as a three year Multi-Purpose Service pilot project in June 1995. The original Committee of Management comprised representatives from each of the dissolved organisations which amalgamated to form the new organisation.

Far East Gippsland Support Service commenced without major governance, management, medical or overall financial problems (although some of the amalgamating services were financially unviable), with issues largely confined to the complexities of a fundamental rural service restructure, including insecurities from some amalgamating services, some staff unease and concerns relating to the long term future. This stable environment was a significant contribution to the ability of the Board and management to re-engineer the service in its initial years. The availability of a $3.2 million facility redevelopment funds has been identified by the Board and management as the major incentive for change.

7.3 The Far East Gippsland MPS model58 The Far East Gippsland Multi-Purpose Service operates an integrated service delivery model based on a single point of entry, continuum of care, performance plans and measurement models, multi skilling Skills Audit Plans linking to Training Plans and case management59. The model takes a population health approach and is firmly based on Ottowa Charter principles.

Whilst these features may be seen in other services, the distinguishing characteristic of the Far East Gippsland MPS is its recognition of the interdependence between a health service, medical service, town economy and the community in small rural communities. "You see, if the hospital closes down, there's a good chance you will lose your doctors. If the Doctors leave, you are going to have a struggle to keep your hospital."60 In addition, the health service is the largest employer in the town and "if for this reason alone, (it) has a corporate responsibility to ensure sustainability of the community …"61

The Far East Gippsland Multi-Purpose Service has taken full advantage of the benefits of service integration which include: • decreased pressure on individual services due to an ability to use beds flexibly and not maximise bed occupancy to maintain financial viability • assistance with staff recruitment through the provision of a professional support, opportunities for training, the development of a synergistic work environment, reduced professional isolation and an increased ability to offer full time employment • coordinated health promotion plans of a sufficient mass to be effective • increased efficiency and effectiveness arising from single governance • the presence of a single integrated organisation for community contact62.

In particular the Far East Gippsland MPS has sought to establish a larger organisation as a means of providing sustainable clinical services. Whilst community services have significantly expanded, acute health services have been afforded a similar priority through the

58 Also see Vagg, J., Rural Models of Integration: A Multi-Purpose Service Model of Integration. 2nd International Conference , Primary Health Care 2000 59 ibid., p9 60 ibid. p10 61 ibid., p11 62 Based on Powerpoint presentation for Primary Health Care 2000 Conference ibid.

Multi-Purpose Services Program Evaluation, Victoria 98 Far East Gippsland Multi-Purpose Service development of a new operating theatre and the skilling of nursing staff as the basis for an effective acute service. This MPS has sought to demonstrate that "organisational size counts"63.

A unifying paradigm of "treatment, prevention and support" has been adopted as the basis for service provision (Figure 7.2).

Figure 7.2 Far East Gippsland Support Service Service Paradigm

The above diagram was developed by staff to best illustrate the method of achieving continuity of care through the application "treatment, prevention and support" according to client need. These three unifying principles are adopted across the main service areas of acute care, community support and residential care, which link to domestic and administrative services. All parts of the organisation function as a single point of contact, using planning meetings and inter disciplinary referrals to provide a holistic service.

Using community based needs analysis, the Far East Gippsland Multi-Purpose Service has shaped its services to directly relate to community issues. The span encompasses all service sectors, but extends its reach to reflect specific issues such as youth support, family dysfunction and is now moving into a community development phase.

The Far East Gippsland MPS model is both comprehensive in scope and reflective of its community. It includes an impressive span of services, whilst ensuring that specific needs are targeted to ensure that individual needs are addressed. It is this feature of the Far East Gippsland Support Service that illustrates the depth to which service responses can be developed under a Multi-Purpose Service model.

7.3.1 Services

63 ibid.

Multi-Purpose Services Program Evaluation, Victoria 99 Far East Gippsland Multi-Purpose Service

Far East Gippsland Support Service consists of 15 acute beds (plus 3 Accident & Emergency cubicles) (surgical, medical, paediatric and level 2 obstetric admissions), a 15 bed nursing home and 20 bed hostel plus a wide range of community support services including community health, neighbourhood house, HACC services and targetted services (women's health, youth, maternal and child health and others). Prior to the commencement of the MPS there had been 23 acute and 20 hostel beds, but many of the acute beds were used for Nursing Home Type patients (Table 7.1).

Table 7.1 Far East Gippsland Support Service Bed based services Bed type Pre MPS Post MPS Acute 23 15 Hostel 20 20 Nursing home 0 15 Total 43 50

The services at Far East Gippsland MPS need to be understood in terms of their range and depth. The range of services is broad, with most services usually found in large urban communities, except for specialist medical and surgical services and a more accessible psychiatric service. Given that Far East Gippsland is a small, isolated rural community, this service range is a major achievement and a clear demonstration of the effectiveness of flexible funding. It is to be noted that all services are not cashed out services under the Multi-Purpose Service Program (such as SAAP and Ambulance Service), but the MPS Program created the pre-conditions to facilitate service integration which are unlikely to have been achieved under a conventional programmatic model.

Far East Gippsland Support Service has a staff complement of over 125 professionals and support workers occupying 71 equivalent full time positions. This major rural workforce is a significant contribution to community sustainability. Service size has overcome the major professional and recruitment barriers endemic to small rural communities and provided full time, specialist positions in identified high needs areas, particularly counselling. Far East Gippsland MPS, for example, has several dimensions to counselling including a psychologist, domestic family violence counsellor and social workers. This enables the service to match individual identified need, and importantly, it provide a level of choice not usually available to rural consumers.

A comparison of pre and post MPS service profiles indicates that many services to be available at both time periods but the Multi-Purpose Service model has provided three main benefits: • most pre MPS services have been expanded, with none eliminated or reduced (including acute) • services are provided by one organisation. This permits a continuum of care that was not previously achievable • service access has increased. Many part time, visiting services have been replaced with full time, local services.

The MPS restructure has facilitated professional recruitment by the attraction of an interdisciplinary, coordinated workplace (Table 7.3). Professional staff continuity has been enhanced, with the traditional problem of professional turnover progressively reduced.

Multi-Purpose Services Program Evaluation, Victoria 100 Far East Gippsland Multi-Purpose Service

The total staff complement has expanded by 15.90FTE since 1995/96. This represents significant workforce expansion, particulary in community development/education (Table 7.2).

Table 7.2 Far East Gippsland Health & Support Service Staff Profile Changes (EFT) 1994/95 1995/96* 1999/2000 No. % No. % No. % Nursing 22.1 41.3 23.4 42.2 21.54 30.2 Personal care workers 9.2 17.2 7.8 14.1 7.08 9.9 Community development/education 5.5 10.3 6.7 12.1 **16.71 23.4 Hotel & allied 12.9 24.1 13.8 24.9 19.97 27.9 Administration & Clerical 3.7 6.9 3.7 6.7 6.09 8.5 TOTAL 53.51 100 55.5 100 71.39 100 * MPS commenced July 1995 ** Includes community nurses

Table 7.3 Far East Gippsland Support Service Service Structure Administration Environmental Community Support Residential Hospital

Officer Manager Team Leader Unit Manager Unit Manager Patient Reporting Maintenance Maternal & Child Health Hostel Dialysis System Domestic Neighborhood House Nursing Home Accident & Reception-Central Catering Home & Community Emergency Payroll/Personnel HR management Care Operating Suite Medical Records Industrial relations Social Work Acute & Reception-CSS Community Health Obstetrics Accounts Nursing X-Ray Information District Nursing Technology Women’s Health Physiotherapy Nutritionist Supported Accommodation Family Violence Unit Occupational Therapy Speech Therapy Psychologist Adult Day Activities Alcohol & Other Drugs Counselling Outreach Services

Mental Health Visiting Services Ambulance Service

7.4. Service Effectiveness 7.4.1 Service targeting Service targeting is a major strengths of the Far East Gippsland Multi-Purpose Service. It has completed two needs assessments incorporating all households in the catchment area. Experience has demonstrated that few people wished to attend community meetings to discuss needs, and the first household survey provided an opportunity for all to participate. A second needs survey was completed in 1999. The survey results were combined with staff and Board members' experience of service gaps. Consumer satisfaction surveys linked to specific

Multi-Purpose Services Program Evaluation, Victoria 101 Far East Gippsland Multi-Purpose Service service types, are also used to refine service targets. This combination of community perceptions and staff/Board knowledge has enabled the services to be appropriately targetted.

The needs assessment lead to both service expansion and improved service targetting (particularly for youth and family breakdown) and a signficant expansion of occasions of service across most community services. Far East Gippsland Support Service has opted for a constant review process to refine its targetting, rather than cost-benefit analysis which would be difficult and costly to implement. It is also considered that once the community profile base is established by an initial Needs Assessment, it may not be cost-effective to repeat the exercise at the same level of detail. Subsequent suveys should focus on detailed service issues. The organisational Service Plan provides the basis for service targetting, with all managers monitoring performance against objectives.

7.4.2 Access The expanded service range provided serves as the main indicator of improved service access. However, management has suggested that access is difficult to objectively measure. Case management is provided to consumers who need this level of support, but it is not known whether most of the needs of all community members are met.

Indicators of expanding occasions of service serve as a surrogate for improved service access (Figure 7.3). All services, except delivered meals, have expanded, with significant increases in specific home care and ADASS (Table 7.4).

Other access indicators may be obtained from related service activity data. (Table 7.5). Acute separations increased by 3.5% per annum between 1996/97 and 1999/00, indicating a maintenance of an effective basic service, as previously existed but is now enhanced by improved facilities and continuous acute nurse training.

Residential aged care activity has slightly declined by 1.1% per annum, with high care (nursing home) activity increasing and low care (hostel) activity decreasing. This utilisation pattern is consistent with an expanding domiciliary support service which seeks to support people in their own homes for as long as possible. As of September 2000 5 hostel beds were vacant, and used for respite if required. This flexibility, without financial penalty to the service provider, is a hallmark of the Multi-Purpose Service model.

Table 7.4 Far East Gippsland Support Service HACC Service Performance, 1994/95 to 1997/98 Service Change (%) 1994/95 1997/98 Five year annual average Home help (hours) 2 7508 7822 Home maintenance (hours) 26 897 1470 Specific home help (hours) 245 321 2412 Meals on wheels (number) -7 5130 4536 Podiatry (occasions of service) 29 348 541 ADASS (attendances) 265 689 3009 ADASS (hours) 183 3966 17206

Multi-Purpose Services Program Evaluation, Victoria 102 Far East Gippsland Multi-Purpose Service

7850 600 7800

7750 500

7700 400 7650 Home 7600 Help Podiatry (hours) 300 Hours

7550 Number

7500 200

7450 100 7400

7350 0 1994/95 1995/96 1996/97 1997/98 1994/95 1995/96 1996/97 1997/98 Year Year

3000 3500

2500 3000

2000 2500

Home 2000 1500 Maintenance

Hours ADASS 1500 Attendances 1000 1000 Specific Home Help 500 of attendances Number 500

0 0 1994/95 1995/96 1996/97 1997/98 1994/95 1995/96 1996/97 1997/98 Year Year

Figure 7.3 Far East Gippsland Support Service HACC Service Performance,

Table 7.5 Far East Gippsland Support Service Service Activity Measures 1996/97 and 1999/2000 1996/97 1997/98 1998/99 1999/00 Separations Acute 712 722 779 708 Non acute 20 21 29 12 Same day 158 203 220 298 Total 890 946 1028 1018

Patient days Acute 3211 2430 2731 2506 Non acute 260 500 375 279 Same day 158 203 220 298 Total 3629 3122 3326 3083 Nursing home 5104 5256 5480 5532 Hostel 6663 6893 6235 5713 Total 11767 12149 11715 11244

Acute average length of stay (days) 4.4 3.4 4.0 3.8 Acute occupancy (%) 63.4 53.5 57.0 44.9 Emergency medical treatment 1416 1636 1455 1417 Outpatient services 1057 898 863 851 Dialysis 0 109 62 92

Multi-Purpose Services Program Evaluation, Victoria 103 Far East Gippsland Multi-Purpose Service

Table 7.5 continued 1996/97 1997/98 1998/99 1999/00

Community health Public dental 372 350 559 555 Immunisation 0 321 2811 n/a Allied health 2664 2600 2811 3239 Health promotion 200 348 330 340 Community nurses 471 474 734 405 Counselling 102 153 478 535 Drug & Alcohol 149 125 0 0 Intake 1894 1079 752 661 Social work 260 317 313 469 Tubbut outreach 285 459 465 439 Youth program 240 656 546 559 Women's health 25 179 278 374 Cardiac rehabilitation 27 61 74 72 Housing 1070 923 1249 1252 Family Violence Unit 3303 829 787 1409 Neighbourhood House 758 780 736 1852 Maternal & Child Health 3704 3498 2646 1919

HACC Hours of service 9636 12245 13118 * Meals on wheels 5170 4651 4400 * ADASS attendances 2075 3009 2431 * Visiting nursing 2360 2278 2596 * Volunteer 0 10890 21949 * *Reporting method changed: Service District nurse 1562 hours Home care 8558 visits Personal care 1200 hours ADASS 13,542 hours Delivered meals 5,345 meals Volunteer Network program 15,153 hours Respite care 515 hours Property maintenance 1,533 hours Outreach services 124 hours Changes in community health and HACC activity also reflect significant expansion across most services (Figure 7.4). Far East Gippsland Support Service is able to fund the gap between income from all sources and service expenditure, and this further illustrates the flexibility of the Multi- Purpose Service model.

600000

500000

Funding gap 400000

300000

200000

100000

0 1994/95 1995/96 1996/97 1997/98 1998/99

Total HACC Income Total HACC Expenditure

Figure 7.4 Far East Gippsland Support Service HACC Income & Expenditure

Multi-Purpose Services Program Evaluation, Victoria 104 Far East Gippsland Multi-Purpose Service

7.4.3 Flexibility and innovation Far East Gippsland Support Service demonstrates a wide range of flexible and innovative services. Four contrasting examples have been selected as illustrations.

Family Violence Unit Using Police Family Incidence Reports, the Far East Gippsland was found to have the highest rate of domestic violence in Victoria, with double the State average and, following the completion of the Commonwealth funded project, the Board decided to maintain the Family Violence Unit from its pooled budget.

The Family Violence Unit is managed by an experienced, specialist counsellor. The Coordinator was attracted to Far East Gippsland Support Service by the opportunity to adopt a community development perspective to family violence which includes the service as part of a broader community health service. It provides increased access to other services such as Emergency Relief Fund, housing assistance, women's health support and community nursing. The model has also been found to increase credibility for the Counsellor because she is part of a wider service, and it has fostered a close relationship with the Police.

In particular, the service was established as a client driven initiative, with the Counsellor guided by the expressed needs of the consumer. The initial service developed a safety network for the provision of crisis response and included 13 bush nursing centres and 11 police stations across the district. A crisis response is maintained at all hours and the service now includes the provision for working with perpetrators as appropriate. The service seeks to offer real choices including escape, separation, couples' counselling, men's behaviour change groups and women's groups. One worker has been able to provide a comprehensive service because back up is available from other staff, and this may not have been more difficult under a different model.

This service received the Institute of Criminology's Violence Prevention Award for 1998.

Infection Control The second example of innovation and responsiveness is drawn from a different service perspective. Far East Gippsland Support Service has funded an Infection Control Practitioner one day a fortnight as a component of a wider acute nursing position as a means of improving acute care standards.

The Infection Control Practitioner reported that: "The Multi-Purpose Service has brought great change in the staffing attitudes across the entire health field, with Infection Control being an area of great co-operation and enthusiasm. ….Community services play a great part in educating the public how to deal with their issues, however the advice needs to be consistent. Services are centred around the patient/client. All staff receive the same Infection Control education as appropriate to their field. This is made so much easier by having all services on site. ….. Representatives from each department meet twice weekly to assess patient/client needs and can share the necessary information and (develop) the continuum of care. Patients/clients can be more easily reassured and advised and often feel more confident to ask questions. ……Because we are an MPS people can feel more free to visit and obtain information in anonymity and can often walk away with much more information than they came for."64

Youth Program

64 Presentation by Levina Zutt, Division 1 Nurse, Far East Gippsland Support Service (Sept 2000)

Multi-Purpose Services Program Evaluation, Victoria 105 Far East Gippsland Multi-Purpose Service

A third contrasting service innovation is the Far East Gippsland Support Service Youth Program. The program aims to facilitate projects and programs that increase youth awareness of health and well being and provide realistic options to support their lifestyles in a positive manner.

A 0.8EFT Youth Worker was funded to identify youth issues and provide resources to support local workers and, in 1997, a Youth Forum of 14 young people was established to identify issues and support youth development. Boredom was identified as a significant issue and the service has worked co-operatively with other programs to assist young people to organise events such as a Mocktail night, FreeZA and movies. Programs currently range from a Wilderness Program which seeks to develop self esteem for students at risk, School Holiday Programs and a popular Surfing Program for young women.

The success of the program has lead to the development of a Youth Unit, which consists of the Youth Worker and SAAP worker jointly developing programs. The Program has continued to expand and has included a Snow Experience for young indigenous people, drug and alcohol education, and links to SAAP programs such as a six week young parenting program and related programs such as Finding Work Leaving Home, Girls in the Bush and Budgeting Program.

The workers reported that: "The Far East Gippsland Support Service is responsible for the unique holistic approach to young people. This Multi-Purpose Service provides the flexibility to achieve these programs (and) for SAAP, these programs work towards prevention and early intervention of homelessness."

Information Technology Far East Gippsland Health Multi-Purpose Service is actively exploring potential benefits that might be achieved from the application of technologies for rural health services. It has a particular interest in improved cost effectiveness and the removal of barriers for consumers who have to travel for specialist consultations which is expensive, disruptive to home life and may difficult to manage if leave of absence from work is required particularly in cases where periodic consultations are required.

A number of strategies are being actively explored including: • telemedicine for designated diagnostic consultations. This service development has potential but there remains the need to address specific medico-legal and fee for service issues. • distance learning. A link has been established between a number of regional providers to access an Alfred Hospital Trauma Centre project to update specific acute nursing skills in accident and emergency procedures, such as abdominal trauma. • digitising medical images. Currently X ray slides are forwarded by bus to Traralgon for specialist consultations and consideration is being given to the technology required to forward digitised images and receive a more responsive service. • video conferencing. Far East Gippsland has established a video conferencing unit for a range of communications. Consideration is being given to its wider application for allied health applications. • electronic Intervention Order transmittal. Previously the Family Violence Unit Counsellor was required to drive to Bairnsdale to obtain an Intervention Order. It is now possible to use fax and video conferencing to achieve the same outcome. • point of presence (PoP) site. A PoP site has been established for the hospital and the community (Cann River and Nowa Nowa) to access the internet.

7.4.4 Improved cost effectiveness

Multi-Purpose Services Program Evaluation, Victoria 106 Far East Gippsland Multi-Purpose Service

The Far East Gippsland Multi-Purpose Service commenced with a budget of $2.2mil in 1994/95 and $2.5mil. in 1995/96, its first full year of operation. By 1998/99 the budget had considerably expanded to $4.8mil., a 92% growth over four years. This has been achieved by expansion of the base budget, combined with opportunistic management relating to new program opportunities.

The Quick Asset Ratio, which relates current assets to current liabilities, indicates the Far East Gippsland Health Multi-Purpose Service to be a viable organisation.65 Figure 7.5 indicates continuously improving viability over the period, although it is to be noted that the objective is to breakeven and not produce surpluses as occurs in the private sector.

5.00

4.00

3.00

2.00

1.00

0.00 1987/88 1988/89 1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/1998

-1.00

-2.00 Figure 7.5 Far East Gippsland Support Service Quick Asset Ratio

Improving cost effectiveness is also demonstrated by service substitutions from the acute to community sectors. Acute bed days have declined from 3211 in 1996/97 to 2506 in 1999/00, although this is partly attributable to changes in the length of stay from 4.4 days to 3.8 days. Community services have expanded over this period (Table 7.5).

A further indication of improved cost effectiveness has occurred in residential aged care. Hostel bed days have declined from 6663 in 1996/97 to 5713 in 1999/00 due to the ability to support more people at home. Nursing home occupancy has slightly increased over the period (Table 7.5).

7.4.5 Cultural appropriateness Far East Gippsland is the only Multi-Purpose Service under review that has a significant Aboriginal population. Moogji Co-operative is based in Orbost and supports the Aboriginal and Torres Strait Islander community of 353 persons.

Moogji reported a positive working relationship with the Far East Gippsland Multi-Purpose Service in several key areas. Cooperation with and successful outcomes were cited to have been achieved with the Youth Service, SAAP, and Maternal and Child Health Services, each being considered to provide an excellent service. Recreational programs such as surfing, canoeing and snow trips were

65 (An index of 2.0, for example, indicates an organisation's ability to pay its liabilities twice over)

Multi-Purpose Services Program Evaluation, Victoria 107 Far East Gippsland Multi-Purpose Service recognised as producing real social benefits to local Kooris. Other MPS activities acknowledged as effective include the Well Women’s Project, the provision of local anaesthetic facilities for dentistry, and the training of the MPS community nurse to facilitate mentorship of candidates for the Aboriginal Health Worker Certificate.

The Moogji Council is attempting to change emphasis in its community support role away from crisis management to a preventive and early detection focus to avert crises where possible. A new 5 year Health Plan had been drafted to reflect this strategic approach.

Although there is no clinic at the Moogji Co-operative, it conducts a wide range of local primary and preventive health activities such as hearing and vision tests, diabetes screening and liaison, with nearby clinics such as that located at Bairnsdale.

Anecdotally, up to 15% of community health business conducted by Far East Gippsland Support Service is provided to Koori clients.

The development of the Far East Gippsland Multi-Purpose Service into a “one stop shop” for health and community services was seen as an advance in service delivery for Kooris. The principal gap was identified as the lack of integration of the regional adult mental health service provided. This discontinuity in service delivery was also identified in consultations with staff and in the community focus group.

