SHASP:
Interim Integrated Case
Management Guidelines
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
i
Contents
1
Introduction
1
1.1
1.2
1.3
Context
Purpose
Structure of this document
1
2
2
2
The Social Housing Advocacy and Support Program
4
2.1
2.2
2.3
2.4
SHASP aims and objectives
Client outcomes and indicators
Target group
Eligibility
4
4
4
5
3
The Integrated Case Management Model
6
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
Definition and benefits of case management
Principles of the Integrated Case Management Model
Integrated Case Management Model components
Referrals, screening and intake
Assessment and case planning
Implementation of the case plan
Monitoring and review
Case closure and transition
6
6
7
8
13
16
20
21
4
Partnerships and collaborative working
25
4.1
4.2
4.3
Partnerships with OoH
Collaborative working with other services
Support for High Risk Tenancies program (SFHRT)
25
26
27
5
Monitoring and reporting
29
5.1
5.2
5.3
Data collection and management
Reporting
Continuous improvement
29
31
31
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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1 Introduction
The Social Housing Advocacy and Support Program (SHASP) is a Victorian Government funded
program to achieve improved housing outcomes for public housing tenants, forming part of
the government’s commitment to sustaining tenancies.
The guidelines outline the Interim Integrated Case Management Model for the SHASP services.
SHASP provides interventions and supports to address needs and risk factors that make
tenancies vulnerable. The program is underpinned by a case management approach, involving
prioritisation of referrals, assessment of risks related to tenancies and the development of an
outcome-focused case plan to address those risks. The program is delivered through
partnership, joint working and collaboration with the Office of Housing and other services as
appropriate to address clients’ tenancy-related risks.
Interim Guidelines
These are the interim guidelines to support the delivery of SHASP services over the period
1st October to 30 June 2012. Readers should note that the prescribed timeframe is indicative
timeframe and will be dependent on the sector reform timelines.
There is the capacity to revise the guidelines after the interim period.
1.1
Context
These guidelines build on existing good practice in the SHASP sector. They also build on recent
improvements in partnership and collaborative working arrangements between SHASP
providers and the Office of Housing (OoH) that resulted from service improvement initiatives
following the 2009 SHASP evaluation1.
SHASP services are moving to a case management approach to delivering services for a
number of reasons.
Over recent years, there has been a significant shift in the SHASP client profile. Clients are
increasingly vulnerable and lack other suitable tenancy support2. In addition, the service is
working with increasing numbers of single parent families who are at risk of experiencing
homelessness.
This change in client profile, combined with changes to funding for SHASP services, has
necessitated a move towards a case management approach that enables a more holistic,
integrated response to address clients’ needs, while targeting resources to those most in need.
The move to a case management approach also aligns with the move towards a personalised,
holistic response outlined in Human Services: The case for change3. This paper describes an
integrated approach to delivering human services, underpinned by case management, that is
being piloted in two locations, through ‘Service Connect’. Concurrently, Victoria is undertaking
1
Health Outcomes International (2009) Evaluation of the Social Housing Advocacy and Support Program (SHASP)
Department of Human Services; Melbourne.
2
H&CB Investment logic map attachment 1.
3
Department of Human Services (2011) Human Services: The case for change, Victorian Government: Melbourne
pp 26- 29.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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a public consultation process as part of the Pathways to a Fair and Sustainable Social Housing
System4 initiative to seek community views about changes to the public housing system.
Within this context, these are interim guidelines that will be reviewed and revised to
incorporate the outcomes of the Service Connect pilots and the Pathways to a Fair and
Sustainable Social Housing System project.
1.2
Purpose
The purpose of the SHASP Integrated Case Management Guidelines (the Guidelines) is to:
•
Articulate the shared vision for how the SHASP will operate going forward
•
Outline the new integrated case management approach to be used by SHASP and the
nature of services and supports that will be provided
•
Create consistency in approach, reflecting contemporary good practice, while allowing a
degree of flexibility to be responsive to local needs and service system structures
•
Enable direction of resources to individuals most in need and ensure parity in responses
(for example in relation to identifying risk and enabling decisions regarding prioritization)
•
Outline roles and responsibilities for stakeholders in delivering SHASP and supporting
SHASP clients.
The guidelines are intended for use by SHASP managers and staff, OoH Managers and staff,
and staff from other services working with the SHASP client group.
While these Guidelines provide consistency for SHASP across Victoria, practical arrangements
for delivering the program are described in local Memorandum of Understandings (MOUs).
These are developed and agreed locally by SHASP providers and the relevant OoH offices.
1.3
Structure of this document
The guidelines are structured as follows:
Introduction
This describes the context and purpose of the
guidelines.
Page 1
The Social Housing
Advocacy and Support
Program
This describes the aims, objectives and outcomes of
SHASP and outlines the target group and eligibility
criteria for the service.
Page 4
The Integrated Case
Management Model
This provides an overview of a case management
approach and describes the principles and elements
of the integrated case management model.
Page 6
4
Victorian Government (2012) Pathways to a Fair and Sustainable Social Housing System: Public consultation
discussion paper. Viewed at
http://www.dhs.vic.gov.au/__data/assets/pdf_file/0006/709053/housingframeworkdiscussionpaper_27042012.pdf
on 30th July 2012.
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Partnerships and
collaborative working
This describes the partnership approach required
with the OoH and the arrangements for
collaboration in working with other stakeholders.
Page 25
Monitoring and reporting
This outlines the responsibilities and requirements
for data monitoring and reporting and the need for
continuous improvement.
Page 29
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2 The Social Housing Advocacy and Support Program
2.1
SHASP aims and objectives
The overall aim of SHASP is to provide support to public housing tenants and residents in order
to assist them to sustain their housing. Within this aim, the goals are to:
2.2
•
identify and address underlying issues which contribute to the risk of tenancy breakdown
for the individual
•
support tenants to achieve outcomes that lead to successful, sustainable public housing
tenancies
•
reduce preventable exits from public housing
•
prevent homelessness.
Client outcomes and indicators
SHASP services work with clients to achieve short term outcomes, or milestones, which
provide a platform to achieve longer-term outcomes, such as sustained, successful tenancies
and independence.
The intended outcome for SHASP is that clients maintain safe, appropriate, sustainable
accommodation.
Indicators of this include that clients:
2.3
•
are engaged in appropriate services to meet their assessed needs and to achieve their
tenancy related goals, or be on track to working towards achieving these
•
have addressed risks that posed an immediate risk to their tenancy
•
are paying rent and (if appropriate) have reduced their rental arrears
•
are not at imminent risk of eviction.
