Literature Review To Inform a Department of Human Services Project on Responding to People with High and Complex Needs 8 September 2002 Prepared by: Thomson Goodall Associates Pty Ltd 260 Dendy Street East Brighton Vic 3187 Tel: (03) 9592 5868 Fax: (03) 9553 8736 email: [email protected] Published by the Operations Division Victorian Government Department of Human Services Melbourne Victoria September 2002 Also published on www.dhs.vic.gov.au (C) Copyright State of Victoria, Department of Human Services 2002 This publication is copyright. No part may be reproduced by any process except in accordance with the provisions of the Copyright act 1 INTRODUCTION 1 Layout of the Review 2 2 DEFINING AND UNDERSTANDING COMPLEX NEEDS 4 2.1 Introduction 4 2.2 Homelessness Perspectives 5 2.3 Primary Care Perspectives 7 2.4 Disability Perspective 7 2.5 Dual Disability / Dual Disorder Perspective 9 2.6 Personality Disorder Perspectives 10 2.7 Child Protection 15 2.8 Aspergers Syndrome 18 2.9 Criminal Justice Involvement 18 2.10 Concluding Comment 19 3 GOVERNMENT POLICY FRAMEWORKS 20 3.1 Introduction 20 3.2 Deinstitutionalisation 20 3.3 National Policy Context (Australia) 25 3.4 Victoria - Policy and Program Development 26 Mental Health 26 Child and Adolescent Mental Health 27 Disability 27 Juvenile Justice 29 Drug treatment Services 29 The Working Together Strategy 30 Multi Service Client Project 30 Victorian Homelessness Strategy 30 3.5 Selected Policy Contexts of Other States and Territories 31 Western Australia 31 South Australia 31 Australian Capital Territory 32 3.6 United Kingdom 33 4 LEGISLATIVE CONTEXT RELATING TO PEOPLE WITH HIGH AND COMPLEX NEEDS 34 4.1 Introduction 34 4.2 National Context 34 4.3 Victoria 36 Introduction 36 Victorian Government Social Development Committee 36 Community Protection (Violent Offenders) Act 37 Mental Health (Amendment) Act 1996 42 Intellectually Disabled Persons’ Services Act 1986 43 Guardianship and Administration Act 1986 45 Sentencing Act 1991 46 Crimes (Mental Impairment and Unfitness to be Tried) Act 1997 47 Alcoholics and Drug-dependent Persons Act 1968 47 4.4 Selected Legislation in other States and Territories 47 4.5 United Kingdom 49 4.6 Legislation in Other Countries 51 5 SERVICE SYSTEM ISSUES, BARRIERS AND GAPS, RELEVANT TO EFFECTIVE RESPONSES TO PEOPLE WITH COMPLEX NEEDS 53 5.1 Introduction 53 5.2 Service System Gaps and Barriers 54 5.3 Mental Health Services 56 5.4 Forensic Mental Health Services 58 5.5 Disability Services 60 5.6 Child Protection Services 65 5.7 Juvenile Justice 67 5.8 Child and Adolescent Mental Health 68 5.9 Housing and Homelessness 69 5.10 Drug Treatment Services 71 5.11 Gaps and Barriers not Identified by the Literature 72 6 TOWARDS IMPROVED RESPONSES 73 6.1 Introduction 73 6.2 Legislative context 73 6.3 System Based Responses to Improve Services to People with High and Complex Needs 76 6.3.1 Introduction 76 6.3.2 Departmental Program Coordination, and Planning 77 6.3.3 Service System Principles 77 6.3.4 Collaborative Approaches 78 6.3.5 Specialist Responses 80 6.4 Service Principles and Practice Approaches 81 6.4.1 Introduction 81 6.4.2 Service Delivery Principles 81 6.4.3 Practice Approaches 83 6.5 Service Models 84 6.5.1 Introduction 84 6.5.2 Accommodation 85 6.5.3 Outreach 87 6.5.4 Service Delivery Components 87 6.5.5 Functions Within the Service System 89 6.6 Resourcing and Staffing 91 6.6.1 Introduction 91 6.6.2 Resourcing 91 6.6.3 Staffing 92 6.6.4 Stakeholder Participation 92 Concluding Comment 93 Introductory Comments on Methodology This literature review is based on literature identified and procured by the Victorian Department of Human Services (DHS). The literature was sourced through searches of various databases using key words, with documents sourced through the DHS Library. The literature was then supplemented with select documents identified by Thomson Goodall Associates Pty Ltd. It is important to note that the literature sourced by DHS and Thomson Goodall Associates is not exhaustive. Key areas were given priority in order to inform the broader Project objectives. In many instances, however, the review refers to other material, which the reader can source independently if greater detail is required. Thomson Goodall Associates assumes no responsibility for the scope and breadth of the literature review. 