Gaps in the service spectrum identified as particularly relevant to Koori health needs in Orbost were: • adult mental health integration • greater access to counselling services, especially rapid response and out of hours support • a Memorandum of Understanding between Moogji and Far East Gippsland Support Service covering both access issues and a framework for cooperation, as well as the provision of employment opportunities • a perceived rigidity in the exacting compliance with HACC guidelines, requiring the purchase of HACC services from other providers • no local female general practitioner • no local presence of a health service liaison officer • a greater presence for the Alcohol and Drugs worker (currently 0.2EFT)

Overall, however, the service system is seen to be sound for a remote rural community, with further work required to improve indigenous health.

7.5 Client impacts 7.5.1 Client feedback A focus group was attended by 15 community members including the mayor, two Police Officers, a receptionist from the Multi-Purpose Service, Senior Citizens Centre representative and a cross section of community members.

Perceptions of service availability One person attending the group session had, of his own initiative, undertaken a straw poll of 20 customers attending his shop, to establish their extent of understanding of the Multi-Purpose Service. Respondents, aged between 20 and around the mid 50's, were asked "did they know what Far East Gippsland Support Service is". Several understood it to be "the hospital" (the base for all Multi-Purpose Service programs) and the remaining 13 did not know what it was, responding "don't know", "no idea" and "what's that". (One person thought it was an item or a tool). All respondents knew where the hospital is located.

Multi-Purpose Services Program Evaluation, Victoria 108 Far East Gippsland Multi-Purpose Service

(The 1996 Needs Survey also asked the same question and established that 38% had heard of the MPS, 50% had not and 12% were unsure).

This unrepresentative poll was undertaken "to see if the general citizen that lives in our community is aware of the service provided." Discussion centred on this issue and the group agreed that firstly, the community is often not aware of the services available in a community until it needs them and, secondly, although those closely involved in any organisation consider their services to be central, the community does not always have the same perception. It was considered difficult to engage a community in daily service issues.

Police representatives indicated that people known to them had a sound understanding of emergency relief and associated services, but the wider community probably had little need to know that such services exist. The group also suggested that information and advertising of services had limited effect and that delegation of a watching brief to community leaders met their expectations.

The group considered that, overall, the availability of services is "high" (Figure 7.6). The recent loss of a general practitioner from the practice is an immediate issue and the group considered that the retention of doctors was foundational for the health service.

How would you rate the availability of health and How well met are the health/community needs in community services in this community? this community?

60.00% 70.00% 50.00% 60.00% 50.00% 40.00% 40.00% 30.00% 30.00% 20.00% 20.00% 10.00% 10.00%

0.00% 0.00% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW

Figure 7.6 Perceived service availability Figure 7.7 Extent to which health/community needs met

How would you rate the change in health and How easy is it to obtain the following services in this community services in this community today, community? compared to about five years ago? 50.00% 60.00%

50.00% 40.00%

40.00% 30.00% 30.00% 20.00% 20.00% 10.00% 10.00%

0.00% 0.00% VERY LOW LOW MODERATE HIGH VERY HIGH DON'T KNOW SIGNIFICANT MINOR NO CHANGE IMPROVED SIGNIFICANT DON'T KNOW DECLINE DECLINE IMPROVEMENT

Figure 7.8 Perceived ease of access Figure 7.9 Rated change between current services and five years previously

Perceptions of service responsiveness to health/community needs

Multi-Purpose Services Program Evaluation, Victoria 109 Far East Gippsland Multi-Purpose Service

It was considered that the Far East Gippsland Multi-Purpose Service services are responsive to community needs. Overall, the group felt that their needs are "well met" (Figure 7.7). People with psychiatric conditions represented a challenge for the Police, who find it difficult to obtain after hours support and it was reported by a former acute nurse that acute nursing staff may benefit from specific training in psychiatric nursing to better respond to these needs.

However, the group generally considered that "great progress has been made", there is informal multi cultural support and that the presence of a Youth Worker has been of considerable assistance.

Access Most of the group considered service access to be "easy" (Figure 7.8). It was recognised that specialist services were difficult to obtain, but this was accepted as a part of rural life. Similarly, services to people in outlying areas were considered to be less accessible than those to people living in town. However, emergency response was considered to be "as good as possible".

The group considered whether access had improved significantly and that generally it was an issue. If a service is needed, then it could be readily obtained by ringing "the hospital".

Consultation It was considered that there many opportunities exist for consultation, but generally the wider community is not interested in participation unless there is a specific issues, such as a threat to a service. Some group members found it difficult to find the phone number of the Multi-Purpose Service now that the service name has changed, but this was of minor concern. The distribution of a Health Needs Survey questionnaire was widely appreciated. However, the group did not feel an affinity with decision making processes, whilst also not feeling alienated by this fact.

It was also considered that there had been minimal opportunity to influence the change from the traditional structures to the MPS model, even though community meetings were held to discuss the change. "We felt that it was going to happen, anyway and we had to accept it." Insecurity existed, particularly from the Board of the aged care hostel, but it was agreed that in retrospect these concerns have been proven to be unfounded.

Service improvements The focus group considered that services has "improved" compared to five years ago, with some services rated as "significant improvement" (Figure 7.9). Residential aged care, home based nursing and allied health were cited as the most improved services. (Prior to the MPS there had been no nursing home, with high care consumers supported in hospital based beds).

Some felt that the establishment of a "one stop shop" on the hospital site was less desirable than the former main street based shopfront service for community health, but others considered that organisational strength had developed due to the change. In particular, the neighbourhood house is now a thriving, fully integrated service rather than a marginalised operation.

It was also considered that the facility redevelopments had been fundamental to service improvements. These changes had enabled management to recruit and retain professional staff and the doctors had been provided with the facilities required for them to provide a sound medical and surgical service.

Multi-Purpose Services Model

Multi-Purpose Services Program Evaluation, Victoria 110 Far East Gippsland Multi-Purpose Service

The Multi-Purpose Service was considered by this community group to have provided security for the health and community services in Orbost. It was felt that services to outlying areas may still be limited but this was to be expected.

Overall, management structures were perceived to have "improved" or "significantly improved". There is now a single decision making body and this provides for focus and coordination between services.

"Service flexibility" was also perceived to have "improved" or "significantly improved". The group felt that community health services in particular are now more responsive to community need and cited the response provided during a period of flooding when family relief and counselling as a sound outcome. It was also indicated that many more services are now available locally, thereby circumventing the need to travel over 100 kilometres to Bairnsdale.

The group also identified a perverse outcome of Multi-Purpose Service improvements. It considered that there is now an expectation that services will be provided immediately, and this is not always possible. Some group members suggested that some community members had forgotten how difficult it had previously been to access a service,

Most of the group also considered that community control of health and community services had "improved" but others considered that there had been "no change". It appears that opportunities do exist for the community to influence the services through surveys and direct participation in activities, with variable responses to according to personal preference.

7.5.2 Other evidence of satisfaction Far East Gippsland Support Service conducts a range of service specific consumer satisfaction surveys as part of its continuous quality improvement objectives. A representative sample of these surveys includes: • Board of Management Survey (Evaluation of information provided to new Board members) • Internal Staff Survey 1998 • Hostel/Nursing Home Survey 1998 • Inpatient Survey 1998

This range of surveys indicates a commitment to service evaluation and improvement. The results of all surveys indicate a high level of satisfaction. New Board members indicated that they had been reasonably well briefed and provided with the range of information required for them to undertake their duties.

The 1998 Staff Survey (31% response rate) indicated satisfaction with the work environment, overall satisfaction with staff development opportunities (26% dissatisfied, based on 34 responses) and positive support for organisational flexibility. Several areas for improvement were identified by staff. This in-depth survey demonstrates a desire to involve staff and identify issues for further improvement. The results indicated several opportunities for development within an overall positive organisational environment.

The Acute Inpatient Survey results demonstrated an overwhelmingly positive response to the service.

The Hostel/Nursing Home Survey indicated satisfaction across most areas of service. Eighty eight per cent (15 respondents) consider the hostel/nursing home to be their home and there was a positive response to most aspects of the service including activities, meals, diet and personal care.

Multi-Purpose Services Program Evaluation, Victoria 111 Far East Gippsland Multi-Purpose Service

7.6 Barriers to implementation 7.6.1 Development phase The Board President reported the following issues relating to the Far East Gippsland Support Service development phase. This confirms other investigation undertaken as part of the evaluation: "Numerous problems were encountered due to fragmentation caused by health services delivered by separate agencies and small programs with limited viability. Shire personnel did not have the expertise to be managing home help services well and there was little or no communication with hospital personnel as to who would be needing the service.

Many professionals in the Orbost area worked in relative isolation and there was an array of entry points into the health and aged care service system which caused confusion to the people who used it. Very minimal cross servicing existed between services and therefore coordinated flow on from say acute hospital stay to home recuperation did not exist.

…… The (MPS) philosophy, together with its flexible funding concept, seemed to embrace our every needs and address our ongoing problems peculiar to us because of our geographical remoteness. Prior to this time and reading through many problems covering numerous years, the same problems were identified time and time again: • services eroded through lack of funding • staffing problems because of lack of funding or the inability to offer incentives for professionals to relocate to our area • lack of funding to maintain full service delivery • lack of capital works funding to repair or replace building structure in need of urgent repair, and the list went on.

Taking all of these problems and many more into consideration, the Committee decided in its wisdom to pursue one of the three pilots offered to rural Victorian hospitals. It was the best decision we ever made and we have not looked back since.

…… Like many rural towns, parochialism is extensive in Orbost and it is not hard to appreciate how difficult it was trying to convince a committee of one service to join another and to relinquish management when members of that committee actually built services, such as the aged care hostel here in Orbost, with their own hands and dollars. There was widespread feeling that the hospital was attempting a general takeover in a power play struggle and that if services relented and gave in, they would be swallowed up and eventually lost.

However, we overcame these obstacles through numerous community consultations and in 1994 every service in Orbost united and signed an agreement to form a dedicated Committee of Management, to work towards a Multi-Purpose Service.

…. Since those early days we have established 40 plus services, all based on community needs and we have undertaken two community surveys to ensure thaat our service is community needs driven.

We have been able to encourage our staff at every level of service dleivery to undertake professional development to increase their skill base and enable them to undertake a variety of cross servicing experiences.

Multi-Purpose Services Program Evaluation, Victoria 112 Far East Gippsland Multi-Purpose Service

….. Because we have been able to maintain stability and viability in the service we can continue to look ahead with enthusiasm and vision. We have been able to undertake capital works programs that 10 years ago we would not have contemplated. …..We have been able to increase our staffing levels in the management area by introducing a Deputy CEO and accountant. …. We are always looking to increase patient access to specialist services."66

The Far East Gippsland experience suggests that there were no significant barriers to development of its Multi-Purpose Service, other than those relating to major organisational restructure, and this factor was a significant contribution to service redevelopment.

7.6.2 First triennium The initial years of operation also did not present significant service development barriers.

The Board reported that the insecurities relating to recurrent funding presented a risk, although not a barrier. The Board was unable to obtain a commitment of on-going funding beyond the first triennium but this insecurity was matched to the promise of $3.2 mil. for capital redevelopment. Without the capital grants, the decision would have been more difficult.

The development of a financial reporting system that is clear to all Board members also presents an ongoing challenge. Public sector financing and reporting was reported to present complications for community Boards and it was suggested that reporting within a single accountability framework would be preferable to the existing arrangements.

Part of this success is attributable to the development of an effective working relationship with government departments. Both management and regional officers of the Department of Human Services reported that the focus on outputs, using a needs based approach, has benefited service development. This is partly attributable to the effective Executive Management from the outset, which developed trust and confidence in a service which both Government and the Board had a vested interest in its success.

7.6.3 On-going barriers Whilst no significant on-going barriers exist for the Far East Gippsland Multi-Purpose Service, a number of areas for further program development were identified and include: • improved Program accountability to ensure operational responsibility to funds provision • clarifying lines of accountability for Multi-Purpose Services, particularly to Regional and Central offices of the Department of Human Services • linking MPS funds to Award increases • consideration of the extent to which the model should be further operationalised to include additional cashed out services such as Medical Benefits Scheme and Pharmaceutical Benefits Scheme • clarifying the link between Multi-Purpose Service success and dependency on capital redevelopment grants as an essential systems change incentive • acknowledging and better understanding the link between flexible services for rural communities and support for the local economy.

The Board understands its main challenge for the future is to further develop the Multi-Purpose Service model as a community development concept, to understand the link between service development and local economies and to further encourage a holistic approach to health in its community.

66 Lesley Harding, President, Far East Gippsland Support Service Board of Management

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7.7 Key Factors for Success Discussions with Board, management, staff and the community identified six key factors for the success of the Far East Gippsland Health Multi-Purpose Service.

They are: • Opportunities provided by the model. As occurred in other Multi-Purpose Services, Far East Gippsland Support Service has used the flexibility of the model to provide a more effective service. Vertical integration, pooled funding and local control over decision making have produced tangible benefits for this community. Service amalgamations, for example, have improved service efficiency and in particular cost effectiveness by facilitating the development of multiple roles for staff. It also facilitated economies of scale that have lead to more specialist positions and the filling of service gaps, particularly in allied health services. Case management approaches are now possible and professional isolation has been reduced. Furthermore, it is reversed priorities from Program accountability as the service driver to community need as the primary rationale for service developments.

• Relatively simple pre-MPS service arrangement. The service catchment did not have potentially competing organisations (such as several hospitals) and this factor met a primary pre-condition of appropriate Multi-Purpose Service development.

• Stable governance The Board appreciated the potential offered by the Multi-Purpose Service model and enthusiastically supported the concept from the outset.

• Skilled executive management. The Board considers they have been "we were lucky" in attracting two effective Executive Officers to redevelop the service. The Board was also actively supported by executives from the Bairnsdale Regional Health Service with advice and assistance in the formative years. The Board suggests that Multi-Purpose Services "must have a good CEO at the helm, one that works cohesively with the Board, one that can advise accordingly and one that is innovative in targeting funding and in organisational management".

• General practitioner relationships. The Board further identified the development of an effective working relationship with the general practitioners as a key factor in the success of this Multi-Purpose Service. It recognises the dependency of the community on its doctors and the need for an effective health service by the doctors. The Board includes a long standing general practitioner as a member. Another general practitioner suggested that the sound relationship with the Multi-Purpose Service was of major benefit in improving service access and cited an example of an elderly woman collapsing at home on a Saturday and immediately being admitted to the hostel, which previously would have been a more attenuated procedure. (She had previously been assessed by the Aged Care Assessment Service).

• Ability to attract quality professionals: As a service expands, it has the ability to attract full time professionals who appreciate the benefits of working in a coordinated, multi disciplinary service, and this has worked to Far East Gippsland Multi-Purpose Service's benefit. Whereas other small communities are having difficulty attracting staff, it has been found that even general practitioner recruitment is not a major barrier and that professionals borne in the local community are prepared to return to the area.

These key factors for success identified by those responsible for the Far East Gippsland Support Service have a strong organisational management and development focus. They indicate the importance of developing an interdependent organisational system that is efficient and effective for the Board, management, staff and general practitioners.

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7.8 Quality Assurance Far East Gippsland Support Service uses the ACHS EQuIP Evaluation and Quality Improvement Program as its basis for quality assurance and in May 1999 was awarded three year accreditation. The organisation, which has two part time EQuIP Coordinators.

The EQuIP surveyors reported in summary that: "At the macro level this Service is commended on setting up this Multi-Purpose Service . Without doubt this has improved the services and outcomes which are provided to patients, residents and clients.

This amalgamation has: improved efficiencies and achieved cost savings; improved continuity of care and discharge planning; provided support and professional supervision for previously isolated staff; and established a case management approach to care. New capital work, expansion of services, renovations and the location of all services on one site have improved the performance of this Service.

There are signs that there is a change from existing cultures, into one culture. Surveyors, whilst commending efforts to date, were unable to determine a culture of improving performance.

Not all staff were familiar with EQuIP. The Service is performing some good Quality Activities, however, it needs to move forward and do these activities better. This will require an evaluation of programs with a view to moving the focus from structure and Process to Outcomes.

Because of the geographic location of Orbost there is a perception of "tyranny of distance". This has been largely overcome by locating all services on one site, providing transport to specialist services etc.

Some excellent work is being undertaken in the areas of family violence, drug and alcohol, women's health, child care, adult literacy and a program of youth services. The hospital, nursing home and hostel have also moved forward along the road of continuous improvement. These areas present very well and a great deal of effort has gone into making those services more "homely".

Management and staff are aware that they have accomplished major changes over the last 3- 5 years. They are also aware that all services need to be evaluated, assessed and improved as necessary. This will improve feedback and lead to a culture of continuous improvement. Each department needs to work at developing a culture of improving performance with a view to benchmarking and achieving best practice."

An overall rating of "moderate achievement" was achieved across all functions

7.9 Overview Far East Gippsland Support Service is widely acknowledged as a leading edge example of service provision to small remote rural communities. It has received several service Awards for practice development, achieved three year EQuIP accreditation and is a sound example of flexible care service models.

This Evaluation has established that the Far East Gippsland Multi-Purpose Service includes many of the features of systematic planning and integration common to all Multi-Purpose Services, yet this particular service has a distinctive defining character.

Multi-Purpose Services Program Evaluation, Victoria 115 Far East Gippsland Multi-Purpose Service

An important distinguishing feature of this Multi-Purpose Service is its initial developmental experience. Far East Gippsland Support Service had a relatively smooth beginning compared to the significant issues other MPSs under review, and this coincidence of features provided a sound basis for development and growth.

The following factors contributed to the Far East Gippsland's Multi-Purpose Service's early success: • willingness by organisations to take advantage of the opportunities offered by the model: Certainly, initial insecurities existed within existing Committees of Management, but the incentives and perceived benefits were sufficient for those organisations to accept radical change within a community used to traditional service delivery structures.

• all existing major providers agreed to join the Multi-Purpose Service: Far East Gippsland Support Service commenced with all of the major services agreeing to become part of the MPS, including the hospital, hostel, Shire, Community Health Service and others. Once the decision had been made and the six amalgamating organisations were equally represented on the new Board, the new organisation had a governance platform for integrated service planning and service redevelopment. The Board representation gradually changed as former allegiances faded, but respect of former structures and equality in the new born organisation were important at the outset.

• capital incentive. It is widely recognised that the availability of $3.2mil. capital grant was a significant incentive to all organisations and the community to accept the risks of major service restructuring. These funds were to provide the community with a new acute service, separate residential high care beds and existing facility refurbishment opportunities. Many people emphasised the importance of this incentive for this small rural community.

• no loss of services. No service was to be reduced or lose its identity due to the restructure. The Far East Gippsland experience suggests that when introducing a Multi-Purpose Service into a rural area, the community is primarily interested in service retention as a foundational part of the way of life, and this factor surpasses the promise of something new and yet unproven. Preservation of traditional institutions (such as an "old folks home") becomes particularly important when community funding has supported its development. Multi-Purpose Service that commenced with an agenda that required acute beds closures, even if they were under utilised, had a more difficult birth.

• general practitioner support. Far East Gippsland Support Service recognised the importance of its general practitioners base from the outset. The Board and management clearly understood the pre-conditions required to provide effective general practice medicine and ensured that the facilities, such as a new operating theatre, and improved support, such as a contemporarily trained and skilled acute nurse workforce, were provided. Conversely, the doctors also appreciated the incentives of the new hospital facilities and integrated allied health and social support services offered to their patients. A well developed and maintained acute service is a key feature of the Far East Gippsland MPS.

• single site. The ability to amalgamate all services onto a single site also strongly underpins this Multi-Purpose Service. Services previously had been distributed across the town, creating isolation and inefficiencies, and the ability to draw all services together cannot be underestimated as a key factor for success. Some community members suggest that the former shopfront location had advantages, but on balance the benefits of service co-location have demonstrated significant continuum of care benefits.

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The second distinguishing characteristic of the Far East Gippsland Support Service MPS is the extent to which the service profile has responded to its identified community needs. By adopting a population health approach the Far East Gippsland MPS has developed a distinct service that is clearly responds to the social dimensions of this community. Whilst ensuring that the service structure supports all community groups especially families and older people, Far East Gippsland Support Service has clearly understood and tackled social justice issues arising from high unemployment, social security dependency and at risk behaviours. Drug & alcohol support, family violence counselling, psychology, housing support, emergency relief and youth services stand alongside the more traditional service regime and demonstrate the depth to which a Multi-Purpose Service model can be implemented even in communities with a relatively small population base, and reflects a sound understanding of the need to address some of the primary determinants of ill- health.

The symptoms of a wider social malaise including violence, depression, substance misuse, self esteem, coping skills and related issues receive an appropriate priority within a service that is professionally provided. The one dimension that would benefit from consideration is the further development of after hours emergency social services, particularly for people with psychiatric conditions. (It is to be noted that Latrobe Regional Hospital manages the Mental Health services). It is this attention to the underlying casual factors that demonstrates the depth to which this service supports its community.

Far East Gippsland Support Service is further characterised by its sheer size and breadth. It maintains a workforce of some 125 people filling 71 equivalent full time positions to support a population catchment of approximately 8,000 people and it has expanded its budget from $3.1 mil in 1994/95 to $4.5 mil. today. Over 40 services are now part of the MPS compared to a far narrower pre-MPS service regime. The flexibility provided by the Multi-Purpose Service model has been a significant contributing factor underlying management's ability to grow the business.

Far East Gippsland Support Service has also availed itself of the opportunities provided by the model to innovate. Just one example is Wilderness Program for youth which targeted ten secondary students at risk of dropping out of school and has contributed to all but one student staying at school, undertaking further training or getting a job. Similarly, "The Shed" program for older men in need of socialisation has provided a focus and meaning to their lives. These seemingly small initiatives serve to illustrate how the service model can best adapt and respond uninhibited by traditional program boundaries.