Target group
SHASP services are targeted to public housing tenants and residents.
SHASP provides services to public housing tenants and residents who are vulnerable to or at
risk of tenancy breakdown and failure due to the experience of a range of factors, including
multiple and/or complex needs.
“Vulnerable or at-risk clients are those whose personal circumstances are impacting on
their ability to sustain a long term tenancy. This is identified when tenancies are
jeopardised, for example, due to rental arrears and/or anti-social behaviour. These
personal circumstances may include a combination of issues such as family violence and
relationship issues, compulsive behaviours, disability, physical and mental health issues,
lack of living skills5, language barriers and age.”
5
Adapted from Attch 1 NWMR Tenants at Risk.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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The SHASP target group are likely to be experiencing a number of these issues.
2.4
Eligibility
All public housing tenants and residents are eligible for SHASP services, however, the following
indicators and risk factors may suggest particular vulnerability and risk to the tenancy.
•
prior and/or current debt
•
rent arrears
•
history of housing instability/
homelessness
•
cultural factors (communication
barriers)
•
poor living skills
•
relationship issues (e.g. family/
domestic violence, family breakdown,
history of abuse)
•
household factors (social isolation,
social instability)
•
disability
•
compulsive behaviours
•
substance misuse
•
disability
•
antisocial behaviour
•
history of disputes
•
mental illness currently not
managed
•
no response to a contract review
•
failure to maintain the property
(e.g. hoarding, squalor)
•
moving into a new area without
adequate supports.
•
contact with multiple agencies,
including frequent use of
emergency services
SHASP is a voluntary service and whilst SHASP providers will use their best efforts to engage
with prospective clients through assertive outreach, it is recognised that some tenants will
chose not to work with the service.
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3 The Integrated Case Management Model
3.1
Definition and benefits of case management
The main objective of case management is to ensure that clients are provided with the full
range of services / responses that they require, in a consistent, timely, effective and efficient
manner. The emphasis is on seamless, continuity of care, achieved through need based,
coordinated and comprehensive planning and service provision6.
The Case Management Society of Australia defines case management7 as:
“a collaborative process of assessment, planning, facilitation and advocacy for options and
services to meet an individual’s needs through communication and available resources to
promote quality cost effective outcomes.”
Case management is a collaborative, client focused approach8 in which services and responses
are coordinated and delivered based on assessed risk and need, to achieve goals (outcomes)
that are identified by the individual.
Effective case management is underpinned by principles, a flexible, individualised service
response, relevant staff skills and knowledge, and a collaborative, partnership approach within
the wider service system.
Integrated case management is fundamental to providing effective support to individuals with
multiple and/or complex needs. It enables seamless, coordinated access to a range of services
that can address different aspects of an individual’s need. Within a case management model,
all services work in a coordinated way to achieve shared outcomes for the individual.
Case management includes providing direct services in line with an individual’s case plan, as
well as “coordinating access to and delivery of a range of other support services9” to deliver
the case plan.
3.2
Principles of the Integrated Case Management Model
The SHASP Integrated Case Management Model is underpinned by six principles which reflect
contemporary practice and the Victorian Government’s forward direction outlined in Human
Services: A Case for Change10. The principles include:
1. Outcome focused and client centred
Clients are empowered to sustain their tenancy and identify their goals and aspirations
which impact on the sustainability of their tenancy. SHASP services will work with clients
to support them to achieve these goals. This requires a flexible, culturally appropriate,
individualised and holistic approach, based on assessed need and risk: there is no “one size
6
HomeGround Services (2010) SHASP Service Manual p 56.
Viewed at http://www.cmsa.org.au/definition.html on 23rd July 2012.
8
Case Management Resource Kit for SAAP Services (1996) Viewed at http://www.fahcsia.gov.au/ourresponsibilities/housing-support/publications-articles/homelessness-general/saap-evaluation-and-researchpublications/saap-case-management-resource-kit on 23rd July 2012.
9
Case Management Resource Kit for SAAP Services (1996) ibid.
10
DHS 2011 op.cit.
7
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
6
fits all” approach. This recognises that individuals’ needs and capacity to manage their
lives may change over time.
2. Building independence
SHASP services build on clients’ strengths to enhance their capabilities and capacity, to
empower them to live independently in suitable, stable accommodation, and to build
family and community resilience.
3. Prevention and early intervention
SHASP services, within the wider system, should focus on addressing the causes of tenancy
breakdown before the tenancy fails, and breaking the cycle of factors that lead to repeat
tenancy breakdown (and homelessness).
4. Targeted and appropriate to risk
Responses are tailored to be most effective at addressing identified risk and priority and
are targeted to individuals who have the least capacity to self manage to sustain their
tenancy.
5. Partnership and coordination
Strong partnerships and coordinated approaches with the OoH and other universal and
specialist services, at both delivery and policy levels, are essential to address the causes
and consequences of tenancy breakdown.
SHASP services work in a coordinated way with other services to reduce duplication of
effort and resources and to focus on shared outcomes for clients.
6. Value and respect
Public housing tenants have the right to access quality supports to enable them to sustain
their tenancies. SHASP clients will be valued, respected and treated fairly and impartially,
regardless of cultural background, legal status, sexual preference and identity or religion.
3.3
Integrated Case Management Model components
The following are components of the SHASP Integrated Case Management Model:
•
Referrals, screening and intake
•
Determining need through holistic assessment and developing the outcome focused case
plan
•
Implementing the case plan, including case work and case coordination
•
Monitoring and review of the case plan
•
Case closure and transition.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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Figure 1: Integrated Case Management elements
Re-referral for ex-clients
after case closure
Referral and
screening
Prioritisation
and allocation
Assessment and
case planning
Implementation
of case plan
Exit planning
Case closure
Monitoring and
review
Source: KPMG
Approaches to undertake these components, including tools, and roles and responsibilities, are
described below.
3.4
Referrals, screening and intake
Clearly defined referral and service access pathways are important to provide timely,
accessible support to people whose tenancies are at risk.
Referral, intake and screening for SHASP services is underpinned by the following principles:
•
there is clear, jointly agreed responsibility for all aspects of referral, intake, and screening
activities, including management of the waiting list
•
pathways are clearly defined and transparent and are clearly communicated to all
stakeholders, including tenants and other services
•
information gathered at referral enables screening to determine eligibility and
prioritisation to enable decisions about allocation to SHASP
•
referrals and prioritisation decisions involve collaboration between SHASP and the OoH
(including multiple offices where appropriate) and are undertaken in a timely, transparent
way. This includes processes to respond to referrals that need a rapid (high priority)
response to prevent eviction.