1 INTRODUCTION Over the past few years there have been growing concerns about the difficulty of providing services to a small, but significant group of people in Victoria whose complex needs challenge existing policy and legislative frameworks and service systems. These concerns have been expressed by a range of people and agencies including many within the health, welfare and criminal justice systems. People falling within this group include those children, adolescents and adults who may experience various combinations of mental illness and disorders, intellectual disability, acquired brain injury, physical disability, drug and/or alcohol misuse. The extreme challenging and/or dangerous behaviours amongst this group often result in involvement in juvenile or criminal justice systems. Social isolation, family dysfunction, physical and sexual abuse, homelessness and repeated crises are frequently key features of their life experiences. Several specialist and generalist services are often involved in service provision, including mental health, disability, child protection, juvenile justice, drug treatment, health, education, housing and support programs, aged care, as well as the range of generic community services and resources. Different responses, eligibility criteria and approaches mean that people with high and complex needs are frequently referred from service to service. Without a clear mandate, expertise or service model, services are often ill equipped and unable to effectively assist. Service responses or ‘packages’ are often developed on a case by case basis and at high cost, frequently as a last resort in the midst of one of repeated crises. The Department of Human Services is thus undertaking this project to investigate how strategies can be developed and implemented from a whole Department perspective to respond to people whose needs require a higher level of service planning and provision than the service system currently provides. While there are many clients with complex needs requiring improved service responses, this project only considers those at the extreme end of the continuum of complexity. The presenting factors that have been defined by DHS as characterising this target population are a combination of all the following: 1 Having multiple and complex presenting problems. Having high and complex needs that are not met or sustained by existing services. Having challenging behaviours that place the individual at high risk to self, service staff and\or the community. 1 Victorian Department of Human Services (2002) Complex Clients Project, Project Brief, Operations Division, DHS, Melbourne. 1 Chronic or episodic behaviours and\or conditions that require long-term service responses. Requiring a service response from two or more DHS programs (or criminal justice) areas. Having a specific need for which there is no current service system response, and\or require a current tailored funding package (usually at high cost). The objectives of the Complex Clients Project are to: 1. Identify, quantify and develop a comprehensive profile of the types of individuals with complex needs (the target group) and the costs/resources associated with service provision to these individuals; 2. Identify strengths and weaknesses of current legislative frameworks that define the provision of services to the target group; 3. Identify strengths and weaknesses of policy frameworks, service responses and any gaps in services; 4. Identify examples of best practice (including anecdotal) and evidence- based research, both locally and internationally, regarding service provision; 5. Develop a service framework and strategic plan for improving responses to the target group taking into account current resource usage, potential resource demands and future workforce requirements; 6. Define appropriate service responses and propose reconfiguration of resource allocations to provide these; 7. Develop recommendations on how service solutions may be supported by legislative change. There is a vast amount of literature about co-occurring and multiple disorders, or disabilities, particularly where these are accompanied by behaviours and needs which challenge the service system and the communities in which people live. Although broader than the focus of this project, much of this literature is relevant in identifying and understanding some of the key issues and service system challenges specifically associated with effective responses to people deemed to be at the extreme end of the continuum. The literature review that follows presents select findings from policy, legislative, program, administrative and practice developments in a range of disciplines and sectors. These have been selected to inform thinking about appropriate responses for the specific target group for this project. Layout of the Review The Literature Review is set out as follows. Section 2 reviews literature which seeks to define and understand what is meant by ‘complex needs’. A number of perspectives are identified including homelessness, primary care, disability, dual disability, personality disorder and child protection perspectives. 2 In Section 3 government policies in relation to responding