The Far East Gippsland Multi-Purpose Service approach is underpinned by a sound philosophy and rigorous practice framework. A model of service integration has been progressively conceptualised and is understood and practiced by all staff. Using a "treatment-prevention-support" paradigm, the service has been able to integrate acute care, aged care, community health, community support, domestic services and administration into a service that works to provide continuity of care according to identified needs. The ability to attract skilled and committed staff has greatly contributed to this model. It would appear that the flexibility offered by a MPS model has assisted in attracting staff to an organisation that links services, reduces professional isolation and provides opportunities for skills development. Far East Gippsland Support Service can now demonstrate a skill base that would have been inconceivable in this small rural community prior to the introduction of the Multi-Purpose Service.

Whilst the MPS model provided the launching platform for this successful service. the primary driver has been highly effective executive management, supported by a stable, effective Board. Governance and management have provided a sound foundation since the service's inception. The presence of effective executive management with a sound understanding of management, finances,

Multi-Purpose Services Program Evaluation, Victoria 117 Far East Gippsland Multi-Purpose Service clinical practice, social support and government programs, and a willingness to operate in an opportunistic manner cannot be underestimated as a major contributor to service development. The combination of knowledge and skills combined with vision and commitment transformed an opportunity into a reality.

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8. Multi-Purpose Services Program Evaluation Findings

he evaluation of the Multi-Purpose Services Program has identified significantly improved health and primary care service gains to small rural communities in Victoria. It has T established that the application of a single, flexible funds pool for each Multi-Purpose Service is a significant contributing factor in the success achieved in delivering coordinated and client centred health, residential aged care, primary health and community care service provision. Whilst the Program is producing effective outcomes in an innovative manner, it has also been established that existing accountability procedures are inadequate for whole of program accountability, although most Multi-Purpose Services have developed appropriate management information processes in their own right.

Overall, the Program is meeting its objectives. It serves as an exceptional demonstration of a flexible care service model for small rural communities. The flexibility inherent in the model provides the foundation for that success but it has also been established that experienced management, vision and an entrepreneurial perspective is required to realise its potential.

This concluding chapter evaluates the Multi-Purpose Services Program against the program objectives incorporated in the Terms of Reference67 (see Appendix 1). The report concludes with recommendations for the consideration of the Commonwealth Department of Health and Aged Car and Department of Human Services (Victoria) to inform future Multi-Purpose Service policy directions.

8.1 Issue 1: Nature and extent of change due to the Multi-Purpose Services model What actually changed in communities that adopted the Multi-Purpose Service model?

Four significant themes have been identified.

First, management and service delivery structures were enhanced. The delivery of services by multiple providers moved to a single governance model. This change of itself was a significant contributor to service development given that pre-MPS Boards and committees often lacked the expertise to effectively manage program developmental and accountability requirements, even though service delivery volumes were relatively low. Organisations frequently operated with part time positions, small program budgets and separate administrative and service delivery structures. Community expertise to manage the services was thinly spread and there was limited integrated continuity if care.

Secondly, service integration occurred. Service integration provided the basis for service expansion and reform. In particular it permitted existing services to expand and new services to be introduced based on identified need. Service integration was particularly enabled by all service providers working for the same organisation thereby avoiding multiple referrals and inter-agency case management. Staff could also adopt roles that extended uninhibited by traditional program boundaries each with their separate accountability requirements. Staff could also be multi-skilled and support clients according to need, whether they were requiring acute care or aged care. Specialist services, such as counselling, also became available to clients according to need.

Service integration also lead to the rationalisation and realignment of services based on need rather than funding availability, with the opportunity to downscale, eliminate or expand any one service without financial penalty. Multi-Purpose Services were restructure their staff profiles to an integrated community-wide program without loss of employment of total staff complements. All

67 The order in which the evaluation issues are considered has been rearranged to assist report continuity.

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Multi-Purpose Services have significantly expanded their workforce in accordance with service developments. Staff satisfaction increased as opportunities to work in integrated multi-disciplinary teams and this has assisted with professional workforce recruitment and provided the conditions to attract allied health professionals back to small rural communities.

Service integration also lead to a shift in the scale of service operations. Service amalgamation established a critical mass to permit the introduction of previously prohibitive developments, such as comprehensive staff training programs and the recruitment of service specialists such as youth workers or domestic violence counsellors. It was often possible to establish full time positions, make more effective use vehicles and develop resource libraries.

Thirdly, services expanded. All MPSs have demonstrated post-MPS service expansion, often of significant proportions. Communities that previously had narrow, traditional service regimes can now demonstrate a range of community services comparable to those of provincial cities.

Fourthly, service viability has improved. In all pre-MPS communities the financial viability of key services had been at risk. In most cases this applied to the hospital but it also included residential aged care facilities. Whilst not expanding to the budget, the Multi-Purpose Services Program permitted service substitution and rationalisation which contributed to improved cost effectiveness. In several instances (but not all), under utilised acute beds were been reduced and community services expanded, without reductions in occupied bed days. In other instances, residential aged care facilities have not been required to achieve financial viability, thereby releasing funds to support previous service gaps. This has been achieved without loss of acute or residential aged care services, even though the bed numbers may have been reduced. To the contrary bed-based services have become more responsive to community need by including respite, palliative care and a more appropriate mix of low and a high care residential aged care compared to stand alone, at risk, small rural hospitals with significant proportions of inappropriately accommodated nursing home type patients.

The primary mechanism that powers Multi-Purpose Service flexibility is the pooled budget, of which the contribution by the Acute Program is the most significant contributor. Pre-MPS cash out rates are based on a review of WIES payments three years prior to the formation of a Multi-Purpose Service and a Multi-Purpose Service is dependent on the level of pre-WIES for its future flexibility given that the MPS Program does not inject additional funds into the system.

Residential aged care funding also provides Multi-Purpose Services with the opportunity to redistribute funds if some beds are not required, but for most communities there is a continuing high demand for bed-based services. Even for communities where home based high care has been developed and all available residential aged care beds are required, a perverse incentive remains to fill beds because service providers lose the revenue generated from resident fees. Thus, for example, it costs Upper Murray Health & Community Services an estimated $100,000 in lost revenue by maintaining high care residents at home rather than in its residential aged care facility which currently has 8 vacant places.

Finding 1: Nature and extent of change due to MPS model Management and service delivery structures were enhanced; service integration occurred; services expanded and service viability improved. The Multi-Purpose Service Program has delivered significant benefits to small rural communities in Victoria including improved governance, service integration, service expansion and overall service viability. The future success of the model is dependent on the size and mix of the funds pool.

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8.2 Issue 2: Effectiveness of the Multi-Purpose Service Program How effective has the Multi-Purpose Services program been for small rural communities?

A related inquiry is to determine the extent to which effectiveness improvements are due to the Multi-Purpose Services model. "Effectiveness" is examined from the following perspectives: targeting of the identified needs of communities, improved access to services, increased coordination/flexibility/innovation, cost effectiveness and cultural appropriateness.

8.2.1 Issue 2a: Targeting community needs a) Cultural fit demonstrated The Multi-Purpose Service Program has clearly demonstrated improved targeting to meet identified community needs.

Multi-Purpose Services have completed comprehensive community needs assessments in their initial development periods, the results of which have been directly linked to service plans. Far East Gippsland, for example, includes a significant low income population and a high demand for social supports and the Multi-Purpose Service profile has been developed to reflect that community's specific needs. The service range includes all traditional acute, aged residential care, community health and HACC services, but it has been modified and extended the range to include counselling, domestic violence, youth support, drug and alcohol, supported accommodation, community support and community development programs. Whilst elements of these services existed prior to the Multi-Purpose Service, they now include a wider range of staff positions, full time support and the ability to provide integrated continuity of care for clients and avoid the need for inter service referrals. A similar matching of identified community need to service structures exists in Otway where child care and adult education have extended the traditional service regimes. Upper Murray MPS is a further sophisticated example of improved targeting to meet community needs. Mallee Track MPS has a simpler service structure, but it has developed effective links between community needs and services required by a widely dispersed community, as demonstrated by the maintenance and development of community nursing and support services to small, isolated farming communities.

It is concluded that most Multi-Purpose Services in Victoria demonstrate advanced "cultural fit" between identified community needs and the service profiles. Basic support services have been retained and improved and a health prevention dimension provided to address community well- being issues. Small, traditional health and community services have been replaced with integrated systems encompassing treatment, prevention, health promotion, rehabilitation and community development. These outcomes are consistent with the Ottawa Charter and policy objectives set by the AHMAC Rural Health Care Taskforce in 1990. Such outcomes are also supported by primary health care principles identified in the Healthy Horizons report of the Commonwealth Department of Health and Community Services and Rural Health Matters: Strategic Directions 1999-2009 report of the Department of Human Services (Victoria). b) Community needs identified Community needs were comprehensively identified in the initial phases of Multi-Purpose Service formation and several services are in the process of completing second needs surveys. Experience has shown that a new Multi-Purpose Service needs to undertake a sound needs assessment at the outset (in this the Upper Murray MPS provides an instructive illustration), but the second assessment should focus on areas of unmet or under developed need. The Multi-Purpose Services Program provides an effective framework for integrated service delivery and the service providers have demonstrated how health service structures can directly reflect identified community need and evidence based interventions.

Multi-Purpose Services Program Evaluation, Victoria 121 Multi-Purpose Services Program Evaluation Findings c) Client satisfaction Whilst all Multi-Purpose Services undertake individual service assessments (often as a component of their quality accreditation processes), there is limited evidence of a consistent assessment of client satisfaction assessment across all services within a Multi-Purpose Service. Each Multi- Purpose Service can demonstrate high levels of client satisfaction for individual services, but Boards of Management and Executives generally have no overall measure of community satisfaction and they are unable to quantitatively demonstrate changes to community attitudes to the service performance over time, other than through anecdotal feedback and service specific surveys.

Focus group sessions undertaken as part of this project suggest the likelihood of a high degree of acceptance of the Multi-Purpose Service does exist, but reliable, broadly based evidence is unavailable. d) Health outcomes In common with other health and community service providers, all Multi-Purpose Services use process indicators or output indicators as indirect measures of health outcomes and service provision and these are presented in previous chapters. Measures include increased occasions of service, the number of complex clients supported at home, clients referred for case management and related measures.

Upper Murray Health & Community Services is also attempting to measure health outcomes. The methodological limitations of measurement in small populations, the time period required to establish the validity of a health outcome and problems associated with the control of variables are acknowledged. Nevertheless, Upper Murray Health & Community Services has identified three health interventions which it is seeking to measure: • reduction in morbidity and mortality associated with cardio-vascular disease • reduction in morbidity due to acute asthma • reduced cancer incidence in the Upper Murray.

These outcome measures are matched against complementary service delivery, financial, personnel and asset/risk management key performance measures.

All services demonstrate improvements to process indicators since the introduction of the Multi- Purpose Service program. Both the range and volume of service has measurably increased.68

However, it should be noted that for small rural communities, service delivery growth trends may stabilise once all clients are integrated into the system. Once this point of service development has been achieved increases in occasions of service may become less appropriate than service quality measures of improved targeting.

Finding 2a: Targeting community needs The Multi-Purpose Service program in Victoria has demonstrated a high level of responsiveness to the identified needs of small rural communities. Improved time series measures of client and community satisfaction would assist in monitoring future service responses.

68 See previous chapters.

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8.2.2 Issue 2b: Access Improved access to services has occurred in all Multi-Purpose Services since their introduction.

Access developments have been demonstrated in the following dimensions: a) increased range of available services Most Multi-Purpose Services have increased the range of services available to the community, including significant service additions and developments. Otway MPS, for example, has 37 different services available to a community of 3,225, Upper Murray has 30 core services and 14 visiting services integrated into the service mix for a population of 3,264 and Far East Gippsland has 24 core services and a range of visiting services to support a population of approximately 4,500. Mallee Track has a narrower service range but it makes extensive use of community nurses to optimise access for clients. Alpine Health maintains a narrow service range and coordinates with local government and regional service providers. b) increased individual service utilisation A significant increase has occurred in the use of community health, community and home based services since the introduction of the Multi-Purpose Services Program.

A more appropriate use of services has also occurred. Bed-based services are managed according to need, with all Multi-Purpose Services adopting a flexible approach to bed utilisation. Acute, aged residential high care and aged residential low care beds are being managed as a continuum, with a flexible transition at the inter-service boundaries. Whilst all services maintain a core of beds in each service type, flexibility exists to modify use according to need. At the acute/residential high care interface beds may be used for respite or palliative care, whilst the aged high care/low care service distinction has been altered by ageing in place approaches.

There is no program-wide evidence of reduced access to acute beds as a result of the Multi-Purpose Services Program. Acute services offered to the community is similar in the pre and post MPS periods. Some acute bed numbers have been reduced, mainly by the more appropriate care of nursing home type residents and, in some instances by the transfer of maternity services to larger hospitals with more appropriate infrastructures. Reduced lengths of stay at hospital are leading to earlier returns to home than previously occurred.

There is limited anecdotal evidence in some localities of a small proportion of residents preferring to use general practitioners and hospitals in other townships for reasons for preference or to be near relatives.

Some Multi-Purpose Service experienced significant conflict with general practitioners in the initial years related to issues such as operating theatre access, conditions and maintenance of services and procedural facilities.

Finding 2b: Access The Multi-Purpose Service Program has significantly expanded the range of services available to small rural communities in Victoria, particularly community and primary health services. New service relationships have been developed without detriment to previously existing services.

8.2.3 Issue 2c: Coordination, flexibility and innovation Coordination and flexibility are the hallmarks of the Multi-Purpose Service model. Specific service approaches are also occurring but such methods are only innovative relative to traditional programmatic responses. They are a normal component of a Multi-Purpose Service.

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The Multi-Purpose Service provides a high level of service coordination, with benefits for clients. Each Multi-Purpose Service has based its coordinating mechanisms on local needs and preferences, with common elements including: • entry point advocacy. Clients can enter the service at any point and are linked into an integrated service structure • staff with a service wide perspective. Staff understand the whole-of-service options and linkages and are able to establish appropriate service responses. • single intake assessment. Multi-Purpose Services have introduced systems to reduce multiple assessments and to transfer information with the client • care plan preparation • continuity of care across services.

These processes are not unique to the Multi-Purpose Services model and are found in a wide range of other flexible care services. However, the Multi-Purpose Services Program also includes service integration which delivers all services from within a single service structure, thereby largely eliminating service brokerage approaches. Furthermore the Multi-Purpose Service model enables the service to respond to each person's needs. Services as diverse as financing the purchase of dentures for a client, taking a carer on holiday, increasing the quantum of services for as long as required, working with a client over an extended period until a problem is resolved, linking a broad range of services from emergency relief funding to housing/clothing/transport or counselling/home care/and activity programs may be accessed according to need. It is these added dimensions that provide the Multi-Purpose Services Program with the ability to be comprehensively responsive to individual needs.

Innovation is not an objective of Multi-Purpose Services but it is a common outcome. Most services demonstrate unconventional approaches in all dimensions of the service including management, staff and service development. A marked feature of the Program is the high level of staff satisfaction, relatively flat organisational structures, program management delegations, flexibility of staff to respond according to needs and not be constrained by program boundaries, inter-disciplinary work practices, opportunities to influence the service system and expanded opportunities for professional development.

Whilst innovation occurs in many other Programs, the Multi-Purpose Services Program provides the ability to regularly innovate as an element of standard practice, and importantly, to implement the innovation in a timely fashion without the necessity of identifying an external source of funds. Upper Murray Health & Community Services is sound example of this approach as illustrated by the incorporation of a small fitness gym as part of its commitment to staff health and well-being as is Far East Gippsland Support Service's Wilderness program to support youth at risk.

However, the infrastructure to support the Multi-Purpose Services practices (common assessment instruments, care planning records and information transfer mechanisms between programs) is commonly unsophisticated with limited evidence of application or analysis of data to assess service efficiency or effectiveness. This is partly due to the small size of the services and the priority placed in service provision rather than systems development. Future practice could be further enhanced by the development of appropriate electronic systems to track clients, measure service activity and determine service trends.

Finding 2c: Coordination, flexibility and innovation The Multi-Purpose Services model provides a flexible structure for the coordinating and facilitating services that are responsive to the needs of people living in small rural communities in Victoria. The combination of continuity of care best practice and funding flexibility raises service

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responsiveness to a high level. The introduction of improved client information systems would facilitate an improved understanding of processes and support service accountability measures.

8.2.4 Issue 2d: Cost effectiveness "Cost effectiveness" may be defined as the attainment of beneficial outcomes with the funds available for that purpose, and contrasts to "cost efficiency" which seeks to maximise productivity within a given budget. For most Multi-Purpose Services cost effectiveness is a process outcome rather than a targeted and measured objective. Many examples exist to support cost effective objectives but there is a need for a consistent data set to support a consistent whole-of-program assessment.

Cost effectiveness surrogates have been identified in the following areas: - service delivery indicators All Multi-Purpose Services demonstrate an (often significant) expansion of services since their inception, within the same underlying service budget. Examples include increased acute separations, higher bed occupancy, post surgical support, pre and post-natal care, palliative care and dialysis and expansion of community services. A wide range of indicators has been reported in previous chapters.

- budget efficiency indicators Multi-Purpose Services also demonstrate an effective application of available funds, which, is often incorrectly attributed as service substitution.

Service substitution within the Multi-Purpose Services model is a misnomer, as in most instances a similar level of service (such as acute care) is commonly maintained or more appropriately allocated (by, for example, the provision of aged high care at home or in a residential care setting rather than an acute bed). Program funds contributed to the funds pool (such as WIES or HACC) become flexible "MPS funds" and not a combination of program funds that are accountable back to their source. Former program funds are "cashed out" and combined into a new single budget pool. Examples of improved cost effectiveness arising from improved budget efficiency produced by the pooled budget, include early discharge to home based support services, effective use of acute beds by more appropriate care for nursing home type patients, home based palliative care, high level aged care in the home and home based rehabilitation. Whilst these cost effective measures are not solely attributable to the Multi-Purpose Service model and may occur under other models and programs, the benefits are retained in the same organisation and can applied to any area of identified community need.

- economy of scale indicators Most Multi-Purpose Services have expanded the size and diversification of services. This has permitted the development of services that would not have been sustainable under former operating platforms. Specialist services such as counselling and certain allied health services, for example, are now more available and can be provided without a cost increase due to service amalgamations and a larger client base. A speech therapist, for example, may work across acute care, residential care, community care and home care sectors as required, as might a counsellor or health educator.

- workforce indicators All MPSs have expanded their workforce since the introduction of the service. Data collection across Multi-Purpose Services does not facilitate comparative analysis but growth in total workforce has been facilitated by the success of services in attracting new programs and expanding services, without a change to the underlying Multi-Purpose Service budget. The leverage provided

Multi-Purpose Services Program Evaluation, Victoria 125 Multi-Purpose Services Program Evaluation Findings by the flexibility of the Multi-Purpose Service model has enabled the services to grow the business and provide additional services to the rural communities. e) cost saving indicators The Multi-Purpose Service Program has also facilitated service cost savings, although this is not a program objective.69 Examples include recurrent salary cost savings achieved at Corryong through the use of night shift staff across acute and residential aged care settings and a cost saving to the community by adopting a salaried Medical Officer model of medical care. Most Multi-Purpose Services have also been able to achieve cost savings by the elimination of administrative duplications and the introduction of simpler management structures.

In addition Upper Murray Health & Community Services has sought to provide an evidence-based approach to support the effective allocation of resources70. Allocative efficiency requires a high level of knowledge of health service needs and an understanding of the effectiveness and cost effectiveness of service that can meet those needs. Using research to identify evidence-based, cost effective interventions and a comprehensive community consultation process, Upper Murray MPS has attempted to identify practices and services that will deliver the most effective outcomes for available funds. It is providing services in accordance with this evidence-based framework and represents one of the most significant attempts to achieve allocative efficiency across a population based health service in a small community. Evidence to date suggests that a high prevention (including primary prevention, treatment and rehabilitation), high support based model of service delivery will have the highest utility for rural communities, and this represents a significant established finding and is an MPS outcome of benefit to all rural health services.

Finding 2d: Cost effectiveness The Multi-Purpose Service Program has provided the conditions for a more cost effective service structure. Cost effectiveness indicators are being developed in service delivery, budget efficiency, economies of scale, workforce development and service cost savings. Evidence based analysis has found that a high prevention, high support based model of service delivery has the highest utility for small rural communities.

8.2.5 Cultural appropriateness Otway, Mallee Track, Upper Murray and Far East Gippsland MPSs all support rural catchments predominated by people of English speaking backgrounds and cultures. The Alpine Health catchment includes a long standing community of Italian heritage who relate to the generic services. Given the small numbers of people from other cultures no Multi-Purpose Service was found to take particular approaches for people from diverse linguistic and cultural backgrounds. Each service reported that support clients individually according to their identified needs.

Far East Gippsland also includes an Aboriginal and Torres Strait Islander community (353 persons in 1997) which is primarily supported by Moogji Aboriginal Co-operative (a Community Controlled Health Organisation) located in Orbost. As reported in the Far East Gippsland Support Service evaluation (see Chapter 7) Moogji reported a positive working relationship with the Multi- Purpose Service, particularly in youth support programs, Maternal and Child Health and supported accommodation assistance. Several gaps for Koori health were also identified including mental health, counselling and other services as reported above. Anecdotally, up to 15% of community health business conducted by Far East Gippsland Support Service is provided to Koori clients.

69 "The (MPS) approach is designed to bring about a redistribution of program funds going into a locality rather than to be used by either the States/Territories or the Commonwealth to achieve program savings." Multi-Purpose Services Taskforce Final Report 1992 p15 70 See, Evans F. and Hoodless M., Achieving Allocative Efficiency Through Evidence-based Needs Assessment (1999)

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Overall, limited evidence suggests that a sound working relationship is functioning between the Far East Gippsland MPS and the Koori community.

Overall finding on program effectiveness The question to be addressed in this section was "How effective has the Multi- Purpose Services Program been for small rural communities?" Detailed comparative program indicators have not been developed to quantify effectiveness measures. However, there is site related evidence of effective targeting of community needs, high levels of service satisfaction, increased service access (particularly to community health, community care and well- being services) without loss of acute services, exemplary levels of service coordination and individual client focused service development. These service developments have been achieved without budget supplementation, other than that derived from additional contracts competitively attracted by Multi-Purpose Services71. Evidence has been established to support the finding that high prevention, high support based models of service delivery produce the highest utility (effectiveness and cost effectiveness) for rural communities.