There will be a requirement for each agency/ region to develop a defined referral model in
accordance with these principles. The proposed model will be included in MOUs and funding
agreements with agencies.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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Figure 2: SHASP referral process
Source: KPMG
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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3.4.1
Referral and initial screening
The primary point of entry to SHASP services is through either the OoH or SHASP provider, as
agreed locally and articulated in the MoU. The referral pathway will enable clients to be
referred from a range of different sources, including self referrals and those from OoH, SHASP
and other services. Referral pathways should be streamlined so there are no barriers to
access, clients do not have to ‘repeat their story’ and there is consistency in decisions about
prioritisation.
The officer / team member receiving the referral will:
•
contact the tenant and (if unknown) gather information to determine whether they are
eligible for SHASP services
•
if the tenant is eligible for SHASP services, provide information about the service and seek
the client’s consent to be referred
•
gather initial information to complete the standard referral form
•
If the tenant is not eligible for SHASP, provide information and advice and/or make
referrals to other services, as appropriate
Initial screening to inform the referral may take place by telephone or face to face. The
following information will be captured on a standard referral pro forma:
•
tenant contact details and basic information, such as gender, age and whether the person
is from an Aboriginal or CALD background
•
other tenants at the address, specifically whether there are any children at the address
•
tenancy status
•
primary reason for seeking support or area of immediate risk to tenancy
•
desired outcome from the referral
•
urgency of the referral (e.g. date for eviction / Victorian Civil and Administrative Tribunal
(VCAT) hearing)
•
whether the tenant has previously been a SHASP client and, if so, dates service was
received
•
any support issues or areas of risk or need that are known at time of referral
•
where known, other supports / services currently or recently engaged.
The purpose of the initial screening and the completion of the referral form is to gather
sufficient information to enable a decision about the priority of the referral.
3.4.2
Prioritisation and allocation
The purpose of prioritisation and allocation is to consider the capacity of SHASP services to
take on new cases, to consistently prioritise referrals for access to SHASP and to manage
SHASP waiting lists.
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All referrals are discussed and considered jointly by SHASP and OoH, using mechanisms agreed
locally and identified in the local MoU. Discussions regarding prioritisation and allocation may
take place during face to face meetings, by email or telephone or using any or all of these
approaches, as appropriate. Frequency of discussions will also be agreed locally and described
in local MoUs.
All referrals, including high priority and duty of care referrals (see below), are discussed and
prioritised for access on a case by case basis. Decisions regarding prioritisation should include
consideration of the risk of the tenancy, including whether tenants:
•
are in crisis and are at imminent risk of losing their tenancy
•
have been given a Notice to Vacate (prioritisation is given to earlier dates)
•
have a scheduled VCAT hearing (prioritisation is given to earlier dates)
•
have current rental arrears (amount and length of time is considered in prioritisation
decisions)
•
are not involved in other services
•
do not have the capacity to self manage (and require managed or guided support)
•
have children or young people living with them who are likely to be at risk if the tenancy
breaks down
•
have been on the waiting list for over three months
•
have recently (within the last six months) exited from SHASP services and who are
re-referring
•
have multiple indictors that suggest they are vulnerable to the risk of tenancy breakdown.
A common prioritisation tool is used to facilitate consistent prioritisation across all SHASP
services, but referrals should be considered on a case by case basis.
Feedback is provided to the referrer about the outcome of the prioritisation and allocation
meeting. Where tenants have not been allocated a case worker, information and advice is
provided about other services that can be approached by the tenant for support. The
responsibility for undertaking these activities is agreed locally and articulated in Local MoUs.
Duty of care referrals
As a landlord, the OoH has a duty of care towards public housing tenants who are likely to be
affected by OoH activities, action or inaction. To meet this duty of care, the OoH may make a
timely referral to SHASP to seek support for public housing tenants where there is
considerable concern about the security of the client’s tenancy.
Under a duty of care referral, it will not be possible to obtain consent from the tenant for the
referral, due to the tenant’s lack of willingness to engage in services. In these cases, the
Housing Act 1983 (Vic) allows for “the disclosure of tenant information without prior consent,
without breaching the information Privacy Principles11”.
11
Wombat Housing and Support Services March 2009, SHASP Duty of Care Referrals for Tenancies at Risk).
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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Duty of care referrals must be discussed and mutually agreed by the SHASP manager and OoH,
as outlined in outlined in local Memorandums of Understanding between SHASP providers and
the OoH. If there is an imminent and direct risk of crisis involving the client, these should be
directed to the appropriate emergency/ statutory service, such as police, ambulance or child
protection.
SHASP workers will employ an assertive outreach approach to engage the client and will
provide feedback to OoH about the outcome of attempts to engage.
High priority referrals 12
SHASP does not provide a crisis response. However, occasions may arise where a client
referred to SHASP requires a more immediate response to avert an eviction, for example, if the
tenant has been served an immediate Notice to Vacate for Danger or Damage.
The capacity for SHASP to accept these referrals is based on the prioritisation processes
described above, and upon the following factors:
3.4.3
•
the capacity of the SHASP service to respond
•
a decision about whether it is possible that the tenancy can be reinstated or eviction
prevented. Discussions between OoH and SHASP regarding a high priority referral will take
place on an ‘as needs’ basis to enable an appropriate timely response to the client.
Waiting lists and active holding
Tenants who are not prioritised for access to SHASP services are placed on a waiting list.
Waiting list management includes regularly reviewing and re-prioritising tenants on the
waiting list. As part of this approach, services are encouraged to apply active holding
techniques, which may improving the timeliness of response through actively engaging clients
at the point of referral where a case worker cannot be immediately allocated.
The purpose of active holding may differ dependent on needs but may include:
•
addressing immediate needs/prevent needs from escalating
•
referring clients into alternate services while they are waiting for a response
•
reduce the dropout rate among clients waiting for more extended periods.
Active holding may include one or more of the following responses:
•
A regular phone call to check in on the client and determine whether needs have changed,
i.e. whether there is still a requirement for SHASP services or the client requires a different
service response
•
Active engagement at the point of referral, to address immediate needs and divert the
client from long-term case management. This may involve referring the client into other
programs, or workers may meet with the client and develop a very brief case plan with a
few very specific goals.