8.3 Issue 3: Impact of the Multi-Purpose Service model on clients This evaluation has also considered the following: "What impact has the Multi-Purpose Services model had on clients and have community needs been appropriately met?"

There is clear evidence that the client service choice, appropriateness of care and continuity of care have improved in communities supported by Multi-Purpose Services and, in several instances represent sound "best practice" case studies for rural community health and community support service systems.

Most Multi-Purpose Services are able to provide case study evidence of positive outcomes directly attributable to the service model. The case study of Mrs X in Corryong72, for example, demonstrated that the application of a client centred continuity of care approach produced an outcome which enabled the consumer to remain in her home with her husband, for both people to be appropriately supported and for Mrs X to regain access to community activities. Had this level of support be unavailable service it is highly likely that she would have been admitted to residential care and separated from her husband. The achieved outcome was directly attributable to the service provided by the Upper Murray Health & Community Services team but it is not unique to the Multi- Purpose Services model. Many other programs can demonstrate similar outcomes. It is likely that the client centred principles inherent in the Multi-Purpose Service model are capable of demonstration under several models (such as Primary Care Partnerships, Community Options, Rural Health services, Healthstreams, Coordinated Care Trials and others) but the benefit of a single, pooled MPS budget facilitates responsiveness to individual client needs.

One significant advance in client centred care that is being increasingly understood relates to the benefits accrued from removing program boundaries when servicing small rural communities. The clearest example relates to residential aged care services, although similar benefits can also be identified in community health and community care services. The Multi-Purpose Service model enables providers to base service provision on "service appropriateness" rather than service efficiency measures and the fact that 8 of the 20 high care beds in a high care residential facility in

71 This evaluation is focussed on the Multi-Purpose Service Program as a whole and did not evaluate individual Multi- Purpose Services viability. 72 See Chapter 6

Multi-Purpose Services Program Evaluation, Victoria 127 Multi-Purpose Services Program Evaluation Findings one Multi-Purpose Service are not filled and that 12 high care residents are being supported at home, clearly demonstrates the flexibility of the model to respond to client needs. The model offers the opportunity to manage the needs of clients and not fill beds to justify service effectiveness. The model also permits a timely response to identified need and, if necessary, an MPS can offer residential care places immediately if it is required. Similarly, the flexible management of all bed based services optimises responsiveness to community needs. This client centred approach is only possible if there is a single budget, staff structures link across traditional program areas and the services are encouraged to measure performance based on client outcomes and not facility occupancy.

Links between Multi-Purpose Services and sub regional services have also been well established and all Multi-Purpose Services incorporate regional services (such as mental health counselling) into their services. Further consideration needs to be given to effectiveness of these arrangements, with current arrangements being appropriate to some Multi-Purpose Services and cashing out some of these services into the MPS funds pool requiring further consideration in other instances.

Focus group responses from this project, although unrepresentative, provided a positive indication of the impact of the Multi-Purpose Service on clients, with the results confirmed by supporting information provided by service providers. Table 8.1 indicates that focus group participants rated an "improvement" or "significant improvement" to services since the introduction of the Multi- Purpose Services Program into their community. Other similar positive ratings of service performance are included as Appendix 3.

Table 8.1 How would you rate the change in health and community services in this community today, compared to about five years ago? Multi-Purpose Service Improved Significantly improved Don't know# (per cent) Otway 35.3 58.8 5.9 Mallee Track 66.7 33.3 0 Alpine 76.9 7.7 7.7 Upper Murray 16.7 83.3 0 Far East Gippsland 45.5 36.4 18.2 Total (average) 48.2 43.9 6.4 * No neutral or negative ratings provided by respondents # Participant may not have lived in the area five years ago.

The single identified weakness of the Multi-Purpose Service Program identified for clients relates to issues of client rights and safeguards. Although all services accord a high priority to client rights there is no consistent program-wide approach or access to an independent complaints resolution system.

Finding 3: Impact of Multi-Purpose Services model on clients The Multi-Purpose Services model has increased choice, care coordination and client centred care for small rural communities in Victoria. The range of services has expanded and is responsive to identified community needs. Available indicators, including community feedback, suggest that the Multi- Purpose Service has produced significant benefits for rural clients.

8.4 Issue 4: Key factors for MPS success What, then, are the key factors of success for the Multi-Purpose Services model?

It has been possible to identify pre-conditions that should be met to implement a successful Multi- Purpose Service.

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They are: - Small communities All successful Multi-Purpose Services examined in this project have been small catchments, commonly populations of 3,000 to 4,000. Community size is a determinant of service complexity and small communities have simple service arrangements. The Alpine Health clearly demonstrates the barriers that exist when attempting to introduce a vertically integrated model of service delivery into a larger community.

Commonly the small service services also means that efficiency thresholds cannot be achieved due to part time positions being meet a range of requirements including accountability, administrative and service delivery. In addition., small communities are likely to have service viability pressures and an inability to attract professional staff to provide a service. Service management expertise is also likely to be limited and the infrastructure required to provide a service may be under developed. These limitations can be addressed by the Multi-Purpose Services model.

- Contiguous service boundaries It can be demonstrated that successful Multi-Purpose Service implementation occurs when amalgamating core services exist within contiguous service boundaries. Instances of multiple catchments within a single service area creates complexities for funds pooling and promoting service amalgamations. In Alpine for example, two community health services were based outside the proposed MPS service catchment and their catchments included only part of the Alpine Health catchment, and they did not join the MPS. Any complex pre-MPS service structure has the potential to affect the successful implementation of a Multi-Purpose Service.

- Single set of pre-MPS services Services that include multiples of the same service type may create barriers for the successful implementation of a Multi-Purpose Service. For example, if there are several hospitals, experience shows that those rural communities are likely to be concerned with service rationalisation. Most rural communities examined in this project wish to retain their traditional service structures and were opposed to any loss of service, and they were threatened by new structures. The community acceptance of a Multi-Purpose Service proposal has a higher chance of success if benefits are maximised and losses minimised, and this normally involves the removal of threat to existing institutions and services.

However, it is possible to establish a Multi site Multi-Purpose Services where several services of the same type exist, provided that the proposed changes do not threaten existing structures. For example, the Mallee Track catchment included a significant district hospital and three bush nursing services and there was perceived benefit to the small communities in joining an alliance that would be supported by the larger health provider.

- Common community Areas with a common community have greater success in forming a Multi-Purpose Service than those with several towns of similar size and structures. Again, Alpine with three distinct, similarly sized towns each with their own cultures, historic antecedents and infrastructure had reduced commonality of purpose (other than to save their hospitals) and this created barriers for service integration. Ideally the community should also be supportive of the proposed change, and this is often difficult to achieve. Most Multi-Purpose Services had to transit through a period of reluctant acceptance until such time as the benefits of the restructure became apparent.

- General practitioner support The gaining of general practitioner support for the change is also important. Far East Gippsland MPS clearly understood this issue and worked closely to ensure that they provided the

Multi-Purpose Services Program Evaluation, Victoria 129 Multi-Purpose Services Program Evaluation Findings infrastructure, skilled professional staff and support services to enable doctors to provide a medical service to the community. Other Multi-Purpose Services which experienced conflictual relationships with general practitioners who felt threatened by loss of control and perceived reduced service access, had difficult gestations. Particular barriers exist when there is a larger number of general practitioners distributed across several practices and there is associated relationships with hospitals. This issue presents a challenge for new Multi-Purpose Services and requires awareness, well developed support strategies and the development of inclusive consultative mechanisms from the outset.

- Capital incentives Although facility redevelopment grants are independent of Multi-Purpose Service Agreements, all Multi-Purpose Services examined in this project came with the undertaking of capital funding. All Boards indicated that the promise of redevelopment grants was foundational in achieving community acceptance for the change to a Multi-Purpose Service , and several suggested that they would have been unlikely to accept the reforms without that incentive, given the that model does not provide additional recurrent funding. Multi-Purpose Services that took several years to achieve community acceptance were often those whose building program was delayed, compared to rapid acceptance from communities that saw early evidence of redevelopment. g) Management expertise The attainment of appropriate management expertise is fundamental to Multi-Purpose Service success. Successful Multi-Purpose Services are those that have a Chief Executive Officer with the following skills: • Program knowledge. This includes an understanding of acute, residential aged care, HACC, community health and community service programs, and expertise in more than one of these sectors.

• Management expertise. Management experience should include a combination of financial, human resource management (including a sound appreciation of industrial relations) and service management. Services that have only focussed on one of these dimensions were unable to fully implement the model.

• Vision. The Chief Executive must be capable of understanding the potential offered by the MPS model and of translating that vision into a reality. The Multi-Purpose Services Program provides the framework to develop successful services but it relies heavily on executive vision to operationalise its potential. CEOs should ideally have a sound community development perspective.

• Entrepreneurial skills. The Multi-Purpose Service model has few service development boundaries and successful Chief Executives have demonstrated entrepreneurial skill in attracting additional program funds into the program. One MPS has incorporated the SAAP program and another adult education and child care, according to identified community needs. One Multi-Purpose Service has expanded its budget from $2.8mil. in 1995 to $4.3 mil in 1999/2000 for a community of little over 3,000 and others have also been able to attract funding from additional programs. Another MPS supports a staff establishment of 71EFT and is a significant component of the rural economy, as are all Multi-Purpose Services.

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These seven key factors for success for Multi-Purpose Service implementation may in considered as two groups: Group 1: Pre existing conditions These include small population size, contiguous service boundaries, single set of services and a common community. Consideration should be given to the achievement of these four factors as an entry level pre-condition of a potential Multi-Purpose Service.

Group 2: Developed conditions The remaining desideratum for a successful Multi-Purpose Service include general practitioner support, capital incentives and management expertise. The importance of each factor will vary between sites but ideally all pre-conditions should be developed.

Finding 4: Key factors for MPS success The key factors for success (KFS) of a Multi-Purpose Service occur in two broad groupings. Group 1 may be termed "pre MPS conditions" and should include a small population, contiguous service boundaries for core existing services, a single set of services and a common community. Group 2 KFSs may be termed "developed conditions" and include general practitioner support, capital incentives and management expertise.

8.5 Issue 5: Barriers to successful MPS implementation What then are the barriers to successful implementation of the Multi-Purpose Service model?

The Project Brief indicates that consideration be given to barriers at the developmental stage, during the first triennium and subsequent phases. It was found that these time distinctions become blurred particularly between the pre-MPS and first triennial period because many developmental issues extended for several years following the signing of the Tripartite Agreements. Nevertheless it is possible to broadly consider barriers applicable to each phase. a) Development phase Barriers during the development phase were the most challenging for Multi-Purpose Services. Four of the five Multi-Purpose Services experienced considerable problems over a long period (up to four years) before a stable, successfully operating service was established. The only service that had a smooth commencement (Far East Gippsland MPS) met most of the identified pre-conditions for a service from the outset, particularly the identification of an effective Chief Executive Officer to drive the change process.

The Development Phase barriers may be broadly grouped into the following categories: • Uncertainty and suspicion. Most Multi-Purpose Services considered that the proposed model was being imposed upon them. There were two related agendas which included the establishment of viability for small rural hospitals around the time of case mix funding introduction, and the introduction of a new Commonwealth/State initiative (the Multi-Purpose Services Program) which offered the potential for improved health services but came without additional funding. The new model required the dissolution of long established committees of management and their replacement with a single Board. Boards reported that the new proposition was long on rhetoric and short on detail. Communities considered that they had to commit to the concept and take the chance that it would be effective, without funding guarantees beyond the first three years. Some community committees also felt threatened by the larger organisations (particularly hospital boards) and considered that they would lose control of their services.

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Thus the first learnings from these experiences are that: - preliminary investigations should be undertaken to identify communities are likely to best meet the pre-conditions for MPS development. Other models (such as Healthstreams or Regional Health Services) may be more appropriate for some communities. Ideally the initiative should come from the community. - there is a need for detailed information to be available to communities at the initial discussion stage. (This was not possible to achieve when the Multi-Purpose Services Program was first introduced). - a participatory consultation process should be lead by professionals experienced in community development before a commitment is made to the change. - fundamental service redevelopment should not be driven by the need to resolve specific short term service viability problems. - Government mechanisms should be in place to support and develop the process during the negotiating phase, extending into the early years of operation..

• Chief Executive Officer selection. Most communities felt that they had neither the control, the expertise nor the resources to effectively negotiate the change process with Government. There were multiple expectations of Government Departments (amalgamations, needs identification, legal negotiations and maintenance of existing services in an environment of uncertainty) but not the resources address these demands.

Experience shows that: - resources need to provided to support the change process - an experienced local "change agent" is lead the community at this time.

• General practitioners and staff participation Existing service providers often considered that they were peripheral to the decision making process and placed in defensive positions. There was concern for loss of jobs and lack of clarity relating to the role of general practitioners in the new service. This identified barrier indicates the need to develop an inclusive and effective dialogue with those directly impacted by the proposed change. b) First triennium Many of the issues that existed during the development period had not been fully resolved at the time of the signing of the MPS Tripartite Agreements and this created implementation complexities whilst Boards and management sought to resolve whilst service redevelopment commenced.

The identified barriers during this phase may be broadly grouped into the following categories:

• Continuing uncertainty. Several Multi-Purpose Services reported that once the Service Agreement was signed they did not receive on-going departmental support. Boards considered that they were operating in a vague policy and financial environment and in most instances did not have a Chief Executive with the appropriate mix of skills to operationalise the MPS concept. A wide range of problems continued including the difficulty of releasing historic allegiances and practices, establishing new systems, managing a confusing budget process, uncertainty as to whom the organisation was responsible and what was expected of them, undertaking significant community consultations whilst maintaining services, managing an uncertain (and sometimes hostile) industrial environment and similar matters. Boards and staff progressively addressed these challenges and stability and progress was achieved.

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The main learnings from this period are that: - CEO appointment. Boards should seek to identify an effective Chief Executive Officer as their highest priority and be prepared to change that position if the incumbent is not appropriate to the task.

- Proactivity. Boards need to also take a proactive stance during this period. Multi-Purpose Services bring a high level of accountability for the services provided to a community and the model provides them with the ability to drive the service system within a broad policy framework. Thus Boards of new Multi-Purpose Services should proceed to identify their strategic directions and develop a service plan as a high priority. All Board members may not have the expertise required to govern such as a service and may require support to develop their role73.

• Multiple expectations. During the initial years of operation there is a pressure to meet multiple expectations and this is often occurring in a climate of uncertainty and major change.

This experience suggests that: - Programmed development phases. There is a need to address development tasks as a phased sequence of events, with each phase supported by appropriate processes, detailed information, departmental support and agreed timelines.

- Systems development. Early priority should be given to developing reporting systems that link to organisational strategic plans and Departmental accountability requirements.

• Facility redevelopment delays. Facility redevelopment delays can lead to loss of community confidence in the model and limitations the organisational changes required to achieve the cost savings that are necessary to implement new service developments.

The learning from this experience is that facility redevelopment is a significant contributor to service redevelopment and should occur as a part of the service planning process and commence as soon as practicable. c) On-going Four main themes have been identified as on-going issues for Multi-Purpose Services in Victoria.

They are: • Program guidelines. The development of comprehensive program guidelines would assist many of the identified barriers to Multi-Purpose Service implementation.

• Program management responsibility. The clarification of reporting responsibilities of Multi- Purpose Services to Commonwealth and State Departments, including Regional Office roles would assist service accountability.

• Program accountability. The existing MPS Program Accountability arrangements have been found to be inconsistent, unreliable, overlapping and incorporating elements of both program and pooled funding models. Further, the required data is not directly linked to Service Agreement Performance Indicators, the supplied data is not analysed and there is no formal system for monitoring of the Program as a whole. This situation is symptomatic of the

73 It is noted that a draft Multi-Purpose Service Board Resource Manual was developed in 1999.

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significant number of priority issues that have required management during the establishment of the Multi-Purpose Services. Now that most Multi-Purpose Services are stable, well managed services, it is appropriate that this next phase of Program development be further addressed74.

• Testing the limits of the Multi-Purpose Service model. Some Multi-Purpose Services have extended the service model to its current limits and have limited options for further budget expansion or financial leverage resulting from further restructuring. Both Upper Murray Health & Community Services and Far East Gippsland Support Service are close to their limits of growth under current funding arrangements.

The demonstrated success of Multi-Purpose Services suggests that it is an ideal model for testing new service concepts. It is possible to introduce innovations and measure outcomes under controlled environments largely due to the small size of the services and their relative isolation. One such area for possible future exploration may be the cashing out and pooling of Medicare Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS) funds as provided for under the Aged Care Act 1997. Consideration might be given to appointing the Upper Murray Health & Community Services to undertake a feasibility study incorporating MBS and PBS into a shadow budget arrangement for one year to assess the likely financial benefit to a rural community that might accrue of these services were incorporated into the MPS budget pool.

Finding 5: Barriers to successful MPS implementation Significant barriers occurred for most Multi-Purpose Services during their development and initial operational phases, and it took several years to establish stable, successful services. These barriers can be addressed through the introduction of program guidelines, affording priority to the development of MPS Boards, the early recruitment of skilled Chief Executive Officers, the development of an appropriate sequence of developmental activities and the introduction of reporting arrangements and accountability systems designed to relate to MPS program objectives.

8.6 Issue 6: Multi site versus single site implementation issues Consideration is given in this section to the question "Under what conditions are multi-site Multi- Purpose Service models successful?"

Three Multi-Purpose Services examined in this project are single site models and two are based on a multi-campus approach. The two multi-site models illustrate different sets of issues. For the Mallee Track MPS, the service is based at a major centre (Ouyen) with service delivery centres in small isolated rural townships (Patchewollock, Underbool and Murrayville) and the model acknowledges and enhances the pre-MPS service delivery structure. All communities are represented on the Board and staff from all sites participate in service planning and delivery. All significant services are based in Ouyen with outreach to other communities as appropriate.

This Mallee Track model effectively operates in the same manner as single site Multi-Purpose Services, the only significant difference being that the outposting of a single position in each of the

74 Work commenced on the development of a MPS accountability framework and a consultancy report was produced in March 1999. See, Harrison D., and Hoffman D., Multi-Purpose Services Output-based Services Framework Latrobe University with Health Care Consulting Australia Pty Ltd and AusCARE Pty Ltd.

Multi-Purpose Services Program Evaluation, Victoria 134 Multi-Purpose Services Program Evaluation Findings smaller communities under the multi-site model. The retention and redevelopment of facilities in each small community is the distinguishing feature, rather than provision of services to these communities. All Multi-Purpose Services provide services to outlying communities but they do not necessarily maintain a facility. This facility-based recognition is of particular significance to rural communities and represents a significant benefit of the Multi-Purpose Service model. Communities like Patchewollock with a population of approximately round 200 are largely bereft of facilities and the loss of a community nurse, ambulance service and community centre with visiting medical and allied health services would significantly affect the town's future. Whilst it would be an exaggeration to contend that loss of these services would close the towns, it is clear that these long established small rural communities would be forced to travel long distances to receive basic health and community support and an important focus of community life would be lost, particularly given the fact that the MPS facility is used for a wide range of community purposes. The Mallee Track MPS has demonstrated that it is possible to provide enhanced health services to small rural communities without significant cost increases, and as such is an important contribution to rural Australia.

Alpine Health is a contrasting example of a Multi-Purpose model. It has three dominant sites of relatively significant status and the MPS is administratively based at one site but the service operates effectively as three services, with some inter-linkage. Like Mallee Track MPS, this approach acknowledges community structures and a single site model would have been impossible to implement. However, as established in the review of Alpine Health (see Chapter 5), this arrangement does not meet the pre-conditions for a Multi-Purpose Service and the introduction of a multi-site approach into an area with several hospitals and established and parallel service structures creates major barriers for the effective operation of a vertically integrated service model.

Finding 6: Multi-purpose versus single site implementation issues Multi-site Multi-Purpose Service arrangements are of benefit and best suited to communities where services in small outlying centres are maintained and reinforced by their association with a larger service centre. Multi-site models incorporating several towns with similar size each with a hospital and similar service structures are likely to have significant barriers to effective implementation.

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Figure 8.1 Patchewollock Service Centre, Mallee Track MPS

Figure 8.2 Community Nursing, Allied Health and General Practitioner Clinics, Patchewollock (Population 200)

8.7 Issue 7: Likely impact of current initiatives The final issue for consideration relates to the position of the Multi-Purpose Services model and the question addressed in this review is "What is the future of the MPS model relative to the emerging flexible and coordinated health service initiatives."

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The Multi-Purpose Service Program has delivered significant benefits for small rural communities in Victoria and demonstrated how a vertically integrated approach can be operationalised. And the model is at the forefront of population-based health service innovation in an area of traditional structural problems for rural Australia such as professional workforce recruitment and retention, the provision of basic services and health service viability. However, it also been established that the model is often a significant challenge for communities and is benefited by capital incentives and it requires an extended developmental period. It has also been found that the model works best when certain pre-conditions are met.

These findings suggest that the Multi-Purpose Service whilst being a major success may not be appropriate for all rural communities and represents one option for coordinated and enhanced rural health service delivery. Perhaps its major limitation is the time required to develop and implement the service reforms. Its major benefit has been the flexibility offered by a pooled budget approach to health service delivery for small rural communities. The success of the model is also highly dependent on the size of the pre-MPS budget, particularly the acute health and aged residential care components as this provides the majority of the base funding base for service reallocation.

The recently introduced Regional Health Services (RHS) Program provides an added option for small rural communities. The RHS Program is likely to benefit a larger number of rural communities than the Multi-Purpose Services Program and to provide primary health care funds within relatively short timeframes. This program offers particular benefits to small communities requiring additional resources to fill specific service gap. For Multi-Purpose Services, the Regional Health Services Program provides an added opportunity for further service growth and conducting planning exercises and needs analysis. It also provides potential Multi-Purpose Services with the opportunity to explore the flexible services model.