•
Providing a letter or email to the tenant:
12
Based on current procedures described in Wombat Housing and Support Services, SHASP Support Program
Processes and Procedures.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
12
•
–
explaining that they are on the waiting list and will be contacted when a place
becomes available
–
providing information and contact details about other services that could be contacted
for support
–
advising the tenant to re-refer themselves if their circumstances change
holding information or group sessions.
The waiting list management and active holding response is undertaken as agreed locally and
stated in the MOU.
3.4.4
Allocation of a case worker
Tenants who are accepted into SHASP services are allocated a case worker based on
considerations that include:
•
location of the client and case worker
•
capacity of case workers, in terms of total case load and mix of cases
•
specific skills and experience of case workers in relation to the characteristics and needs of
the client, for example experience working with hoarders, or with young people
•
if known and relevant, age, gender and preferences of the tenant.
The case worker provides a constant point of contact for the client and undertakes all
elements of case management. The client may request a change of case worker at any time,
and processes for doing this should be explained to the client during the first visit and as
appropriate thereafter.
3.4.5
Initial engagement and risk assessment
Following allocation, the case worker should contact the client to introduce themselves, set up
a first appointment and provide additional verbal and written information about SHASP. Prior
to undertaking the initial meeting with the client, a risk assessment should be undertaken to
identify any risks to the case worker’s safety and to consider strategies to remove, reduce
and/or manage these risks.
Case workers should use an assertive and flexible approach to establish initial contact and to
engage clients. This may involve attempting to make contact over a two week period, using a
variety of different approaches (telephone, visitation, letter, email) over a range of different
times and days.
3.5
Assessment and case planning
Effective assessment that identifies strengths, needs and areas of risk impacting on ability to
maintain tenancy is fundamental to enabling services and supports to be put in place. The
information gathered in the assessment informs the development of the case plan which
articulates the client’s goals (or outcomes) to resolve the factors that are placing the tenancy
at risk and identifies the supports and interventions that are needed to achieve these.
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3.5.1
Holistic assessment
Once a client has been allocated to a case worker, the worker undertakes an assessment to:
•
commence building a trusting relationship with the client and, if appropriate, their family
and carers
•
understand the presenting issues and the context of the client’s tenancy related matters
•
establish (and manage if required) the client’s expectations about the service and SHASP’s
expectations of the client
•
identify tenancy support needs and any risks which may contribute to tenancy breakdown
or instability. This may include considering the risks and needs of family members or
carers living with the individual
•
understand the client’s history and identify historical risk factors (such as a history of
financial management problems)
•
identify strengths which can be built upon
•
understand the individual’s goals and aspirations in relation to their tenancy.
Consent is also sought from the client to request information from other relevant services with
which the client is involved or has previously been involved.
The assessment is completed using the common assessment framework that operates across
all SHASP services. The assessment is holistic in its approach; that is, it considers the ‘whole
person’, taking into account their physical, environmental, emotional, psycho-social, and
lifestyle situation. A holistic assessment attempts to understand the interplay of personal,
relationship and social factors that impact on the current situation for each client13. This may
require information to be gathered from a range of different sources, with the client’s consent.
Some information relating to the assessment may have been gathered prior to the allocation
of a case worker, for example, through the intake and prioritisation process. It is good practice
to build on previous assessments and information gathering exercises to prevent the client
from having to repeat their story. Where information is already known, the case worker
should use the assessment process as an opportunity to explore any changes or to supplement
the available information.
The assessment should be commenced at the first meeting between the case worker and the
client. However, some clients may prefer to develop a trusting relationship with their case
worker over a number of meetings / contacts before they are willing to divulge information.
Therefore, the case worker should aim to complete the assessment, to inform the case plan,
over the first few visits.
To undertake effective assessments, case workers must:
•
be familiar with the assessment and case planning tools
•
be able to build rapport and develop trust
13
Viewed at
http://legacy.communitydoor.org.au/resources/etraining/units/chccs402a/section1/section1topic03.html on 23rd
July 2012.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
14
•
be objective, impartial and non-judgmental
•
have a good understanding of the tenancy related issues that SHASP clients face, including
the environment and context that contributes to these.
Assessment for high priority referrals
For high priority referrals, where a timely intervention is critical to avoid imminent eviction,
the SHASP worker may be required to initially undertake a briefer, targeted assessment. This
should be sufficient to inform actions that need to be taken immediately to prevent the
eviction. A holistic assessment, described above, should be undertaken subsequently to
inform longer-term planning for the client once the imminent risk of eviction has been
resolved.
3.5.2
Case planning
Information gathered during the assessment informs the case plan. The case plan is an
essential component of an integrated case management approach. It provides the framework
for all interventions and supports that are required to achieve a client’s goals and is shared by
all services and providers working with the client (based on the client’s consent).
The case plan is developed (and reviewed) in consultation with the client to enhance the
client’s ‘ownership’ of the plan and the likelihood that change will be achieved, and to
facilitate independence and self-management. It should be developed at completion of the
assessment and include:
•
identified housing risks
•
the client’s goals and aspirations, in their own words, which are focused on sustaining the
tenancy
•
details about the resources, interventions and supports needed to achieve those goals,
including those required from other services and providers
•
responsibilities regarding implementing elements of the plan, including responsibility of
the case worker, the client and other services
•
(if required) details of case meetings with OoH staff, for example for complex clients where
hoarding and squalor place the tenancy at risk
•
timeframes (including length of duration and completion dates) for implementation of the
plan elements
•
measures to demonstrate that goals (and milestones towards goals) have been achieved
•
mechanisms, including timeframes, to track progress and enable review of the plan to
identify what is working and where changes to the plan are needed
•
consideration of exit or transition planning for the end of the SHASP support period.
The case worker has a responsibility to support the client to make decisions about goals and
priorities to be included in the case plan. The case worker empowers the client to make
decisions and identify appropriate responses, for example through providing information
about available resources or support options.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
15
While the plan will be developed using a standard case plan proforma, individual case plans
will be tailored to the client, based on their assessed needs, to enable a flexible response to
meet their goals. Clients should sign their case plan and be given a copy, which must be in a
format, style and language to which the client can relate14. Copies of the care plan may also be
provided to other services working with the client, if the client provides consent.
3.5.3
Active engagement
While the majority of SHASP clients will engage with the program voluntarily, a number may
be less willing or motivated to engage. SHASP case workers will actively engage clients to
encourage strong engagement, ownership of case plans, self-management, and to support
earlier intervention into emerging risks. Active engagement involves a number of techniques,
for example:
•
timely contact and visits, particularly with new clients, and being reliable in attending
meetings
•
undertaking joint visits with workers already known to the client, if appropriate
•
building a trusting relationship
•
providing useful, concrete support and focusing on building practical skills
•
empowering client decision making
•
using plan English (or interpreters) and using non-judgemental, positive communication
styles.