Similarly the State funded Healthstreams Program offers another alternative for rural communities. It offers the opportunity for WIES substitution to support the development of other services according to identified need.

The Victorian Primary Care Partnerships (PCP) strategy may also be considered as a complementary development. It seeks to develop primary care systems across both urban and rural communities and is based on voluntary alliances between existing service providers. Four of the five Multi-Purpose Services examined in this review have joined Primary Care Partnerships. The two programs have been found to be potentially mutually supporting. The main benefits for Multi- Purpose Services include the opportunity to participate in integrated service planning for the catchment, improved linkages to regional and specialist medical services and access to larger scale health promotion programs and the associated funding. It also offers the opportunity to localise health promotion services which would be otherwise unavailable to small rural communities. For other members of the PCPs in rural regions considerable learnings can be obtained from Multi- Purpose Services including evidence based needs assessments, health service planning, coordinated service delivery approaches and population health development.

All participating Multi-Purpose Services reported that PCP strategy development is in its initial phases and the relationships with and impacts on Multi-Purpose Service have yet to be identified.

Finding 7: Likely impact of current initiatives The range of programs encouraging flexibility and integration to rural communities are complementary to each other.

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8.8 Issue 8: Program accountability The most significant issue to emerge from the evaluation of the Multi-Purpose Services Program has been the need for improved program accountability and the question to be addressed in this concluding section is "What actions are necessary to develop a Multi-Purpose Services Program Performance Accountability Framework?"

8.8.1 The problems As currently structured it is not possible assess the performance of the MPS Program in a consistent, whole of program manner.

The following problems have been identified:

1. Program Guidelines There are no detailed guidelines to provide a baseline for program development and operation. Information is provided in a range of publications and draft internal working documents but there is no comprehensive to manual that specifies all elements of the program to service as a baseline for program development and accountability.

2. Funds pool As currently structured there is a lack of clarity in the relationship between the formation of the MPS funds pool and program financial accountability. The MPS funds pool is formed by the cashing out of funds from a range of programs into a single budget for each Multi-Purpose Service based on an established formula (Figure 8.1). These funds are then applied by Multi-Purpose Services to a wide range of health and community services based on identified need, and these services may bear limited relationship to the basis upon which the contribution was made by each Program to the funds pool. For example, an MPS may receive the funds for aged residential high care beds cashed out at RCS 3 but may decide that a wide mix of services is required to meet its community needs, including fewer aged care places and expanded community care services. Under these conditions it is not possible to account for expenditure based on funding contributions from Programs that no longer hold.

ModelModel ofof MPSMPS ThroughputThroughput

HACC Res. aged care OTHER WIES Funds pool

Service activity

Occupied bed days Occasions of service

Acute Residential Care HACC Direct Care Hours

Figure 8.1 Multi-Purpose Services Funds Pool Conceptual Relationships

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The existing performance accountability arrangements does not provide a framework that measures Multi-Purpose Service business in accordance with its operational model. Rather, the existing system includes some elements of pre-MPS model and others that apply to the Multi-Purpose Service Program.

3. Relationship between Performance Indicators and reporting systems. Multi-Purpose Service Tripartite Agreements specify performance indicators but there is no relationship between these indicators and the current MPS reporting system and hence it is not possible to quantitatively or consistently assess performance against specified objectives. Most Multi-Purpose Services have developed sound internal reporting frameworks but there is no comparability with other Multi-Purpose Services.

4. Data definitions. There is no standardisation framework for data reporting which creates problems for both intra MPS and inter MPSs comparisons. It is often unclear whether the data reported in one year is the same as that reported in the previous year, particularly in regards to staffing categories, but less in terms of services. Each Multi-Purpose Service also reports data according to their own service structures and in one instance all allied health services may be consolidated and in another a distinction may be drawn between outpatient allied health and home based allied health services. Nor is there is there consistency in the definition of "allied health". There is also a possibility of double counting and this is not possible to establish due to lack of definitional rigour. Further, definitions may change between recording periods with the same service included in another service category to better reflect a service development, thereby invalidating time period comparisons. Differences also exist between in the dates selected for information reporting, or there is lack of clarity on the reporting period.

5. Incomplete records. Several instances exist of missing data. This may be due to changes in recording systems within an Multi-Purpose Service and be reflective of the developmental nature of the services. Most Multi- Purpose Services have sound information collection systems and have demonstrated the application of the data in monitoring program performance at their sites.

Finding 8: Program accountability The Multi-Purpose Services Program requires the further development of guidelines and an accountability framework. Whilst significant benefits can be demonstrated at each service site, the current reporting arrangements are inadequate to quantify program performance on a consistent basis across sites and time periods.

8.8.2 Towards an MPS Performance Framework There is a need to develop an MPS Performance Framework that clearly addresses the following issues:

• Program guidelines. Agreed guidelines are required to define the operational parameters of the program and improve transparency through improved program accountability.

The guidelines should encompass: - program objectives - program management and accountability guidelines - MPS development guidelines - funding guidelines

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- program performance measures75 - program administration guidelines

It would be appropriate for a working party to be formed to develop the guidelines, supported by a Project Officer.

• MPS Performance Framework It is proposed that every Multi-Purpose Service be required to submit an (annual) MPS Accountability Plan.

That plan should have two components: a) MPS Program Indicators. A common core set of MPS indicators should be identified and linked to defined data items that meet the core accountability requirements of contributing Departments and Programs. It is envisaged that the core indicators be limited to a key item data set of approximately 10 items. The principle of a monthly Financial Report, Quarterly Activity Report (with refined content) and Annual Report is sound.

It is also proposed that the Department of Human Services prepare a Multi-Purpose Service Program Annual Report based on the core data set. a) MPS Specific Indicators. Multi-Purpose Services should be permitted to develop performance measures that are specific to their services, given that each Multi-Purpose Service is a unique service model. However, there should be a requirement that each Multi-Purpose Service demonstrate their proposed performance framework and establish agreement with their Department of Human Services Regional Office and the Department of Health and Aged Care, including evidence of a Management Information System (MIS) report that is forwarded monthly to the Board. MPS Annual Reports should continue to demonstrate yearly performance and include the MPS Program indicators and highlights of service performance, including comparisons with previous years and be provided to the State and Commonwealth.

• MPS Planning Framework There is a need to clarify the planning framework within which the Multi-Purpose Services operate and to clearly establish the reporting and accountability linkages. The following conceptual framework has been established to facilitate development of this issues.

The MPS planning framework may be envisaged to consist of the following elements:

Step 1: Community needs assessment: The process commences with an Evidence-based Needs Assessment report. It is suggested that the proposed MPS Program Guidelines include a template for preparation of this report, including guidance on the topics to be addressed, sources of information and community consultation processes. The Upper Murray Health & Community Services Evidence Based Needs Assessment 1997 and recent experience in refining that process may be an appropriate basis for consideration.

75 Useful references: Second National Report on Health Sector Performance Indicators (June 1998). National Health Ministers' Benchmarking Working Group. AGPS Third National Report on Health Sector Performance Indicators (June 1998). National Health Ministers' Benchmarking Working Group. AGPS

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Community Needs Assessment

Figure 8.2 Evidence Based Needs Assessment

Step 2: Service Plan: A Service Plan (or Corporate Plan) provides a detailed three year strategic direction for the organisation. That plan should include identified strategic issues, objectives, strategies, actions, target outcomes, timeframes and nominate responsibility for the each item. The Corporate Plan should also include the proposed MPS Accountability Plan.

It may also be appropriate to develop a separate Strategic Directions document as a precursor to the Corporate Plan. Such a document would identify the organisational mission, strategic principles, organisational structures and broad planning framework. The Otway Health & Community Services Strategic Directions report is one example.

This Plan should be agreed and signed off with the Regional Office of the Department of Human Services and confirmed with the Department of Health and Aged Care.

DHS/DHAC Consultation and Community sign-off Service Plan

Community Needs Assessment

Figure 8.3 Corporate Plan

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Step 3 : Service delivery and performance monitoring: Services are then provided in accordance with the Corporate Plan, with periodic performance monitoring. It is this latter part of the process that is currently inconsistent and under developed on a whole-of-program basis. There is a need to ensure that financial and health outcome measures are identified and realigned to the financial input streams, with outputs that provide consistent measures and a reliable level of service accountability.

MPS Service Activity

DHS/DHAC realignment of input DHS/DHAC streams with output • Financial Consultation and streams performance by Community sign-off service type Service Plan • Health outcomes

Community Needs Assessment

Figure 8.4 Service Performance Monitoring Step 4: System maintenance: The planning cycle then continues, with progressive refinements as required. Successive Evidence-based Needs Plans need not be at the same level of detail as the initial plan and may include refinements. Similarly, Corporate Plans should be produced on a rolled out basis, with annual adjustments. The MPS Accountability Plan component of the Corporate Plan should be agreed with the Department of Human Services and the Department of Health and Aged Care annually.

MPS Service Activity

DHS/DHAC realignment of input DHS/DHAC streams with output • Financial Consultation and streams performance by Community sign-off service type Service Plan • Health outcomes

Community Needs Assessment

Figure 8.5 MPS Conceptual Planning Framework

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8.9 Recommendations The Multi-Purpose Service Program has demonstrated the effective application of a population model of health service delivery, expanded services in small rural communities, client centred continuum of care, service innovations, integrated service systems, community development, efficiencies without loss of services and exemplary service management and leadership. The only significant issue identified for priority consideration relates to the formalisation and improvement of program wide accountability.

It is recommended that: 1. Clear points of contact be established for the Multi-Purpose Service Program within the Department of Human Services and Department of Health and Aged Care for: a) program policy, program development, program-wide accountability and liaison within and between Departments, and b) monitoring of each Multi-Purpose Service's service plans and accountability.

2. Multi-Purpose Service Program Guidelines be prepared to assist the development, implementation and monitoring of MPS services.

3. Commonwealth and State Departments develop a Multi-Purpose Services Quality Framework that ensures the achievement of comparable outcomes to mainstream programs.

4. An MPS Performance Framework be developed by 1 July 2001.

5. All Multi-Purpose Services be required to prepare an agreed MPS Performance Plan by 31 December 2001 in accordance with a framework that includes common core MPS indicators plus MPS site-specific indicators.

6. The Department of Human Services and Department of Health and Aged Care produce a Victorian Multi-Purpose Services Program Annual Report incorporating the proposed core MPS data and highlights of program performance.

7. All Multi-Purpose Services be requested to demonstrate appropriate Complaints Resolution structures encompassing all aspects of their services.

8. Consideration be given to the enhancement of the Multi-Purpose Services program as an exemplar model of health service delivery for small rural communities, and that specific consideration be given to expanding the range and linkage of services, including the pooling of that proportion of regional service program funds delivered to an MPS catchment in instances where the MPS has the capacity and expertise to deliver those services to its community.76

76 Examples include Hospital in The Home, Post Acute Care Program, regional mental health services and others.

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APPENDICES

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Appendix 1. Project Brief

Purpose The purpose of the consultancy is to undertake an evaluation of the Multi-Purpose Services Program in Victoria and provide a written report including recommendations for improvements to the existing program.

Clients The clients are the Commonwealth Department of Health and Aged Care and the Department of Human Services (Victoria).

The clients will be represented by the Multi-Purpose Services Evaluation Steering Committee which will be established to select the consultant, and assist the selected consultant in the overall direction of the project. Membership of the Evaluation Steering Committee will comprise equal representation from the Commonwealth and State Departments. The role of the Steering Committee is to act for the clients for the duration of the project commencing with development of the Terms of Reference, the appointment of the consultant/s and the oversight of the project to the completion and acceptance by the Committee of the final document. The consultant will report directly to the Steering Committee.

The Commonwealth Department of Health and Aged Care and the Department of Human Services (Victoria) will establish a broader Reference Group which will include representation from the sector. The Reference Group will provide a forum for consultation and comment on draft material produced by the consultant.

Background Information on the Multi-Purpose Services Program The Multi-Purpose Services Pilot Program was approved in the 1992/93 budget as a joint Commonwealth/State initiative in concert with relevant State and Territory Authorities. In Victoria the program is jointly administered by the State office of the Commonwealth Department of Health and Aged Care and the Department of Human Services (Victoria). Three pilot sites were established in 1994-1995 and the expansion of the program has continued with commitment by the Commonwealth in 1999 to the maintenance of the program.

The aim of the Multi-Purpose Services Program is to improve provision of services in small rural and remote areas by simplifying funding and accountability mechanisms and by providing a more flexible, coordinated and cost-effective framework for service delivery. The concept involves pooling of State and Commonwealth program funds for health and aged care services. This allows a community to reconfigure services to better meet health needs and to provide staff with flexible work setting options across a range of services.

There are currently seven Multi-Purpose Services sites located in rural and remote areas of Victoria. It is expected that the program will continue to expand to meet the health and aged care needs of rural Victorians. The sites are as follows: • Upper Murray Health and Community Services established in Corryong in July 1995 • Otway Health and Community Services established in Apollo Bay in July 1995 • Far East Gippsland Health and Support Service established in Orbost in July 1995 • Mallee Track Health and Community Services established in Ouyen, Patchewollock, Underbool and Murrayville in November 1996 • Alpine Health established in Bright, Mt Beauty and Myrtleford in January 1997 • Timboon and District Healthcare Service established in Timboon in March 1998.

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• Robinvale and District Health Services has recently been gazetted as a Multi-Purpose Service and will commence operations as a Multi-Purpose Service in the near future.

The philosophies and objectives of the Multi-Purpose Services Program are: • To improve the flexibility of health and aged care programs. • To provide health and aged care services more cost-effectively. • To improve the targeting of health and aged care services to each community’s specific needs. • To improve the coordination of health and aged care services both locally and regionally.

The services offered at MPS sites vary significantly and can include: • Acute inpatient services • High care residential services (formerly known as nursing homes) • Low care residential services (formerly known as hostels) • Community Aged Care Packages (CACPs) • Commonwealth Respite for Carers • General practitioners • Home and Community Care • Community Health services • Ambulance services • Volunteer services • Maternal and Child Health.

Budgets at Multi-Purpose Service sites comprise the recurrent funds committed from a range of eligible Commonwealth and State programs. The programs include: • Commonwealth: Residential Aged Care, Community Aged Care Packages, Respite for Carers (CRC). • State: Hospitals (Acute Health Division), Community Health, Residential Aged Care Specified Grants, Dental, Maternal and Child Health (Aged, Community and Mental Health Division), Neighbourhood Houses (Youth and Family Services Division). • Joint Commonwealth and State: Home and Community Care (HACC).

All Multi-Purpose Services are required to sign a Tripartite Service Agreement with both the Commonwealth Department of Health and Aged Care and the Department of Human Services (Victoria). The Service Agreement negotiated with each site identifies conditions of funding and performance measures for service delivery and is based on an evidence-based community needs analyses and Service Plan.

Multi-Purpose Services are required to provide financial quarterly reports within one month of each operating quarter, six monthly activity reports and annual reports which are submitted within 90 days of the financial year ending. Sites are also required to report on the Victorian Inpatient Minimum Data Set (VIMD) and the Agency Information Management System (AIMS).

Multi-Purpose Services exist in the context of a range of other initiatives. In 1999 the Commonwealth Government announced the establishment of the Regional Health Services Program. This program will incorporate several existing initiatives, including Multi-Purpose Services, as part of a broad policy framework for rural Australia. It will also provide new funds for planning, establishing and delivering new services to improve access to primary health care services. In Victoria, Multi-Purpose Services have also been involved in the establishment of Primary Care Partnerships usually covering two to three local government areas.

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Evaluation Project Objectives The Commonwealth and the State Departments have established the following objectives for the evaluation of the Victorian Multi-Purpose Services Program. These are to:

(i) Evaluate the effectiveness of the Multi-Purpose Services Program at 5 Victorian sites which have been operational for at least the period of one Tripartite Agreement (3 years), focussing in particular on the extent to which each of the following Multi-Purpose Services objectives have been achieved: • Improved targeting of services to meet needs in the community. • Improved access to appropriate services. • Increased co-ordination, flexibility and innovative service delivery. • More cost-effective services. • Delivery of culturally appropriate services.

(ii) Identify the key factors that maximise the opportunities for successful implementation of the Multi-Purpose Services model and achievement of the Multi-Purpose Services objectives in each site. (iii) Identify barriers to successful implementation of the Multi-Purpose Services model: • in the developmental phase (prior to the signing of the Tripartite Agreement) • during the period of the first Tripartite Agreement (three years) • as an ongoing Multi-Purpose Services post the first Tripartite Agreement (second three years and beyond). (iv) Review and assess the impact of the Multi-Purpose Services model on clients and on coordinated service delivery for clients, including the impact of more flexible funding on the nature of services available and whether they have appropriately addressed communities needs between each Multi-Purpose Service and Sub-regional Services. (v) Review and assess the nature and extent of change in service delivery within each site, comparing pre and post commencement date as an Multi-Purpose Service. This will include an analysis of the extent to which the pooling various Commonwealth and State funding streams has altered expenditure levels and patterns. It should also include an analysis of whether there has been an impact on services in surrounding locations. (vi) Review and assess the issues associated with the implementation of multi-site Multi-Purpose Services, in comparison with those based at a single site. (vii) Assess the likely impact of the introduction of current initiatives, including the Regional Health Services Program and the Primary Care Partnerships strategy.

Recommendations arising from this consultancy will be considered by the Commonwealth Department of Health and Aged Care and the Department of Human Services (Victoria) in order to inform future Multi-Purpose Services policy directions.

Key Deliverables The key deliverable is the production of a quality report within the specified time frames of the consultancy. The Report must contain the following elements: (i) A brief Executive summary which include key issues and recommendations (ii) A comprehensive report which addresses each of the project objective as specified in this project brief.

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Appendix 2 Literature Review

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MULTI-PURPOSE SERVICES (MPS) PROGRAM History The Multi-Purpose Services (MPS) is an Australian initiative that resulted from the 1991 Multi-Purpose Services Task Force, was a joint Commonwealth and State Government Aged Care and Health Services group established by the Australian Health Minister's Conference. The MPS Task Force was set the task of developing a framework for the delivery of aged and health care services to rural areas in a flexible, coordinated and cost effective manner.6,14 In 1992 the MPS program began as a three-year pilot. Seventeen The pilot MPSs commenced progressively over several years due to variation between state health systems.14 In 1994, the pilot program was expanded into an ongoing program.

Program Objectives The key objectives of the MPS program are: • To provide an appropriate and flexible mix of services and programs that meet the needs of the individuals and assessed community needs; • To provide an appropriate level and range of services in both a coordinated and cost effective way; • To improve the quality of care for those using the service; • To enhance the targeting of aged care and health services to community needs.

The Concept/Model The Multi-Purpose Services (MPS) program is a Commonwealth/State program that provides a flexible and integrated range of health, community, support and residential services to the population of small isolated rural communities throughout Australia. Typically these communities comprise 5000 or fewer persons, spread over a large geographic area usually more than one hour away from a larger town and distant from mainstream health services. The catchment area for an MPS may involve a single town and its surrounding districts or several towns6.

An MPS has a single board of management encompassing all pooled services.6 ,8,19 The Board, which must become a legally incorporated entity, is responsible for directing activities and resources.6,19 Accountability is for the total range of services rather than separate programs or services.13,14,19 The range of services provided by a MPS may be very diverse and varies between communities as they are determined by the needs of the particular rural community.

Core services provided by an MPS include acute health, nursing home, hostel, community health, community care and home based support.6

Resources Both the Commonwealth and State Governments fund the program. Services are cashed out and pooled. Commonwealth and State governments determine the appropriate level of funding based on a 3 year cycle using existing levels of funding and the assessed needs and demographics of the rural community as a baseline. Once the budget is approved, the MPS becomes the holder of the pooled funds and is free to allocate these funds according to the agreements that will best meet the needs of the community in relation to aged care and health services. An MPS may provide any programs/services that relate to aged care and health services.8 Separate funding may be applied for by the MPS for the provision of other services.8 If the need arises and there are funds available for the area, an MPS may apply for additional services.

Physical Models of an MPS and Management Structure The guidelines for establishing an MPS are State specific due to differences between health systems. The Victorian guidelines are detailed and examine such issues as staff and management structure, service planning and facilities planning. They also provide a detailed description of the functional requirements of the MPS program and a comprehensive accommodation schedule. In contrast, the Western Australian MPS development guide examines the main differences between the State funded integrated health service (IHS) and the MPS program, along with detailing the steps in establishing each of these service programs

Four models of how the physical facilities may be organized are described in the Victorian MPS establishment guidelines written in 1995:

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Model 1 – Single Site In this model, all services are located on a single site in the town. The example indicates a day centre, hospital, nursing home, hostel and community service located on the one site. Under this arrangement appropriate local government services would be included as part of the community services program.6

Model 2 - Multi Site but in the Same Town Services are located over a number of physical locations in the same town. The example shown in the guidelines has a day centre, hospital, nursing home and community services situated in one location and a hostel located at an other location but still within the same town.6 Model 3 – Same Town with Services from MPS Program Linked with Non-MPS Services in Town In this case some local services are not funded by the MPS program but there is a need to have services provided under the MPS umbrella and working as close as possible to provide an effective network of services. This is illustrated by a day centre, hospital and community services are located at one site in the town, and the nursing home and hostel located in the same town but at a different site. Both sites are managed by MPS and are linked to local government services in the town such as maternal & child health nurse and immunisation.6

Model 4 – MPS Services in More than One Town Services are located in two or more reasonably nearby towns. In such cases it may be necessary to provide transport of service users from one town to another. For example three closely located towns have joined together in providing one MPS program with Town 1 providing hospital and nursing home services, Town 2 day centre services and Town 3 a hostel, community services and community health service. Service delivery is integrated under a single board of management. In this example MPS services may also be linked with non-MPS funded services, such as local government services.6

The underlying management structure is similar for each of these four examples. Common to each examples is a Chief Executive Officer to whom the Health Services and Community Services Manager reports. The Health Services Manager is responsible for overseeing the management of hospital, day centre, nursing home, hostel and other health related services. Overseeing/ managing the provision of the range of community services such as community health services, district nursing, home care and a community psychiatric service is the community services manager. Allied health staff are also common to each of the four models and report directly the Chief Executive Officer. Allied health staff may also have reporting lines through to the various health and community services providers. Where some local services are linked to, but are not part of the MPS program as in models three and four, the management and staff structure may include one or more representatives from services, with reporting lines to either or both the MPS CEO and board of management. In the case where MPS services are located over a number of nearby towns, as in model four, each town may have an MPS advisory committee from which each will typically have a representative on the Board of Management.6 These models are provided as examples of possible approaches and do not suggest the necessity to adopt a particular management structure.