If clients are not engaging with SHASP, despite best efforts, this should be discussed with OoH
as part of regular communication to ensure that the OoH are aware of the difficulties in
engagement.
3.6
Implementation of the case plan
Implementation of the case plan involves putting in place the resources, interventions and
supports required to achieve the different tasks identified in the case plan to maintain a
tenancy. The case plan will include activities that can be undertaken by SHASP, as well as
those that require referral, joint working, and/or collaboration with other services. The
implementation of the case plan has a number of elements, described below.
3.6.1
Case work
This refers to the practical, day-to-day involvement with the SHASP client, as outlined in the
case plan. It involves the case worker maintaining the relationship and contact with the client,
delivering a range of interventions and using a range of skills and techniques to assist clients to
achieve their goals.
Case work includes providing direct, tangible support, such as assistance with budgeting and
making referrals, as well as ‘soft’ support in relation to aspects such as increasing motivation,
and building confidence and resilience to enable the client to move towards self-management.
14
SAAP Case Management Resource Kit (1996) op.cit. p 1.20.
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16
Interventions provided by SHASP case workers will vary depending on individual clients’ needs,
but might include:
•
support to address housing risk factors
•
•
meeting with the client as required
and as identified in the case plan
managing and addressing challenging
behaviours
•
developing living and life skills
•
supporting VCAT processes
•
•
supporting the client to address
hoarding behaviour
support for budgeting and financial
management
•
sourcing brokerage
•
assisting clients to access medical, mental
health and legal services, for example.
•
assertive outreach and outreach
support
Case work takes place in a variety of locations, as required and considered appropriate by the
client and case worker. Locations include in the client’s home, at the SHASP service, at an
agreed neutral location (such as a local coffee shop or community centre), and /or at the
offices of other services.
3.6.2
Case coordination
SHASP case workers will undertake case coordination to implement the case plan, unless
another agency has been identified as the case coordinator. Case coordination includes
communication, information sharing, and collaboration with other mainstream and specialist
services that are required to support the client to achieve identified goals. Involvement of
other services is required to addresses potential gaps in meeting social, developmental,
behavioural, educational, informal support network, and financial needs in order to achieve
client outcomes.
Coordination activities may include:
•
providing assistance to the client to support the client to navigate the service system, for
example through providing information about the available services and access criteria and
processes
•
making referrals to other mainstream and specialist services or programs, such as drug and
alcohol, mental health, family services, anger management programs
•
facilitating access to other services, such as attending meetings and helping clients to
complete paperwork
•
reducing barriers to obtaining services, for example through supporting clients to access
relevant health, mental health and legal services
•
sharing and exchanging information, such as assessments and case plans, with other
services, with the client’s consent
•
joint working with clients, as required
•
maintaining regular contact with other services involved in the client’s case, with the
client’s consent, to inform monitoring and review of the case plan (see section 3.7).
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Case coordination by other agencies
3.6.3
•
Where another agency provides the case coordination for a SHASP client, the SHASP case
worker will work with case coordinators as identified in the client’s case plan. This might
involve joint assessment, planning and reviews, as well as working directly with the client
to deliver specific support and interventions that address tenancy – related risks.
•
Alternatively, it may just include providing secondary consultation and advice at key points.
Case conferencing
SHASP case workers may initiate and lead or participate in formal, planned and structured case
conferences on behalf of clients. Case conferences involve a range of providers from all
services involved in supporting a client. The goal is to provide holistic, coordinated, and
integrated services across providers, while reducing duplication. It is good practice for clients
to attend case conferences.
It is expected that OoH would participate in case conferences where hoarding and squalor are
identified as part of their risk management processes.
3.6.4
Secondary consultation
Secondary consultation involves providing information, advice, and support to other
professionals who require expert input to work effectively with their clients. SHASP case
workers are recognised to have expertise and knowledge in a number of areas, such as
hoarding behaviours and relevant legislation, and should provide secondary consultation in
these and other relevant areas if requested. This should be recorded and monitored as a
service activity.
3.6.5
Levels of intervention
For this 9 month period we will be working on a two tiered approach. The level, frequency and
duration of support and case management input required for clients will vary overtime
depending on their identified risks to tenancy and assessed level of need.
Levels of intervention
The SHASP Integrated Case Management service model includes the provision of brief and
integrated case managed interventions to overcome risks to the clients’ tenancy. These are
described in detail below:
Brief
interventions
These clients require a brief, solution focussed intervention aimed at
resolving specific issues that impact on a tenancy. Many of these cases
have an early intervention focus, with an emphasis on education and skill
development for tenants. Clients requiring brief interventions may not
need a case plan to be developed, if risks relating to the tenancy are quickly
addressed.
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Integrated case
managed
Case management of these clients focuses on providing longer term support
to address needs that impact on a client’s ability to maintain their tenancy.
Given the nature of co-occurring risks and needs, it is likely that longer term
and more intensive work will be required to address the issues which are
placing the tenancy at risk and support the sustainability of the tenancy in
the longer term.
During the implementation of these interim guidelines, SHASP services will provide
interventions as follows:
Brief intervention
Longer term / higher intensity intervention
10 per cent of all funded hours
90 per cent of all funded hours
Worker case loads are determined by SHASP providers, based on staffing structures, and local
practices and need.
Monitoring of intervention level during interim period
The distribution of cases described above is indicative only, and reflects the move of the SHASP
program to a case management model that prioritises clients based on the risk to tenancies
and the requirement (wherever possible) to sustain tenancies and promote independence.
The proportion of hours associated with brief or integrated case managed client contact will be
monitored over the period 1 October 2012 – 30 June 2013, through the requirement for SHASP
providers to collect data about the number of service hours provided to each allocated case,
and the duration of service provision.
Frequency and duration of contacts
Frequency and duration of contact should give consideration to the clients’ risks, needs and
complexities. Many clients will require more intensive intervention early in the case
management cycle to address immediate needs and risks, with intensity declining as the
situation is stabilised. Some clients may need support at transition points and may therefore
need several episodes of service delivery. Other clients with complex and diverse needs (i.e.
with significant challenging behaviour, such as hoarders) contacts may be more frequent.
Duration of the service will be guided by the case plan. SHASP services will work with clients
over a period agreed with the client, to achieve goals in relation to the client’s tenancy, or to
implement as much of the case plan as is practicably possible.
As a guide, clients requiring:
•
brief intervention support should aim to exit from the service, having achieved their goals,
within one or two contacts
•
integrated case managed intervention should aim to complete their case plan within 13
weeks.
Expectations of service duration should be discussed with the client as part of implementing
and reviewing the case plan to encourage the client to take responsibility to achieve goals
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within a feasible timeframe. However, a discussion of this nature may not be beneficial for all
clients and case workers should use their professional judgement.
The level, frequency and duration of support required may increase or decrease throughout a
client’s engagement with SHASP, if situations or circumstances change that impact on need
and risk to the tenancy. This will be identified through case monitoring and review (described
in section3.7), and required changes in the nature and intensity of support will be reflected in
revisions to the case plan.
3.7
Monitoring and review
The case plan is a ‘living’ plan that is continually monitored, reviewed and revised by the case
worker and the client throughout the client’s involvement with SHASP. These steps are
explained below.
3.7.1
Monitoring the case plan
Monitoring occurs as part of day-to-day implementation of the case plan, to ensure that the
activities outlined in the plan are taking place as planned. This includes that activities are
occurring in the planned sequence (if necessary), within the planned timeframe and by the
identified people or services.
If activities are not proceeding as planned, and if the activities are still considered to be
appropriate to support the client’s goals, the case manager and/or client, as agreed, will take
steps to address issues. This might include following up referrals or seeking more information,
for example.
3.7.2
Review of the case plan
Case plan reviews take place with the client and involve:
•
considering whether goals have been met, or are on track to being met, using the measure
of success identified in the case plan
•
reflecting on a celebrating success towards achieving goals
•
identifying areas in which goals are not on track to be achieved and why
•
considering whether any changes are required to the case plan to better facilitate the
achievement of goals. This might include introducing additional activities or actions,
revising time frames, or reallocating responsibilities
•
towards the end of the client’s engagement with SHASP, considering specific activities that
might be required to close the case and transition the client to other services as
appropriate.
Case plan reviews provide an opportunity to encourage and support clients through
recognising and building on their achievements and empowering them to ‘own’ their plans.
This is important to support clients to move towards self management and independence.
Although informal reviews of the case plan may take place as part of monitoring (see above), a
formal review should take place as specified in the case plan, and agreed with the client. For
example, case plans for new clients may be formally reviewed on a weekly basis as part of
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establishing a relationship and encouraging engagement. Case plans for clients with complex
and multiple needs may be reviewed on a monthly basis to allow sufficient time between
reviews for activities to be undertaken and changes observed.
3.7.3
Revising the case plan
At any stage of the client’s engagement with SHASP, the case plan can be revised and updated
to better reflect the client’s needs and goals and to acknowledge when goals have been
achieved.
Revisions to the case plan should take place if the clients’ needs, risk factors, circumstances or
aspirations in relation to their tenancy change. Revisions may include changes to activities and
actions, timeframes, and responsibilities, as well as to goals and milestones.
All revisions must be developed and agreed with the client, and the client must receive a copy
of the revised case plan. Other services that are working with the client may also be provided
with a revised case plan, with the client’s consent.
3.7.4
Continued assessment and re-assessment
Continual assessment and re-assessment is important to inform the monitoring, reviewing and
revision of the case plan. It should:
•
identify changes in risks, needs and strengths and changes in behaviour as a result of the
implementation of the case plan
•
be undertaken by the case worker at key points, as indicated by the case plan
•
include information provided by other services involved in implementing the case plan.
This may be gathered verbally, in written format or as part of joint working or case
conferencing mechanisms
•
be both informal, through discussion with the client, and formal, for example using
elements of the assessment tools that relate to an area of risk or need, in which change
was required.
Re-completion of the comprehensive assessment is only necessary if the client’s circumstances
change considerably.
3.8
Case closure and transition
A case should be closed once all identified case plan goals have been achieved, or the case
plan is on track to achieving goals, or the client chooses to cease their engagement with
SHASP.
It is important for case workers and clients to plan for case closure to ensure that, if necessary,
supports are in place to enable the client to continue to successfully maintain their tenancy.
Therefore, planning for case closure and transition to other services should take place
throughout all case management stages.
The level and nature of activity required to close a case will vary depending on the client’s
needs and on the extent to which goals have been met. For example, clients who have
addressed all risks and needs through their involvement with SHASP and/or those who are
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21
able to self-manage the remaining risks are likely to require less transition support at case
closure.
Clients who still have underlying issues and risks that directly or indirectly impact on their
ability to sustain their tenancy are likely to require more formal transitional support at case
closure.
Activities to close a case may include:
3.8.1
•
final review and revision (completion) of case plan. This may require input from other
services involved with the client to ensure there are no on-going issues that should prevent
the case from being closed
•
referrals to other services, including information sharing. This may include a joint meeting
or a case conference, involving the client handing over responsibility to another service
•
contacting the service that initially referred the client to inform them the case is due to be
closed and to provide information about the outcomes of SHASP involvement. This
requires the client’s consent
•
identification of triggers or situations which lead to risk to the tenancy and development of
strategies, or contingencies for the client to address these in a timely way. This might
include identifying when to seek re-engagement with SHASP
•
informing (and involving where appropriate) OoH of the case closure and providing a
summary which outlines outcomes achieved, as well as ongoing issues and strategies to
address these within the limits of client confidentiality
•
closure of the case in client management systems and reporting databases.
Unplanned exits
A case may be closed before goals are achieved and at any time during the implementation of
the case plan if the client has disengaged (or never engaged) from the service despite the best
efforts by the case worker to engage them.
Case workers will use assertive outreach approaches to attempt to engage / re-engage with
the client over a two week period. If these attempts are unsuccessful, the client will be sent a
letter that states the case will be closed if no response is received from the client within two
weeks of the date of the letter.
OoH should be notified of all unplanned exits from SHASP.
3.8.2
Client feedback and evaluation
Client’s are experts in their own live experiences and are best placed to provide feedback
about how services and responses can best support them and address their needs. It is
therefore important to capture client input and feedback to inform continuous improvement
of services.
At the final meeting with the client before case closure, or shortly after case closure, the client
should be provided with the opportunity to provide feedback on the service they received
through SHASP and their experiences and perceived outcomes. Feedback can be sought in a
number of ways, for example through:
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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•
face to face or telephone interviews
•
online surveys
•
written questionnaires.