REGIONAL HEALTH SERVICES PROGRAM History The Regional Health Services Program was introduced as a Federal Budget initiative in 1999/2000 a development to health and health related services to rural and remote Australia.5 The RHS program is part of the overall broader Commonwealth Regional Health Strategy. 4

In 1994, the Australian Health Minister’s Advisory Council approved the National Rural Health Strategy. Health conferences in 1997 highlighted the need for a national focus on the issues affecting health in regional, rural and remote locations. Healthy Horizons emerged as a response for improving the health of rural, regional and remote areas. Its framework and principles underpin the Commonwealth Regional Health Strategy.

Program Objectives The prime aim of the Regional Health Service Program is to improve the health and well being of rural Australians by improving access to an extensive range of health and aged cares services appropriate to each community in an innovative, cost effective and sustainable manner.4,5,21

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In the broader context, the Regional Health Strategy also aims to assist recruitment and retention of doctors and health professionals to work in rural Australia by enhancing the skills of local professionals and reducing professional isolation.4,5,21

The emphasis of this program is that no one community is the same and that local solutions need to be tailored to local priorities.4 The Concept / Model This program draws the following flexible service model initiatives under a common program funding framework: Multipurpose Centre; Multipurpose Services; and Rural Multipurpose Health and Family Services Network.

Compared to an MPS a Regional Health Service has access to a larger range of Commonwealth funds. This program funds both aged care places and primary health care, whereas, in the above mentioned initiatives the largest proportion of funds is typically allocated to aged care places. Secondly, an MPS has a combined Commonwealth/State/Territory structure whereas with a Regional Health Service the Commonwealth Government is seeking to collaborate with State/Territory Governments. An MPS has a single, prescribed and formal, management and staffing structure, whereas, for a Regional Health Service there appears to be no one defined management and staffing structure.

The majority of Regional Health Services will be in communities where the population comprises 5000 or fewer persons. Preference is generally given to locating a Regional health Service in a targeted region, which is a region that through a State/Territory planning process has been identified as having areas needing development by a Regional Health Service Program. A non-targeted region may gain approval for a regional Health Service via a submission that shows level of need and great potential for positive outcomes to its community.5

The needs of each community determine the mix and level of services that are provided. Hence, there will be variation between Region Health Services with regard to the level and range of services offered.4,5 Local and visiting services may be included in addressing the broad range of community and health service needs of the particular community. This program heavily encourages rural Australian communities to come up with innovative methods for delivering sustainable and cost effective health services to their population. Communities need to work together with local health professionals and health service providers in determining their specific requirements. Demonstrating level of need and the potential to make a difference to the health outcomes of the community are important factors that need to be considered when putting together a submission for a Regional Health Service.3, 5

The range of services that may be considered in a Regional Health Service include: Health promotion; GP services Illness and injury prevention; Substance abuse ; Women’s health Children’s services Community nursing Aged care; Community based palliative care; Mental health; Podiatry; Radiology; and Immunisation

Acute services are not provided for under the Regional Health Services Program and thus are not included in the above list.5

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Organisations that want to auspice a Regional Health Service need to demonstrate previous experience in supporting target health services, as well as, have a process in place that ensures sufficient community and local health service professionals' input in decision making. In forming a submission a Regional Health Service the auspicing organisation is required to make a case as to the appropriateness of supporting structures. This includes detailing the management structure it is to have in place during the development stage of the project and, thereafter, the management structure for the ongoing management of the service.3 Organisations that may auspice a Regional Health Service include 5: Voluntary or private or non-profit incorporated organisations; Local government authorities; Approved providers such as Commonwealth-approved nursing homes or hostels; State/Territory Government agencies

State offices of the Commonwealth Department of Health and Age Care are responsible for the administration of the program.

Resources A budget of $42.8 million is to be provided for the period 1999/2000 to 2002/2003.5 Funds can be utilised for planning, which includes needs assessment and community consultation, development, establishment and provision of new and/or a better coordinated range of primary health care services. Funding is also available for information technology and related costs.5

Where aged care places are priority, a flexible care subsidy, in accordance with the Aged Care Act of 1997, may be provided for high care (nursing homes), low care (hostels) and/or community care packages as determined by the needs of the community. Of the $42.8 million allocated for the establishment of Regional Health Services, $2 million has been targeted at aged care places20.

Existing Multi-Purpose Centres, Multi-Purpose Services and Rural Multipurpose Health and Family Services Networks may apply to participate in this program, however, a broadened ranged of services that lead to improved access and better health outcomes must be demonstrated.5

When the program was introduced in 1999 a commitment was made to the establishment of at least 30 Regional Health Service Centres 5,20. At present there are approximately, 100 rural communities in Australia that have access to the Regional Health Service Program funds.4 It is anticipated that by the 2003/2004 there will 250 or more communities that will be benefiting from this program which under the combined initiatives of Multipurpose Centres, Multipurpose Services, the Rural Multipurpose Health and Family Services Network and Regional Health Services will comprise some 130 services.4,5

The 2000/2001 federal budget sees an expansion of the Regional Health Services Program with a Budget allocation of $68.9 million over the next four years for establishing 85 additional Regional Health Services throughout Australia.21

PRIMARY CARE PARTNERSHIPS History The Primary Care Partnerships Strategy (PCP) is a four-year Victorian Government initiative that was launched in April 2000. Program Objectives The goal of the Primary Care Partnership Strategy is to improve the overall health and well being of people living in Victoria. The specific objectives of this initiative are: To improve the experience and outcome for people who use primary care services 12, 16; and To reduce the preventable use of hospital, medical and residential services through a greater emphasis on health promotion programs and by responding to the early signs of disease and/or people's need for support 12; and To deliver more timely and better integrated primary health, home and community support services to the whole community 12.

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These goals are to be achieved by 12,16: • Encouraging collaboration and coordination in planning and delivering primary care services between service providers. • Focusing on population health improvement utilising such strategies as health promotion, early intervention, targeted disease management and through client, care and community involvement. • Improving access to services and increasing availability of service related information.

The Concept / Model Primary Care Partnerships involves a collaborative alliance between service agencies, the community and the department of Human Services. There is no one single model for a PCP as it is the health needs of the catchment population that determine the type and level of primary care services required. The Department of Human Services has developed the "Better Access to Services: A Draft Policy Framework" to assist PCPs with developing their own model, processes and practices for delivering a coordinated and cohesive service that reflects the need and expectations of its clients and catchment community 24. This is a policy framework rather than a plan for developing service delivery models 24.

Underpinning the planning and delivery of services is a social model of health, which in determining people's health and well being takes into consideration the broad range of economic, environmental, biomedical and social/community factors 12,16. Primary Care Partnerships comprise voluntary alliances of primary care providers whom in collaboration with the community and Department of Human Services aim to improve the health of their catchment population through co-ordinated planning and service delivery in response to identified needs 12.

This program is targeted to all persons using primary care services in a given catchment area. The catchment population generally covers two or three local government areas that may include metropolitan, rural and regional areas.

The central focus of this strategy is systems planning. Service provision is in accordance with the community health plan. Each PCP works with the community in its catchment area, local government and the Department of Human Services in developing and implementing a community health plan. To aid PCPs with the process of identifying the health needs of its community and subsequently developing their first community health plan by the end of the first year of funding the Department has established the Partnership Development Plan 23. The Partnership Development Plan mirrors the structure of a community health plan and is negotiated between the Department and the PCP as the basis of the service agreement in the PCP's first year operation. Milestone and funded outcomes that are specified in the Development Plan are monitored quarterly 23.

The three key areas addressed by the community health plans of service planning, co-ordination and partnership exemplify the social health emphasis of this model 12.

A key aspect of this model is the engagement of local communities. In its first year of operation, all PCPs are expected to develop and implement a consumer charter of rights and responsibilities based on access, consumer privacy, consumer choice, flexible and responsive services and identified case review and grievances processes. This in turn will help identify issues of concern to the community and provide information for the long-term development of the Community Engagement Strategy by the Department and which will be implemented from the second year of the PCP's operation 12.

Resources The Primary Care Partnership Strategy will receive a total of $45 million between 200/1 and 2004/5 from the Victorian Government. Major initiatives that will be funded from the partnership strategy are∗: $10 million to develop community health plans; $11.3 million to coordinate data bases about client needs and services; $960,000 for alliances to promote their services to local communities; $10 million to develop a statewide, 24-hour health information referral service;

Media Release Monday April 17, 2000 New Community Health System for All Victorians

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$3.9 million for the Better Access to Services initiative, to identify the full range of health of health and support needs and establish protocols for cross referral $4.4 million for disease management pilot projects; and $4.5 million for health promotions initiatives

Upon signing a Service Agreement Partnerships receive a one off grant for Community Health Plan Partnership Establishment ($50,000 in 2000/2001) and Information Management Establishment ($30,000 in 2000/2001) 23. The same level of funding is available to each PCP regardless of its size. Funding for individual services is not pooled or cashed out.

SMALL RURAL HOSPITALS TASK FORCE

History The Victorian Ministers for Health and Age Care established the Small Rural Hospital Task Force in December 1993 to review the progress and difficulties of small rural hospitals after the introduction of case mix funding earlier in 1993 17. In 1994/95 small rural hospitals also become subject to Commonwealth nursing home funding known as CAM/SAM (Care Aggregated Module / Standard Aggregated Module), and this placed further financial pressures on rural services. Task Force Objectives The terms of reference for the Task Force were 17: To examine the impact of casemix funding on the long term viability of small rural hospitals. To review the rural/isolation payment. To review the type of care provided by small rural hospitals. To examine various models for the delivery of health services, including age care, acute hospitals and primary health services, in small rural communities. To make recommendations in particular circumstances if warranted.

Target Population for Review Those hospitals categorised as being Group E hospitals for casemix funding were the target population of this review. These are typically small rural hospitals with an annual patient throughput of less than 500 patients and have 30 or fewer acute beds 17. The Task Force reviewed 57 small rural hospitals.

Findings The Task Force found:17: • Vulnerability of small rural hospitals under casemix funding due to the impact on the hospitals financial position had by major fluctuations in patient throughput and case complexity and the limited capacity to be able to manage variations in throughput and case complexity. • Concern was expressed about difficulty in recruiting and retention of medical and allied health staff • Referral patterns of medical staff have a critical impact on the viability of small rural hospitals • Average length of stay has increased due to the ageing profile of rural communities. • That hospitals saw one of their roles as being that of a community support service • A variety of cost issues were raised including additional costs that are incurred as a result of being in a rural location and insufficient reimbursement for non discretionary staff costs. • A range of funding issues was also raised. • Several administrative issues were identified, including the cost of implementing new information systems and difficulties in communicating with regional offices under the current program structure. • The process of grouping hospitals to accommodate case mix was also questioned. • Co-location of trained ambulance officers with the hospital in those communities that have trained ambulance officers. • Duplicated management structures across services has limited capacity of communities to develop integrated health care systems.

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Proposed Care Service Models The Task Force recommended that consideration be given to developing an integrated service model targeted to the needs of the particular community and that includes a range of service providers in its development and delivery.

The Task Force also suggested that 17 : • Service models should be flexible and responsive to the changing needs of the community; • There be community participation in decision making and ownership of the reconfigured service; • There be assessment of the viability or non viability of services within existing financial arrangements and; • The service base be broadened to assist in the recruitment and retention of health/medical professionals.

Three management options were offered 17: • Reconfiguration and redevelopment of existing services within the current agency; • Amalgamation and / or integration with other agencies; and • Becoming an outreach service of a larger organisation

The State Government of the day supported the main recommendation of the Task Force and allocated $5 million of capital funding over the proceeding two years to support the role conversion of small rural hospitals.

RURAL HEALTHSTREAMS History In 1996, the Victorian State Government established the Rural Healthstreams program to encourage greater flexibility in funding and service delivery in small rural agencies 25. Currently, there are 22 Rural Healthstreams agencies of which 12 are approved participants in the program with the remaining 10 receiving approval in principle and have the option to work towards endorsement as fully approved agencies25.

Program Objectives The primary objective of the Rural Healthstreams Program is to assist people in rural communities requiring health care and/or services to remain in the community where appropriaate.25,26. This is accomplished through improved service access, increased service integration, more coordinated health care, a more diverse range of services which emphasise on community and home base care, improved patient/client management systems and health promotion and education.

The Model/Concept The Rural Healthstreams Program is an example of a flexible service that allows for increased service responsiveness to individual community needs.25

Healthstreams gives small rural hospitals the option to voluntarily move a proportion of WIES funding to a more flexible funding and delivery system, with a greater emphasis on primary care and community based care tailored to the local community. There is no single Rural Healthstreams model nor a requirement for a single board of management or prescribed management structure.

Program participation is based on involvement in a quality assurance process, which includes the requirements of improved service quality and coordination, accountability and cost effectiveness, access, responsiveness and community consultation. Agencies are free to choose to participate in one or more of the following programs: Community Health Accreditation and Standards Program (CHASP), Australian Council on Healthcare Standards EQUIP Program, ISO9000 Accreditation Program and the Commonwealth Aged Care Accreditation 25.

The single most distinguishing feature of this program is that of service reorientation. Healthstreams agencies have the option of trading bed-based services funding for funding to provide community based services in place of acute and bed based services. Service reorientation is not about cost savings but about being more responsive to the needs of the community 25. A second main characteristic of the program is the

Multi-Purpose Services Program Evaluation, Victoria 155 Literature Review coordinated approach to service delivery in some rural communities, particularly for patients with complex and chronic conditions 25,26.

Resources Rural Healthstreams involves only Victorian State Government funding. Healthstreams agencies are eligible to receive an implementation grant of $30,000 which can be used on service planning, including business and financial planning, information technology that supports reporting requirements, training and development and establishment costs.

Agencies can also apply for a specified grant. This enables agencies to develop proposals for the interchange or substitution of services. In applying for a specified grant agencies need to be able to demonstrate how the interchange or substitution of services being proposed is an improvement on the services provided by the agency under the terms of the original service agreement. In applying for a specified grant Healthstreams agencies need to give details relating to the intended outcome of the service substitution, which service or services are to be interchanged and how the substituted services are to be developed to achieve the intended health come. A specified grant provides funds for those elements and activities associated with the service variation such as new service recurrent costs, capital works and infrastructure costs. For the duration of this grant, agencies are required to report quarterly on the its expenditure and health outcomes.

COORDINATED CARE TRIALS Objectives The main aim of the Coordinated Care Trials is to develop and test different service delivery and funding models to determine the extent to which these models contributes to: Improving the client's health and well being outcomes Better delivery of services which are individually and collectively more responsive to the assessed needs of the client than the current arrangements More efficient way of funding and delivering services

The target population for these trials was largely people with complex and chronic conditions that require care and support and who have difficulties in organising and/or obtaining the appropriate mix of service for themselves.

The nine trials had diverse different numbers of participant and eligibility criteria for trial participants

ON LOK (SAN FRANCISCO, CALIFORNIA) The On Lok program is included as an example of an international approach to coordinated care. Although the base conditions for the model contrast to those of Australian flexible care models, it shares some common principles and serves to illustrate common service development themes.

History The On Lok program began in 1971, as one of America's first day health centres, that took care frail elderly adults of the Chinatown, North Beach and Polk Gulch neighbourhoods. Those attending the centre received hot meals, health and social services, and supervision, and returned home in the evening. During its first phase of implementation, 1972 to 1975 the On Lok program essentially comprised a day centre with a multi disciplinary intake and assessment. During phase two of the program's development from 1975 to 1979, the day health centre expanded to two facilities, a day health centre and a social health maintenance centre, and in-home care and home-delivered meals were also added. Phase three of the program's expansion (1979 to the present) has seen the program become a consolidated model of long-term care that includes: nursing, hospice, acute hospitalisation services, in-patient medical services, physician services, contracted professional services such as dentistry, audiology, optometry, podiatry and psychiatry, housing and outpatient service such as laboratory (ie pathology) testing and x-rays 22.

The program has become more expansive with the recent licensing, in California, of On Lok SeniorHealth as a health plan. This allows On Lok Senior Health to enter into a variety of contractual arrangements with

Multi-Purpose Services Program Evaluation, Victoria 156 Literature Review other health care systems to more effectively meet the needs and expectations of the chronically ill, nursing home senior citizen 31.

Program Objectives The On Lok program has three key objectives and these are:22 To rehabilitate participants as much as possible through a variety of therapeutic services; To maintain health and independence of participants by providing comprehensive medical, social, and nutritional services; To sustain the highest possible quality of life while controlling health care costs through the flexible use of resources.

On Lok's mission is to help frail elderly to live an independent life outside of the nursing home, for as long as it is medically, socially and economically feasible to do so, by providing quality, affordable care services for the well being of frail elderly 22,31. Their mission also includes providing quality affordable services and community based health programs for the well elderly 31.

Target Population The population targeted by this program is well and frail elderly living in the city and county of San Francisco. At the present time On Lok SeniorHealth serves more than 860 frail seniors throughout San Francisco 31.

The Concept/Model On Lok is a non-profit organisation that provides quality affordable services for the well being of San Franciscan elderly and their families. The core program is the On Lok SeniorHealth that is an all-inclusive health plan for nursing home certified frail elderly persons.

The On Lok SeniorHealth Service Program is a consolidated model of long term care that provides a continuum of long term care services. The needs of the individual determine the services that are supplied. This model of care provides a flexible service system that lets service providers have control over the health and community services necessary to meet the needs of the older population in a cost-effective way.

Characteristics of this of this particular model of care are: • Services are integrated into a comprehensive service system that addresses the multiple, interrelated problems of the older population. • All services are delivered in a manner that provides a coordinated response to meet the needs of the users in an efficient and effective manner • At the heart of the program is an interdisciplinary team made up doctors, nurses, social workers, rehabilitation and recreational therapists, dietitians, and para professional staff such as transportation and home care workers. The team has control over services and is free to vary the setting in which services are delivered to best meet the needs of the individual elder. The interdisciplinary team in consultation with the program user and his or her carer makes decisions regarding service allocation. The team works together to provide continuous assessment of program participant’s needs. • Participants have a tailored service plan that is designed to maximise their chance of staying in the community. • The administrative and service structure allows the program to adopt a risk management approach. • Resources are integrated into a single fund, which is drawn upon to provide services.

Current initiatives and programs provided by On Lok include: • Geriatric Interdisciplinary Team Training (GITT) initiative which commenced in 1996 and provides an educational program in interdisciplinary care of the frail elderly. • “End of Life Initiative” which was launched in July 1997 straightforward approach to improving care at the end of members. This initiative focuses on pain and symptom management and supporting meaning at the end of life. • Senior Day Services – offers a vast array of English and Spanish programs for older adults and carers. • A large multipurpose senior centre that offers such things as health promotion, educational and recreational activities and information, referral and social services.

Multi-Purpose Services Program Evaluation, Victoria 157 Literature Review

• The Nutrition Program which provides midday meals for more than 3,500 senior citizens at various locations throughout San Francisco. • Community housing – to accommodate the needs of extremely frail elders, and to prevent premature admission to nursing homes, On Lok operates several senior housing facilities. • Resources • On Lok’s main financial resources are provided by Medicare, Medicaid and the individual. Payment is a form of risk based capitation or per-person monthly rate based on the individual’s eligibility for Medicare and Medicaid. Individuals who are fully eligible for Medicare and Medicaid pay nothing. Individuals who are only partially eligible for Medicaid pay on a sliding scale. Those individuals who are not eligible for Medicaid pay a monthly fee equivalent to the Medicaid capitation rate.

On Lok receives a fixed monthly payment from Medicare and Medicaid for each participant enrolled in the program. These funds which are pooled are managed by On Lok who deliver a full range of services including hospital and nursing home care according to the participants needs.

THE BOUNDARIES BETWEEN HEALTH AND SOCIAL CARE FOR OLDER PEOPLE IN DEVELOPED COUNTRIES31 This international study was undertaken in 1998 and published in Britain in 2000 to examine comparative trends in aged care systems in USA, New Zealand, Australia, Singapore, The Netherlands, Germany and Sweden.

The following lessons were identified for the UK's "Modernising Government" agenda: • The need for a strategy: "In countries like New Zealand and Australia where an effort has been made to draw up a single strategy document setting out the goals and plans to deliver high quality care, it has been easier to set a clear agenda and deliver improvements. "Improving the machinery of Government: "In many countries visited, communication between different central departments is believed to be worse than that between different layers of government." The report found that there are few international ideas about how to obtain more central government policy. • Integrated funding: "For people who need access to multiple service, the consensus is that health and social services budgets need to be more integrated to deliver high quality care".

The ways of achieving this care include: • blended or pooled funds • increasing the scope for home and community care agencies to work across departmental or organisational boundaries • instituting formal coordinated care pilots. • cost sharing: :The challenge is to find acceptable ways for people to meet the costs of long term care whilst not losing their assets."

Consideration was also given to methods of delivering seamless care. It was found that over the next 30 years a larger share of public spending is likely to devoted to chronic care. This means that person centred care is needed to deliver seamless care and evidence suggests that "multidisciplinary teams are worthwhile." A major disincentive in the UK to achieving seamless care is the financial boundaries between health and social services. "Pooled budgets" were found to assist in improving service access.