Although the mechanism for seeking feedback may vary depending on the client’s preference,
questions should be consistent to enable comparability to inform service improvements. Good
practice in seeking feedback from clients includes:
•
ensuring confidentiality of responses (for example through not capturing client information
on surveys)
•
recognising client’s time (for example through providing vouchers as a thank you for
completing the feedback)
•
minimising the likelihood that the client feels pressured into answering in a particular way
(for example through having a worker unknown to the client conducting the interview).
These mechanisms for seeking feedback complement wider feedback activities, such as focus
groups and point-in- time surveys that may take place for specific program evaluations or
reviews.
3.8.3
Re-referrals and re-engagement
SHASP supports re-engagement with the service through:
•
pro-actively encouraging OoH to re-refer clients should there be renewed concerns about a
tenancy
•
working with clients through exit planning to identify factors which place a tenancy at risk,
which should trigger a re-referral to SHASP. The case worker will provide clients with
information about how to re-engage with the service when triggers occur. This approach
empowers the client to be self-aware of the factors that put their tenancy at risk and relies
on them to take positive steps to re-engage with the service.
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Triggers for re-engagement might includethe following factors which place the tenancy at risk:
•
financial difficulty
•
neglect of property
•
family or personal crisis
•
repeat Rent Deduction Service (RDS) cancellation
•
neighbourhood disputes
•
•
multiple agency contacts
concerns by OoH about capacity to sustain
tenancy
•
further VCAT applications or
Notice to Vacate
•
escalating rental arrears or broken agreements.
Earlier identification of re-emerging risk factors (triggers) and prompt re-engagement with
SHASP and, where possible, a known worker, is critical to early intervention and prevention of
tenancy breakdown. Re-engaging clients in SHASP services is likely to achieve more timely
outcomes, given that the client already has a relationship with the service and that information
and history about the client is already known.
Re-referrals to the service are received and prioritised as described in section 3.4 above.
3.8.4
Responding to special needs groups
SHASP services work with clients from particular client groups, including:
•
people from Aboriginal backgrounds
•
people from CALD backgrounds
•
people with intellectual disabilities
•
children and young people
•
elderly people, including those experiencing dementia
•
people experiencing domestic and/or family violence.
The intensity, level and duration of support for clients within these groups is determined on
the basis of individual risks and needs rather than on their membership of a particular client
group. However, to work effectively with these clients, case workers should have relevant
skills and experience, and appropriate cultural awareness. This should be a consideration in
allocating case workers to clients from these groups.
Working with clients from these groups also requires case workers to have specific knowledge
of the relevant services and programs that can be accessed by these clients. In some cases,
working with clients from these groups may also require a case worker to seek secondary
consultation input, use translators, or establish joint case coordination approaches with
relevant specialist workers, for example youth workers, from other services.
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4 Partnerships and collaborative working
In order to deliver effective responses to clients and achieve client outcomes, SHASP should
not operate as a standalone support service, but must be fully integrated into the broader
service system that supports public housing tenants. Partnerships and collaborative working
arrangements underpin this integration at a service level, at an individual case worker level
and at a client level and are essential to deliver an effective case management approach.
To achieve SHASP aims, services must work in close partnership with a range of other services,
including local OoH offices and other housing and support, mainstream and specialist services.
4.1
Partnerships with OoH
A strong, formal partnership with local the OoH office(s) is essential to:
•
establish a shared commitment to client outcomes
•
identify tenants who need support, including duty of care referrals
•
enable consistent referral processes, including joint decisions about prioritisation of
referrals
•
enable joint working, where appropriate
•
facilitate frank and open communication, particularly in cases where there are competing
claims and priorities in relation to a client
•
facilitate sharing of information
•
generate greater understanding of roles, responsibilities and areas of skills and expertise of
professional workers in OoH and SHASP.
The partnership arrangements should be implemented in practice through:
•
joint decisions about prioritisation of referrals to SHASP
•
day to day and ‘as required’ formal and informal contact between OoH and SHASP workers
to consider referrals and to support the delivery of interventions to clients
•
appropriate sharing of information, within the bounds of client confidentiality, to enable
tenancy related risks to be addressed
•
joint case working, reviews and exit planning, as required, to meet needs and address
tenancy risks of clients
•
joint training and professional development opportunities.
Partnerships arrangements between OoH and SHASP should be underpinned by MoUs which
are developed locally and jointly by OoH and the SHASP service and agreed by DHS central
office. The MoU and its practical implementation should be jointly monitored and reviewed
regularly to ensure it is upheld and remains relevant and useful.
SHASP Interim Integrated Case Management Guidelines - 28 September 2012
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MoUs should be consistent with Charter obligations, seek to empower tenants through timely
referrals and clarify the OoH and SHASP roles and duty of care obligations. They should
include, but not be limited to, description of:
•
referral pathways to SHASP
•
roles and responsibilities of SHASP and OoH in relation to referrals, prioritisation,
allocation, waiting list management, case management and closure of SHASP clients
•
agreement on information to be shared
•
approaches to facilitate earlier identification and referral to SHASP by OoH
•
objectives, frequency and nature of formal meetings and informal communication and
joint working between OoH and SHASP
•
mechanisms for ‘as required’ communication, for example for higher priority referrals
•
responsibility and processes for duty of care referrals
•
mechanisms for managing disputes or situations in which consensus and agreement
cannot be reached
•
approaches to jointly ensure continuous improvement, for example through sharing
lessons learnt and collectively considering data related to SHASP program outcomes (or
example, numbers of evictions and possession orders for SHASP clients).
4.2
Collaborative working with other services
In order to implement case plans for clients, SHASP services should also work closely with a
range of other services, depending on client need and case plans. This might include
mainstream, secondary and specialist services, such as:
•
Community groups, particularly Aboriginal and CALD community groups
•
General practitioners
•
Government agencies such as OoH, Centrelink, Medicare, Family Assistance Officeand
Child Protection
•
Education and training organisations
•
Return to work services
•
Legal Aid and other legal services
•
Child FIRST
•
Family Services
•
Alcohol and Other Drug Services
•
Mental Health Services
•
Other housing and advocacy services.
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Collaborative working with these and other services will vary by client and might include
making and receiving referrals and facilitating ‘active referrals’, information sharing, joint
assessments, joint case working, case conferencing and secondary consultation.
If appropriate, these activities should be underpinned by formal arrangements, such as MoUs,
information sharing protocols, referral pathways, and joint working protocols.
SHASP services may also provide training and professional development input to these
services. For example, SHASP workers may attend team meetings to:
•
provide information about SHASP services
•
share expert knowledge such as approaches to working with hoarders and knowledge of
relevant housing legislation.
To facilitate collaborative working with a full range of other services, case workers will need to
have extensive, up-to-date knowledge of local and statewide service systems and of programs
and services to which to refer clients.
In addition, case workers, and SHASP services more generally, will need to take an active part
in local professional networks and forums to foster good working relationships with other
professionals to better support the implementation of case plans.
4.3
Support for High Risk Tenancies program (SFHRT)
SFHRT aims to strengthen the human service system’s response to complex people through
the integration and co-ordination of services to:
•
create sustainable tenancies with high and complex needs
•
develop a greater understanding of the needs and service response options for the
person to address service system barriers and gaps
•
identify service development opportunities within DHS, funded organisations and
interdepartmentally - action these to increase regional capacity.
•
focus specifically on high risk tenancies.
The regional coordinator works across government departments and funded organisations to
explore and negotiate solutions to the presenting issues in order to sustain tenancies and
improve service responses to people with complex needs.
Brokerage is attached to this program.
SfHRT also provides:
•
secondary consultations: staff work collaboratively with key service providers to facilitate
the development of workers skills, knowledge and confidence in managing people with
complex needs. Sessions are conducted in team settings to develop comprehensive and
well targeted strategies to improve outcomes for the person and to promote shared
learning experiences and capacity building within program areas.
•
innovative training and education focusing on broad regional service coordination.
Referral to this program are initially identified by the relevant case manager, Program and
Services Advisor, Senior Housing Officer and raised with their appropriate team leader /
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manager. If the eligibility criteria is met and a reasonable attempt has been made to engage all
other available service options a formal referral to the regional coordination should proceed
through your regional Client Outcomes Unit within Department of Human services.
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5 Monitoring and reporting
Monitoring and reporting supports management of SHASP service delivery in a number of
ways:
•
•
•
5.1
at a client level to:
–
monitor the implementation of the case plan (described in section 3.7)
–
identify outcomes achieved for individuals
at a service level to:
–
record and monitor overall service activity and report on funded targets
–
monitor client group characteristics and ensure services are being targeted to the
correct target group
–
manage and plan service capacity, including case load volume and mix
–
record and monitor collective client outcomes
–
support continuous improvement initiatives
at a system level (all of SHASP services) to understand activity levels, overall outcomes and
capacity of the service system, and to inform continuous improvement across the system.
Data collection and management
Monitoring and reporting must be supported by robust data systems to provide information
and support accountability. Strong data collection is important to:
•
inform decisions about service planning and delivery
•
monitor the performance of services
•
ensure that outcomes for clients are being achieved
•
ensure the best use of resources (accountability).
Client activity data and outcome data should be recorded on an electronic database. This
should include the Specialist Homelessness Information Platform (SHIP), or other databases as
agreed with DHS.
At a minimum, client and activity data should be captured on a monthly basis on:
•
new referrals
•
new clients
•
characteristics of new clients, for example age, family status, gender, ethnicity, location
(address)
•
numbers of closed cases, duration of case management and outcomes achieved at case
closure
•
existing case load (number of current clients)
•
presenting reason
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•
activity type and levels
•
level of service or intensity of service (for example numbers of clients who are capable for
self-management, and those who require guided or managed support)
•
number of clients and length of time on the waiting list.
In addition, client outcome information should be captured at case closure from the following
sources:
•
client case plans
•
client feedback processes conducted at case closure
•
OoH data (e.g. evictions, possession orders, warrants obtained)
•
periodic evaluation and review approaches to seek client feedback on their experiences
and perceived outcomes.
The existing SHIP database enables basic information about client outcomes to be captured
and reported. For example, it captures information about outcome indicators at case closure
(such as tenancy type and income source) as well as capturing broad information about
whether the client has achieved case plan goals (using a yes/no response).
In addition to using the SHIP database15,to provide more detailed information about client
outcomes, SHASP services should work with the Department of Human Services to agree key
outcome domains to be monitored, and a process to capture and report on this information
should be trialled.
5.1.1
Data collection and privacy16
SHASP services and the Department of Human Services require some personal information to
be collected for the purposes of planning, funding, monitoring and evaluating services.
Wherever practicable, information that is collected for these purposes will be non-identifying;
that is, clients will not be identifiable from the information.
The Department and its funded CSOs operate according to strict privacy protocols as set out in
the Health Records Act 2001 and the Information Privacy Act 2000. Collection of data by SHASP
providers will be undertaken in a manner that ensures clients have the right to:
•
be told why the collection is being conducted
•
be told how the information will be used
•
be told who will have access to the information
•
refuse to participate in the collection without affecting their right to receive services.
In fulfilling the above, SHASP services should explain to clients that, whilst identifying
information may be collected, client confidentiality and privacy will be protected.
15
16
Or other aligned database (recognising that not all SHASP services use SHIP).
This is taken from PHIP guidelines 2009-12, p 15.
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5.2
Reporting
Reporting should take place to enable regular performance measurement against a defined set
of key performance indicators, covering outcomes, and outputs and services, and capacity. It
should take place:
•
internally, to inform staff, manage and plan capacity and resource allocation, and monitor
performance against targets and standards
•
to OoH (and other partners as appropriate), as identified in MoUs, to manage capacity and
provide information about SHASP activities
•
to DHS to ensure an appropriate level of accountability. This involves ensuring that the
service is delivering what is intended, in terms of levels of service (quantity), quality,
efficiency and effectiveness. The purpose of this is to ensure that Government funds are
being spent efficiently and effectively.
In addition, services may report performance periodically through annual reports and service
evaluations and reviews.
5.3
Continuous improvement
Continuous improvement is the process of considering what is working well and identifying
areas which could be improved to achieve more effective services, in terms of client outcomes
and more efficient services, for example in terms of service capacity. The focus of continuous
improvement should be on future planning, being able to meet changing client needs and
remaining in line with contemporary practice.
SHASP services should draw on information from service activity and outcome data and from
feedback from clients to monitor performance and identify opportunities for service
improvement. Feedback from partner agencies and other services with whom SHASP have
working relationships should also be sought to feed into continuous improvement processes.
At a whole of service system level, Department of Human Services should support continuous
improvement processes that consider opportunities for improvement across all SHASP
services. This might include, for example, drawing together examples of good practice and key
learnings, and supporting broader implementation of these across all SHASP services.
Consideration may also be given to an evaluation of the SHASP program by a suitably qualified
and independent organisation.
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