The main lessons learned from international experience were found to be: • the need to build capacity in the community to enable people to help themselves • encouraging doctors too be more involved in coordinated care • helping consumers to become more informed users of health care • consolidating successful initiatives by incorporating one-off program funding into mainstream funding • reducing wasteful structures and practices.

The key best practice findings include: • encourage moves towards a population and public health focus • engage all parties (including users and cares) in strategic development

Multi-Purpose Services Program Evaluation, Victoria 158 Literature Review

• introduce flexible resourcing to encourage innovation • develop improved information systems • develop partnerships between service providers • develop quality guidelines and outcome indicators.

ACHIEVING ALLOCATIVE EFFICIENCY THROUGH EVIDENCE BASED NEEDS ASSESSMENT34 This article was written by Frank Evans, CEO Upper Murray Health & Community Services and Mary Hoodless, Manager Community Services, Upper Murray Health & Community Services, a Multi-Purpose Service based at Corryong in the North East of Victoria.

Achieving allocative efficiency is a significant challenge for health service providers. It is beyond the resources or expertise of most small services to undertake detailed cost-benefit analysis of their services. This article describes how Upper Murray Health & Community Services ( a Multi-Purpose Service with a relatively isolated catchment of approximately 3200 people) utilised the evidence produced through Australian and international studies and peak health bodies to identify effective and cost effective services with the potential to produce the greatest health gains for people living in the Upper Murray. The needs assessment combined a soci0-denmmographic, epidemiological approach with a high level of community consultation to produce evidence to support a high prevention, high support based model of health and community services in the Upper Murray. The key characteristic of the recommendations was that all interventions should focus on encouraging and empowering Upper Murray communities and individuals to use their own resources to develop and sustain health promoting action.

COMMUNITY PROCESSES ASSOCIATED WITH A CHANGING RURAL HEALTH SERVICE34 This Master of Applied Science-Research thesis by Mary Hoodless examines the community processes associated with development of Corryong District Hospital and Upper Murray Nursing Home to a Multi- Purpose Service using a case study design. It draws from the literature of rural health conversion primarily using Amundson’s (1993) principles for organising and developing local health services using a community development approach. These principles underpin theoretical propositions which are used as a framework for ordering, collecting and analysing the data. Data analysis was undertaken using an explanation-building approach of the study at hand. The findings of the data collected, within the theoretical propositions, were analysed using an iterative process, stipulating causal links and rival explanations. Findings were interpreted within the theoretical framework proposed.

The purpose of this study was to understand how a rural community responded to the challenge of change to its traditional health service. The community processes used, and the ways key stakeholders participated in the change process, will be examined. Rather than studying change and theories of change, the study sees the Multi-Purpose Service Program as an opportunity to utilise community development approaches given the primary health care focus of the program. How the agency engaged the community in the process of change, and the skills required by the key stakeholders to undertake this process is examined, including implications of these factors for other rural health services.

RURAL MODELS OF INTEGRATION: A Multi-Purpose Service Model of Integration 35 This article researched by Jill Vagg, CEO Far East Gippsland Support Service examines the challenge of delivering health services to rural communities. In particular, it considers the issues of distance, isolation and small organisation size, particularly as it applies to recruitment. The paper examines the Multi-Purpose Service approach as a model of for delivering an integrated health service system and examines integration generally as a possible solution for improving health outcomes to rural communities. Integration as a model for sustaining rural communities is discussed and the interdependence of issues important in rural communities highlighted. The importance of community needs in driving service change is also considered. The Far East Gippsland Support Service Multi-Purpose Service and the changes that have occurred since integration are used as an example of the model. The concepts of continuum of care, treatment, management and support are used as examples of how integration supports have improved outcomes for consumers.

Multi-Purpose Services Program Evaluation, Victoria 159 Literature Review

RURAL HEALTH IN NEW ZEALAND AND AUSTRALIA - Part 1 Improving Rural Health Services Through integration: What are the barriers?36

Janes et al., identify the components of a quality rural health service. They define "quality" as the correct service provided to the correct person, in the correct location, by the correct provider, with the correct equipment, in the correct manner, within the correct timeframe, at the correct cost, with the correct outcome, at the correct cost, with the correct outcome.

"To the correct person" is defined as "the needs of the individual as well as the needs of the population" being identified and met. "By the correct provider": adequate numbers of skilled providers as a team "The correct service": evidence-based care and community input "Within the correct timeframe": the "golden hour, day, week and month" "At the correct location": one stop shop that brings services to the people "In the correct manner": respect and value "With the correct equipment": modern and maintained "At the correct cost": "but who decides?" "With the correct outcome": documenting improvements in health outcomes.

The identified barriers to integration were identified to include lack of workforce planning, Government and Health Funding Authority policy, lack of professional support and continuing education, financial barriers and organisational, individual and personal barriers.

Multi-Purpose Services Program Evaluation, Victoria 160 Literature Review

REFERENCES

1 COAG Working Group on Health and Community Services, (1995) Reform of Health and Community Services Information Paper on Work in Progress. August

2 Collins, N. (1999) Discussion Paper on issues Arising from the Rural Health / Health Streams Reporting Workshop. Department of Human Services, Rural Services Unit, Victoria

3 Commonwealth Department of Health and Aged Care (1999 Version 1.0) Regional Health Services (RHS) Program - Application Information Pack. Canberra

4 Commonwealth Department of Health and Aged Care (2000) More Doctors, Better Services - Regional Health Strategy. Publications Productions Unit, Canberra

5 Commonwealth Department of Health and Aged Care (2000) Policy Framework Commonwealth Regional Health Services Program - Enhancing Primary Health Care in Rural Communities. Indigenous, Rural and Public Health Unit, February, Canberra

6 Department of Human Services, (1996) Multi-Purpose Services Development and Design Guidelines : Health & Aged Care in Rural Communities. August, Victoria

7 Department of Human Services, (1996) Summary of the Healthstreams Program and Cooperative Rural Health Planning. September, Victoria

8 Department of Human Services, (1996) The MPS Option: Health & Aged Care in Rural Communities. August, Victoria

9 Department of Human Services, (1999) Rural Health Matters Initiatives 1999~2001. Corporate Communications Unit / Rural Health Services Unit, Victoria

10 Department of Human Services, (1999) Rural Health Matters Strategic Directions 1999~2001. Corporate Communications Unit / Rural Health Services Unit, Victoria

11 Department of Human Services, (1999) The Aged Care Research and Services Development Presentation Forum. Age, Community and Mental Health Division, April, Victoria

12 Department of Human Services, (2000) Primary Care Partnerships: Going Forward. April, Victoria

13 Health Department of Western Australia, Rural Health Policy Unit, (1995) Multipurpose and Integrated Health Services Development Guide. March, Western Australia

14 Health Managers Australia, (1997) The Multi-Purpose Service National Network Feasibility Study. HMA Group for the Commonwealth Department of Health & Family Services.

15 Jaffe, R. (1996) Victorian Linkages Programs Best Practice Manual. Victorian Linkages Programs Network, Victoria

16 Raysmith, H. (1999) Report of the Review of Primary Health Redevelopment. December, Victoria

17 Small Rural Hospitals Task Force Report. H&CS Pomotions Unit, Victoria

18 Tehan, M., Knowles, R., ( no date) Ministerial Responses to Small Rural Hospitals Task Force Report. H&CS Pomotions Unit, Victoria

19 Andrews, G., Dunn, J., Hagger, C., Sharp, C., Witham, R. (1995 December) Pilot Multi-Purpose Services Program Evaluation: Final Report, Centre for Ageing Studies, Adelaide, S.A

Multi-Purpose Services Program Evaluation, Victoria 161 Literature Review

20 Best, J. (March 2000) Rural Health Stocktake, Commonwealth of Australia, Canberra

21 Commonwealth Department of Health and Aged Care (2000) Budget 2000 - 2001, Regional Health Strategy - Better Health Services for Rural and Regional Australia - Fact Sheet 3 May, Canberra

22 Miller, J.A. (1991) Community-based Long Term CareSage Publications Inc, Newbury Park

23 Department of Human Services (2000) Primary Care partnerships - Partnership Development Plan; 2nd Edition, (July), Victoria

24 Department of Human Services (2000) Primary Care partnerships -Better Access to Services: A Draft Policy Framework for Discussion (July), Victoria

25 Department of Human Services, Rural Health Services Unit (1999) Rural Healthstreams Program Guidelines (October), Victoria

26 Department of Human Services - Rural Health Services Unit Rural Healthstreams Program 2000.

27 Department of Health and Age Care (1999) The Australian Coordinated Care Trials: Background and Trial Descriptions, Publications Prouduction Unit, Canberra

28 Landi, F., Gamgassi, G., Pola, R., Tabaccanti, S., Cavinato, T., Carbonin, P., Bernabei, R., (1999) Impact of Integrated Home Care Services on Hospital Use. Journal of the American Geriatrics Society December Vol 47 No 12 pp1430-1434

29 Bowman, C., Johnson, M., Venables, D., Foote, C., Kane, R.L. (1999) Geriatric Care in the United Kingdom:Aligning Services to Needs. BMJ October Vol 319 pp1119-22

30 Leutz, W.N. (1999) Five Laws for Integrating medical and Social Services: Lessons from the United States and United Kingdom. The Milbank Quarterly, Vol 77, No1

31 Minford, M., The Boundaries Between Health And Social Care For Older People In Developed Countries. HM Treasury & Department of Health June 2000

32 Hoodless M., and Evans F., The Multi-Purpose Service Program: the best health service option for rural Australia Primary Health Care 2000 Conference Melbourne April 2000

33 Evans F., and Hoodless M., Achieving Allocative Efficiency Through An Evidence-based Needs Assessment Rural Social Work Vol 5 December 1999 pp24-30

34 Hoodless M., Community Processes Associated with a Changing Rural Health Service. Master of Applied Science thesis School of Public Health

35 Vagg, J., Rural Models of Integration: A Multi-Purpose Service Model of Integration. 2nd International Conference , Primary Health Care 2000

36 Janes R., Ross J. and Taylor J., Rural Health in New Zealand and Australia - Part 1. Improving Health Services Through Integration: What are the barriers? Health Review (On Line) Enigma Publishing Ltd. October 1999 http://www.enigma.co.nz/hcro_articles/9910/vol3no10_002.htm

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Appendix 3 Focus Group Results

Focus groups were held at each Multi-Purpose Service site, with attendees listed in Appendix 3.

OTWAY MPS

Community member 88.2% Board of Management member 0 Staff 5.9 Other 5.0 n= 17

Service range and balance 1. How would you rate the availability of health and community services in this community:

Very Low Moderate High Very Don't low high know a) health/community services overall 0 0 17.6 47.1 29.4 5.9

b) acute care 0 0 0 47.1 41.2 11.8 (uncomplicated procedures in hospital) c) general practitioners 5.9 17.6 29.4 35.3 5.9 5.9

d) allied health care 0 5.9 47.1 11.8 5.9 29.4 (eg physiotherapy, podiatry, speech therapy) e) home-based nursing services 0 0 0 41.2 35.3 23.5

f) aged residential care 23.5 5.9 23.5 17.6 11.8 17.6 (nursing home/hostel) g) health and fitness information and classes 0 5.9 11.8 23.5 47.1 11.8

h) home care services 0 0 5.9 23.5 47.1 23.5 (cleaning, ironing etc. for aged and disabled) i) community development services 0 5.9 11.8 23.5 17.6 41.2 (neighbourhood house programs, counselling etc.) j) services to people living in outlying localities 0 0 5.9 35.3 5.9 52.9

k) balance between acute, community and home-based services 5.9 5.9 35.3 17.6 5.9 29.4

Service responsiveness to community need 2. How well met are the health/community needs in this community:

Very Poorly Moderately Well Very Don't poorly well know a) total community overall 5.9 11.8 35.3 17.6 17.6 11.8

b) babies health 0 0 0 47.1 29.4 23.5

c) youth health 11.8 11.8 41.2 0 5.9 29.4

d) women's health 0 0 5.9 41.2 52.9 0

e) men's health 0 0 11.8 41.2 17.6 29.4

f) families' health 0 5.9 23.5 41.2 5.9 23.5

g) older people's health and support 5.9 0 17.6 23.5 35.3 17.6

h) people with special needs 5.9 11.8 17.6 17.6 11.8 35.3 eg. people with disabilities i) people from ethnic or cultural backgrounds 0 11.8 0 23.5 0 64.7

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Access 3. How easy is it to obtain the following services in this community Very difficult Difficult Moderately Easy Very Don't easy know a) health and community services overall 0 0 5.9 47.1 47.1 0

b) day to day health/community services 0 5.9 0 47.1 47.1 0

c) emergency care (health and community) 0 0 0 52.9 47.1 0

d) specialist health 17.6 41.2 17.6 5.9 5.9 11.8

e) long term care 23.5 29.4 17.6 0 0 29.4

f) home and community services in outlying localities 0 5.9 5.9 35.3 0 52.9

g) appropriate services for people from ethnic 0 5.9 0 5.9 5.9 82.4 backgrounds

h) appropriate services for Aboriginal people 0 5.9 0 0 0 94.1

Consultation 4. How would you rate the following consultation issues Very low Low Moderate High Very Don't high know a) availability of information about health and community 0 5.9 5.9 35.3 47.1 5.9 services b) the extent to which the community was involved in 0 0 11.8 52.9 11.8 23.5 decision making when the services were to be redeveloped c) on-going consultation to identify community needs 0 11.8 35.3 29.4 5.9 17.6

d) the ways in which consultation occurs 0 5.9 17.6 29.4 5.9 41.2

Service improvements 5. How would you rate the change in health and community services in this community today, compared to about five years ago Significant Minor No Improved Significant Don't decline decline change improvement know a) overall 0 0 0 35.3 58.8 5.9 b) acute health care (hospital) 0 0 17.6 29.4 17.6 35.3 c) general practitioners 0 5.9 11.8 35.3 23.5 23.5 d) allied health services 0 0 0 52.9 5.9 41.2 e) home based nursing 0 0 11.8 23.5 29.4 35.3 f) residential aged care 11.8 41.2 17.6 0 5.9 23.5 g) health and fitness information and classes 0 0 0 41.2 52.9 5.9 h) home care services 0 0 0 47.1 29.4 23.5 i) community development programs 0 0 0 35.3 30.1 23.5

MPS Model 6. To what extent has the MPS model made a noticeable difference to health and community services in this community in terms of …….. Significant Minor No Improved Significant Don't decline decline change improvement know a) health/community services management structures 0 0 0 29.4 64.7 5.9 b) flexibility in addressing priorities of the community 0 0 52.9 29.4 5.9 11.8 c) ability to innovate in way services are provided 0 0 11.8 64.7 17.6 5.9 d) community control over services 0 0 11.8 47.1 23.5 64.7

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MALLEE TRACK MPS

Community member 50.0% Board of Management member 50.0 Staff 0 Other 0 N=6

Service range and balance 1. How would you rate the availability of health and community services in this community:

Very Low Moderate High Very Don't low high know a) health/community services overall 0 0 16.7 50.0 33.3 0

b) acute care 0 0 33.3 50.0 16.7 0 (uncomplicated procedures in hospital) c) general practitioners 0 0 50.0 33.3 16.7 0

d) allied health care 0 16.7 16.7 33.3 33.3 0 (eg physiotherapy, podiatry, speech therapy) e) home-based nursing services 0 0 16.7 33.3 50.0 0

f) aged residential care 0 0 50.0 16.7 33.3 0 (nursing home/hostel) g) health and fitness information and classes 0 33.3 33.3 16.7 16.7 0

h) home care services 0 0 33.3 66.7 0 0 (cleaning, ironing etc. for aged and disabled) i) community development services 0 0 16.7 66.7 16.7 0 (neighbourhood house programs, counselling etc.) j) services to people living in outlying localities 0 0 33.3 33.3 16.7 16.7

k) balance between acute, community and home-based services 0 0 50.0 16.7 33.3 0

Service responsiveness to community need 2. How well met are the health/community needs in this community:

Very Poorly Moderately Well Very Don't poorly well know a) total community overall 0 0 33.3 50.0 16.7 0

b) babies health 0 0 33.3 50.0 16.7 0

c) youth health 0 50.0 33.3 16.7 0 0

d) women's health 0 0 0 83.3 16.7 0

e) men's health 0 16.7 0 66.7 16.7 0

f) families' health 0 0 16.7 66.7 16.7 0

g) older people's health and support 0 0 0 66.7 33.3 0

h) people with special needs 0 0 33.3 33.3 33.3 0 eg. people with disabilities i) people from ethnic or cultural backgrounds 0 0 16.7 50.0 0 33.3

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Access 3. How easy is it to obtain the following services in this community Very difficult Difficult Moderately Easy Very Don't easy know a) health and community services overall 0 0 50.0 33.3 16.7 0

b) day to day health/community services 0 0 16.7 66.7 16.7 0

c) emergency care (health and community) 0 0 16.7 66.7 16.7 0

d) specialist health 0 0 66.7 33.3 0 0

e) long term care 0 0 66.7 16.7 16.7 0

f) home and community services in outlying localities 0 0 50.0 33.3 16.7 0

g) appropriate services for people from ethnic 0 0 16.7 33.3 16.7 33.3 backgrounds

h) appropriate services for Aboriginal people 0 0 16.7 33.3 16.7 33.3

Consultation 4. How would you rate the following consultation issues Very low Low Moderate High Very Don't high know a) availability of information about health and community 0 16.7 0 83.3 0 0 services b) the extent to which the community was involved in 0 0 16.7 50.0 33.3 0 decision making when the services were to be redeveloped c) on-going consultation to identify community needs 0 16.7 33.3 50.0 0 0

d) the ways in which consultation occurs 0 16.7 33.3 50.0 0 0

Service improvements 5. How would you rate the change in health and community services in this community today, compared to about five years ago Significant Minor No Improved Significant Don't decline decline change improvement know a) overall 0 0 0 66.7 33.3 0 b) acute health care (hospital) 0 0 33.3 50.0 16.7 0 c) general practitioners 0 0 16.7 83.3 0 0 d) allied health services 0 0 0 83.3 16.7 0 e) home based nursing 0 0 30 50.0 50.0 0 f) residential aged care 0 0 30 83.3 16.7 0 g) health and fitness information and classes 0 0 33.3 33.3 0 33.3 h) home care services 0 0 0 66.7 33.3 0 i) community development programs 0 0 0 83.3 16.7 0

MPS Model 6. To what extent has the MPS model made a noticeable difference to health and community services in this community in terms of …….. Significant Minor No Improved Significant Don't decline decline change improvement know a) health/community services management structures 0 0 0 50.0 50.0 0 b) flexibility in addressing priorities of the community 0 0 0 50.0 50.0 0 c) ability to innovate in way services are provided 0 0 0 50.0 50.0 0 d) community control over services 0 16.7 0 33.3 50.0 0

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ALPINE HEALTH

Community member 33.8% Board of Management member 38.5 Staff 15.4 Other 15.4 n= 13

Service range and balance 1. How would you rate the availability of health and community services in this community:

Very Low Moderate High Very Don't low high know a) health/community services overall 0 0 30.8 69.2 0 0

b) acute care 0 0 23.1 53.8 15.4 7.7 (uncomplicated procedures in hospital) c) general practitioners 0 7.7 23.1 23.1 23.1 15.4

d) allied health care 0 15.4 53.8 23.1 0 7.7 (eg physiotherapy, podiatry, speech therapy) e) home-based nursing services 0 0 30.8 53.8 0 15.4

f) aged residential care 0 7.7 38.5 53.8 0 0 (nursing home/hostel) g) health and fitness information and classes 0 15.4 61.5 15.4 0 7.7

h) home care services 0 7.7 61.5 23.1 0 7.7 (cleaning, ironing etc. for aged and disabled) i) community development services 7.7 7.7 53.8 23.1 15.4 0 (neighbourhood house programs, counselling etc.) j) services to people living in outlying localities 0 23.1 53.8 7.7 0 15.4

k) balance between acute, community and home-based services 0 0 61.5 30.8 7.7 0

Service responsiveness to community need 2. How well met are the health/community needs in this community:

Very Poorly Moderately Well Very Don't poorly well know a) total community overall 0 7.7 69.3 15.4 0 7.7

b) babies health 0 23.1 23.1 46.2 0 7.7

c) youth health 0 76.9 7.7 15.4 0 0

d) women's health 0 15.4 61.5 23.1 0 0

e) men's health 0 30.8 53.8 15.4 0 0

f) families' health 0 23.1 61.5 7.7 0 7.7

g) older people's health and support 0 0 46.2 38.5 0 15.4

h) people with special needs 0 46.2 30.8 7.7 0 15.4 eg. people with disabilities i) people from ethnic or cultural backgrounds 0 30.8 38.5 7.7 0 23.1

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Access 3. How easy is it to obtain the following services in this community Very difficult Difficult Moderately Easy Very Don't easy know a) health and community services overall 0 0 76.9 15.4 0 7.7

b) day to day health/community services 0 7.7 76.9 15.4 0 0

c) emergency care (health and community) 0 0 38.5 38.5 23.1 0

d) specialist health 7.7 46.2 15.4 23.1 7.7 0

e) long term care 0 7.7 38.5 38.5 7.7 7.7

f) home and community services in outlying localities 7.7 53.8 15.4 7.7 0 15.4

g) appropriate services for people from ethnic 0 23.1 38.5 7.7 15.4 23.1 backgrounds

h) appropriate services for Aboriginal people 30.8 0 15.4 0 7.7 46.2

Consultation 4. How would you rate the following consultation issues Very low Low Moderate High Very Don't high know a) availability of information about health and community 0 0 61.5 15.4 0 23.1 services b) the extent to which the community was involved in 0 7.7 38.5 15.4 0 38.5 decision making when the services were to be redeveloped c) on-going consultation to identify community needs 0 0 53.8 15.4 0 30.8

d) the ways in which consultation occurs 0 1.9 50.0 17.3 0 30.8

Service improvements 5. How would you rate the change in health and community services in this community today, compared to about five years ago Significant Minor No Improved Significant Don't decline decline change improvement know a) overall 0 0 7.7 76.9 7.7 7.7 b) acute health care (hospital) 0 0 30.8 23.1 23.1 23.1 c) general practitioners 15.4 23.1 30.8 23.1 0 7.7 d) allied health services 0 7.7 7.7 69.2 7.7 7.7 e) home based nursing 0 0 23.1 53.8 7.7 15.4 f) residential aged care 0 0 38.5 30.8 15.4 15.4 g) health and fitness information and classes 0 0 38.5 30.8 7.7 23.1 h) home care services 0 30.8 23.1 15.4 7.7 23.1 i) community development programs 0 0 30.8 38.5 7.7 23.1

MPS Model 6. To what extent has the MPS model made a noticeable difference to health and community services in this community in terms of …….. Significant Minor No Improved Significant Don't decline decline change improvement know a) health/community services management structures 0 0 0 76.9 15.4 7.7 b) flexibility in addressing priorities of the community 0 0 23.1 53.8 15.4 7.7 c) ability to innovate in way services are provided 0 0 7.7 69.2 15.4 7.7 d) community control over services 0 7.7 69.2 7.7 7.7 7.7

Multi-Purpose Services Program Evaluation, Victoria 168 Focus Groups Results

UPPER MURRAY MPS

Community member 16.7% Board of Management member 8.3 Staff 58.3 Other 16.7 n=12

Service range and balance 1. How would you rate the availability of health and community services in this community:

Very Low Moderate High Very Don't low high know a) health/community services overall 0 0 0 25.0 75.0 0

b) acute care 0 0 0 41.7 50.0 8.3 (uncomplicated procedures in hospital) c) general practitioners 0 0 0 75.0 25.0 0

d) allied health care 0 0 8.3 33.3 58.3 0 (eg physiotherapy, podiatry, speech therapy) e) home-based nursing services 0 0 0 41.7 50.0 8.3

f) aged residential care 0 8.3 0 25.0 58.3 8.3 (nursing home/hostel) g) health and fitness information and classes 0 0 16.7 25.0 50.0 8.3

h) home care services 0 0 0 41.7 50.0 8.3 (cleaning, ironing etc. for aged and disabled) i) community development services 0 0 0 50.0 41.7 8.3 (neighbourhood house programs, counselling etc.) j) services to people living in outlying localities 0 0 16.7 41.7 41.7 0

k) balance between acute, community and home-based services 0 0 0 50.0 41.7 8.3

Service responsiveness to community need 2. How well met are the health/community needs in this community:

Very Poorly Moderately Well Very Don't poorly well know a) total community overall 0 0 8.3 50.0 33.3 8.3

b) babies health 0 0 16.7 33.3 8.3 41.7

c) youth health 0 0 50.0 8.3 0 41.7

d) women's health 0 0 25.0 25.0 41.7 8.3

e) men's health 0 0 41.7 16.7 16.7 25.0

f) families' health 0 0 25.0 41.7 33.3 0

g) older people's health and support 0 0 8.3 16.7 66.7 8.3

h) people with special needs 0 0 25.0 50.0 8.3 16.7 eg. people with disabilities i) people from ethnic or cultural backgrounds 0 0 25.0 0 0 75.0

Multi-Purpose Services Program Evaluation, Victoria 169 Focus Groups Results

Access 3. How easy is it to obtain the following services in this community Very difficult Difficult Moderately Easy Very Don't easy know a) health and community services overall 0 0 0 41.7 58.3 0

b) day to day health/community services 0 0 0 41.7 58.3 0

c) emergency care (health and community) 8.3 0 16.7 41.7 33.3 0

d) specialist health 0 8.3 33.3 50.0 8.3 0

e) long term care 0 8.3 8.3 25.0 41.7 16.7

f) home and community services in outlying localities 0 0 16.7 25.0 41.7 16.7

g) appropriate services for people from ethnic 0 16.7 0 16.7 0 66.7 backgrounds

h) appropriate services for Aboriginal people 0 16.7 8.3 0 0 75.0

Consultation 4. How would you rate the following consultation issues Very low Low Moderate High Very Don't high know a) availability of information about health and community 0 0 8.3 50.0 25.0 16.7 services b) the extent to which the community was involved in 0 8.3 58.3 16.7 0 16.7 decision making when the services were to be redeveloped c) on-going consultation to identify community needs 0 0 8.3 50.0 33.3 8.3

d) the ways in which consultation occurs 0 0 8.3 50.0 8.3 33.3

Service improvements 5. How would you rate the change in health and community services in this community today, compared to about five years ago Significant Minor No Improved Significant Don't decline decline change improvement know a) overall 0 0 0 16.7 83.3 0 b) acute health care (hospital) 0 8.3 8.3 41.7 41.7 0 c) general practitioners 0 8.3 33.3 8.3 33.3 16.7 d) allied health services 0 0 0 16.7 83.3 0 e) home based nursing 0 0 0 41.7 58.3 0 f) residential aged care 0 0 0 25.0 41.7 33.3 g) health and fitness information and classes 0 0 0 25.0 66.7 8.3 h) home care services 8.3 0 33.3 50.0 8.3 8.3 i) community development programs 0 0 8.3 16.7 66.7 8.3

MPS Model 6. To what extent has the MPS model made a noticeable difference to health and community services in this community in terms of …….. Significant Minor No Improved Significant Don't decline decline change improvement know a) health/community services management structures 0 0 0 16.7 66.7 16.7 b) flexibility in addressing priorities of the community 0 0 0 16.7 66.7 16.7 c) ability to innovate in way services are provided 0 0 0 33.3 50.0 16.7 d) community control over services 0 0 0 25.0 58.3 16.7

Multi-Purpose Services Program Evaluation, Victoria 170 Focus Groups Results

FAR EAST GIPPSLAND MPS

Community member 81.8% Board of Management member 0 Staff 9.1 Other 9.1 n=12

Service range and balance 1. How would you rate the availability of health and community services in this community:

Very Low Moderate High Very Don't low high know a) health/community services overall 0 0 27.3 54.5 18.2 0

b) acute care 0 0 9.1 27.3 36.4 27.3 (uncomplicated procedures in hospital) c) general practitioners 0 0 36.4 45.5 18.2 0

d) allied health care 0 9.1 27.3 36.4 9.1 18.2 (eg physiotherapy, podiatry, speech therapy) e) home-based nursing services 0 0 9.1 63.6 0 27.3

f) aged residential care 0 0 9.1 45.5 36.4 9.1 (nursing home/hostel) g) health and fitness information and classes 0 0 27.3 27.3 0 36.4

h) home care services 0 0 9.1 45.5 18.2 27.3 (cleaning, ironing etc. for aged and disabled) i) community development services 0 0 9.1 81.8 0 9.1 (neighbourhood house programs, counselling etc.) j) services to people living in outlying localities 0 0 36.4 0 0 63.6

k) balance between acute, community and home-based services 0 9.1 18.2 18.2 18.2 36.4

Service responsiveness to community need 2. How well met are the health/community needs in this community:

Very Poorly Moderately Well Very Don't poorly well know a) total community overall 0 0 27.3 63.6 9.1 0

b) babies health 0 0 9.1 18.2 36.4 36.4

c) youth health 0 0 54.5 9.1 0 0

d) women's health 0 9.1 9.1 45.5 18.2 18.2

e) men's health 0 0 45.5 45.5 9.1 9.1

f) families' health 0 0 45.5 45.5 9.1 9.1

g) older people's health and support 0 0 0 0 18.2 18.2

h) people with special needs 0 18.2 27.3 27.3 36.4 36.4 eg. people with disabilities i) people from ethnic or cultural backgrounds 0 18.2 36.4 9.1 20.2 20.2

Multi-Purpose Services Program Evaluation, Victoria 171 Focus Groups Results

Access 3. How easy is it to obtain the following services in this community Very difficult Difficult Moderately Easy Very Don't easy know a) health and community services overall 0 0 36.4 54.5 9.1 0

b) day to day health/community services 0 0 36.4 45.5 9.1 9.1

c) emergency care (health and community) 0 9.1 54.5 27.3 0 9.1

d) specialist health 18.2 45.5 36.4 0 0 0

e) long term care 0 9.1 27.3 36.4 0 27.3

f) home and community services in outlying localities 0 36.4 18.2 0 0 45.5

g) appropriate services for people from ethnic 0 27.3 18.2 0 0 54.5 backgrounds

h) appropriate services for Aboriginal people 0 9.1 36.4 9.1 18.2 27.3

Consultation 4. How would you rate the following consultation issues Very low Low Moderate High Very Don't high know a) availability of information about health and community 0 9.1 45.5 36.4 0 9.1 services b) the extent to which the community was involved in 0 9.1 18.2 18.2 0 54.5 decision making when the services were to be redeveloped c) on-going consultation to identify community needs 0 9.1 54.5 9.1 0 27.3

d) the ways in which consultation occurs 0 27.3 18.2 2.3 9.1 36.4

Service improvements 5. How would you rate the change in health and community services in this community today, compared to about five years ago Significant Minor No Improved Significant Don't decline decline change improvement know a) overall 0 0 0 45.5 36.4 18.2 b) acute health care (hospital) 0 0 18.2 36.4 18.2 27.3 c) general practitioners 0 27.3 45.5 9.1 0 18.2 d) allied health services 0 0 27.3 45.5 18.2 27.3 e) home based nursing 0 0 9.1 27.3 27.3 45.5 f) residential aged care 0 0 36.4 63.6 45.5 27.3 g) health and fitness information and classes 0 0 45.5 9.1 36.4 45.5 h) home care services 0 0 36.4 18.2 45.5 36.4 i) community development programs 0 0 32.3 9.1 45.5 45.5

MPS Model 6. To what extent has the MPS model made a noticeable difference to health and community services in this community in terms of …….. Significant Minor No Improved Significant Don't decline decline change improvement know a) health/community services management structures 0 0 0 36.4 36.4 27.3 b) flexibility in addressing priorities of the community 0 0 0 45.5 27.3 27.3 c) ability to innovate in way services are provided 0 0 0 45.5 27.3 27.3 d) community control over services 0 0 18.2 27.3 9.1 9.1

Multi-Purpose Services Program Evaluation, Victoria 172 Consultations

Appendix 4 Consultations

STEERING COMMITTEE Diane Petchell Director, Health Strategies Department of Health and Aged Care (Chairperson) Branch Jeannine Jacobson Manager, Coordinated and Department of Human Services Home Care Annabel Thorpe Assistant Director, Health Department of Health and Aged Care Strategies Branch Bruce Watson Manager, Integrated Care Department of Human Services Mila Cichello Executive Officer, Rural Health Department of Health and Aged Care Unit, Health Strategies Branch

REFERENCE GROUP Jeannine Jacobson Manager, Coordinated and Department of Human Services (Chairperson) Home Care Bruce Watson Manager, Integrated Care Department of Human Services Jodi Hallas Project Manager MPS and Rural Department of Human Services Health Integration Diane Petchell Director, Health Strategies Department of Health and Aged Care Branch Annabel Thorpe Assistant Director, Health Department of Health and Aged Care Strategies Branch Mila Cichello Manager, Health Strategies Department of Health and Aged Care Branch Margaret O'Loghlin Manager, Aged Care Department of Health and Aged Care Peter Donnelly Manager, Acute Health Department of Human Services Morris Dalton Acute Health Department of Human Services Jan Champlin Health Strategies Branch Rural Department of Human Services Health Chris Walpole Barwon Region Department of Human Services Kim Chadband Hume Region Department of Human Services Greg Blakely Gippsland Region Department of Human Services Marcia Gleeson Professional Officer Australian Nursing Federation Mary Barry CEO Vic. Assocn Health & Extended Care (VAHEC) Greg Knox Vic Healthcare Association Brendan Kay Medical Practitioner Otway Division of General Practice Chris Ward Manager, Northern Region Rural Workforce Agency Vic Ltd Cate Thomas Consumer Representative. Jeanette Grant CEO Otway Health and Community Services Jill Vagg Executive Officer Far East Gippsland Health and Support Wesley Carter Service Sue Green Frank Evans CEO Upper Murray Health and Community Services Lindsay Lynch CEO Mallee Track Health and Community Services Lyndon Seys CEO Alpine Health Joe Caruso Finance Manager Elaine Collins CEO Timboon and District Healthcare Service Graeme Kelly CEO Robinvale and District Health Services

Multi-Purpose Services Program Evaluation, Victoria 173 Consultations

Pauline Bommer Executive Officer Omeo and District Hospital

CONSULTATIONS Name Position Organisation Annabel Thorpe Executive Officer Department of Health and Aged Care Rural Health Unit Health Strategies Branch Mila Cichello Executive Officer Department of Health and Aged Care Health Strategies Branch John Fell Senior Project Officer Department of Health and Aged Care Health Strategies Branch Mandy Jeanroy Department of Health and Aged Care, Canberra Margaret O'Loghlin Area Manager Department of Health and Aged Care Planning and Community Programs Simon Moy Department of Human Services Bruce Watson Manager, Integrated Care Department of Human Services Aged Community and Mental Health Jodi Hallas Project Manager, MPS and Department of Human Services Rural Health Integration Jan Champlin Manager, Redevelopment Department of Human Services Rural Health Services Unit Tracey Slatter Manager, Community Health, Department of Human Services and responsible for Primary Care Partnerships Harold Klein Primary Care Partnerships Department of Human Services David Riley Primary Care Partnerships Department of Human Services David Anderson Manager, Financial Analysis Department of Human Services and Planning, Acute Health Branch David De Bono Aged Community and Mental Department of Human Services Health Jonathon Ashley Aged Community and Mental Department of Human Services Health Felicity Ison Aged Community and Mental Department of Human Services Health Michael Bingham Acute Health Department of Human Services

FIELD CONSULTATIONS Name Position Organisation Otway Health and Community Services John Townshend Department of Human Services Barwon South Western Region Jeanette Grant CEO Otway Health and Community Services Jacinta Bourke Manager, Community Services Otway Health and Community Services Phillip Marsh Quality Improvement Facilitator Otway Health and Community Services

Multi-Purpose Services Program Evaluation, Victoria 174 Consultations

Frank Shields President, Otway Health and Community Board of Management Services Beth Gardiner Senior Vice President, Otway Health and Community Board of Management Services Cheryl Biddle Physiotherapist Otway Health and Community Services Rebecca Smith Otway Health and Community Services Lisa Deppler Community Development Otway Health and Community Worker Services Dr Mark Loeffler General Practitioner Apollo Bay Dr Jim Lawless General Practitioner Apollo Bay Dr Meg Lawless General Practitioner Apollo Bay

Mallee Track Health and Community Services Phil McCann Manager Loddon Mallee Region Aged Community Mental Health Department of Human Services and Disability Services Ron Vine President Mallee Track Health & Community Service Lindsay Lynch CEO/DON Mallee Track Health and Community Services Pam Vallance Clinical and Residential Care Mallee Track Health and Community Manager Services Val Monroe Business Manager Mallee Track Health and Community Services Pat Curson Project Officer Mallee Track Health and Community Services Yvonne Thompson Community Nurse Mallee Track Health and Community Services, Murrayville Trevor Miles Hostel Supervisor Mallee Track Health and Community Services Karen Crook Accountant Mallee Track Health and Community Services Marilyn Smith Community Link/Social Support Mallee Track Health and Community Coordinator Services Tania Mitchell Neighbourhood Houses Mallee Track Health and Community Coordinator Services, Ouyen, Murrayville

Alpine Health John Joyce Manager Partnerships and Hume Region, Department of Human Service Planning Services Otto Schmalz President Alpine Health Board John Pitman Treasurer Alpine Health Board Lyndon Seys CEO Alpine Health Christine Prendergast Board member Alpine Health Andrew Randell Board member Alpine Health Julie Carroll Councillor Alpine Shire Board member Alpine Health Mary Stapleton Department of Human Services Suzanne Cooper CEO Ovens & King Community Health Service Nicki Melville CEO Upper Hume Community Health Services

Multi-Purpose Services Program Evaluation, Victoria 175 Consultations

Bernice Delany Community member Bright Community Focus Group Janet Wycherley Community member Bright Community Focus Group Jan Vonax Community member Myrtleford Community Focus Group Greg Peers Community member & RSL Mt Beauty Trevor Marshall Community Care Program Alpine Health Manager Dr Mark Robinson General Practitioner Alpine Health Inaugural Pres. Alpine Health Jackie Sullivan Health Information Officer Alpine Health

Upper Murray Health & Community Services Neville Maddox Manager, Aged Community Department of Human Services Mental Health, Hume Region Frank Evans CEO/DON Upper Murray Health & Community Services Mary Hoodless Community Services Manager Upper Murray Health & Community Services Linda Dare Manager, Acute and Residential Upper Murray Health & Community Care Services Kerry Flanagan Health Promotion Officer Upper Murray Health & Community Services Jill Boers District Nurse Upper Murray Health & Community Services Sylvia Montgomery Assoc. Charge Nurse Upper Murray Health & Community Services Kate Wheeler Asthma Educator Upper Murray Health & Community Services Elizabeth Wallace Physiotherapist Upper Murray Health & Community Services Margaret Vlacci HACC Worker Upper Murray Health & Community Services Dr David Richards General Practitioner Upper Murray Health & Community Services (locum) Barbara Nankervis Community member Corryong Jo Mc Kinnon Community member Corryong Michelle Wilkinson Nurse Practitioner Upper Murray Health & Community Services Sylvia Montgomery Nurse Practitioner Upper Murray Health & Community Services Judy McDonald NUM and Quality Manager Upper Murray Health & Community Services Gillian Dwerryhouse Chemist Graham Hill President Upper Murray Health & Community Services Board Dick Bayliss Board member Upper Murray Health & Community Services Sgt M Dorman Police Community Liaison Group, Community Rep. Dr David Richards General Practitioner Upper Murray Health & Community Services (locum) Barbara Nankervis Community member Corryong Jo Mc Kinnon Community member Corryong Michelle Wilkinson Nurse Practitioner Upper Murray Health & Community Services Sylvia Montgomery Nurse Practitioner Upper Murray Health & Community Services

Multi-Purpose Services Program Evaluation, Victoria 176 Consultations

Judy McDonald NUM and Quality Manager Upper Murray Health & Community Services

Far East Gippsland Health & Support Service Karen Russell Actg Health Manager Gippsland Region, Department of Human Services Lesley Harding President Far East Gippsland Health & Support Service Dr David Holland Board member Greg Norman Board member Cathy Healey Board member Sandra Pardew Board member Jill Vagg CEO Wesley Carter Manager Deputy CEO/Environmental Services Athalie Mason Coordinator EQuIP Peter Quin Team leader Community Support Services and Social Worker Fiona Ashlin SAAP Worker/Youth Worker Lesley Murray RN HACC & Discharge Planning Samantha Osborne RN Aged Care Levina Zutt RN & Infection Control Intensive Care/Acute Care Practitioner Lauryn Hulme Acute Nurse Unit Manager Acute Care Helen Mc Carthy RN/Community Health Nurse Maternity Enhancement Sue Harris Counsellor Family Violence Unit Gary Green Community Health Nurse Health Promotion Team Chris Allen Director Moogji Aboriginal Council Rachel Tatchell Community Liaison Officer Moogji Aboriginal Council Joanna Blunt Koori Project Officer Social & Emotional Well-Being Project Dr Hulme Hay General Practitioner

FOCUS GROUP ATTENDANCES Otway Health and Community Services Carol Stanesby Linkages Coordinator Community Options, Barwon Randle Fitzgerald Deputy Principal Apollo Bay School Betty Frape Community Member Margaret Kelly Community Member Pat Goodlet Community Member Paddy O'Connor Community Member Debbie Tovey Community Member Ronnie Rochford Community Member Joan McAllister Community Member Jan Nichols Community Member Angelica Miller Community Member Alma Muir Community Member Kim Bazel Community Member Thelma Moroney Community Member Clarice Mustafa Community Member Mary Day Community Member Doris Hanson Community Member Norma Allan Community Member

Mallee Track Health and Community Services Ron Vine President Ouyen Arthur Pattinson Board member Patchewollock Barb Chaplin Board member Murrayville

Multi-Purpose Services Program Evaluation, Victoria 177 Consultations

Otway Health and Community Services Carol Stanesby Linkages Coordinator Community Options, Barwon Randle Fitzgerald Deputy Principal Apollo Bay School Betty Frape Community Member Margaret Kelly Community Member Pat Goodlet Community Member Paddy O'Connor Community Member Debbie Tovey Community Member Ronnie Rochford Community Member Joan McAllister Community Member Jan Nichols Community Member Angelica Miller Community Member Alma Muir Community Member Kim Bazel Community Member Thelma Moroney Community Member Clarice Mustafa Community Member Mary Day Community Member Doris Hanson Community Member Norma Allan Community Member June O Connor Community member Ouyen Carmen McLean Community member Patchewollock Judy Schroeder Community member Murrayville Stephen Brown Community member Murrayville

Upper Murray Health & Community Services Jill Boers District nurse Upper Murray Health & Community Services Mary Hoodless Community Services Manager Upper Murray Health & Community Services Linda Dare Manager, Acute and Residential Care Upper Murray Health & Community Services Joy Gadd Continuing Care and Occupational Upper Murray Health & Community Services Therapy Kerry Flanagan Health Promotion/Community Upper Murray Health & Community Services Development/Public Health Frank Evans CEO/DON Upper Murray Health & Community Services Pamela Menere Treasurer, Board of Management Upper Murray Health & Community Services Patricia George Community Liaison Group St Joseph’s Convent, Corryong Jodi Jarvis Social Work student/ community La Trobe University member Claire Gale Consumer Ian Byatt Consumer

Far East Gippsland Support Service Bill Bolito Mayor East Gippsland Shire S/Const Jason Hellyer Police Orbost S/Const Richard Valentine Police Orbost Kathy Mills Reception Far East Gippsland Support Service Marjory Henderson Senior Citizens Orbost Tracey Barnett Community Jill Shanahan Community Tom Shanahan Community Clive Gerard Community Peter Coulton Community Keith Knight Community Kathy Mills Community

Multi-Purpose Services Program Evaluation, Victoria 178