Housing and Support Program (HASP): Final Evaluation Report
Housing and Support Program (HASP): Final Evaluation Report
Housing and Support Program (HASP): Final Evaluation Report
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Department of Psychiatry (UQ) <strong>and</strong><br />
Service <strong>Evaluation</strong> <strong>and</strong> Research Unit<br />
The Park, Centre for Mental Health<br />
<strong>Final</strong> <strong>Evaluation</strong><br />
<strong>Report</strong><br />
of the Queensl<strong>and</strong> Government’s<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong><br />
November 2010
<strong>Evaluation</strong> team<br />
Dr Tom Meehan<br />
Dept of Psychiatry (University of Queensl<strong>and</strong>)<br />
<strong>and</strong> Director, Service <strong>Evaluation</strong> & Research<br />
The Park, Centre for Mental Health<br />
Wacol Qld 4076<br />
Dr Dan Siskind<br />
Consultant Psychiatrist<br />
Queensl<strong>and</strong> Centre for Mental Health Research<br />
<strong>and</strong> Metro South Health Service District<br />
Ms Kathy Madson<br />
Project Offi cer<br />
Service <strong>Evaluation</strong> & Research Unit<br />
The Park, Centre for Mental Health<br />
Wacol Qld 4076<br />
Ms Nicole Shepherd<br />
Project Offi cer<br />
Service <strong>Evaluation</strong> & Research Unit<br />
The Park, Centre for Mental Health<br />
Wacol Qld 4076<br />
Acknowledgments<br />
We are indebted to a number of organisations <strong>and</strong> individuals for their support <strong>and</strong><br />
assistance during the conduct of this study. We would like to thank the consumers<br />
<strong>and</strong> staff of the various non-government organisations <strong>and</strong> government departments<br />
who so generously gave of their time to participate in this evaluation.<br />
This evaluation was funded by the Queensl<strong>and</strong> Department of Communities<br />
<strong>and</strong> Queensl<strong>and</strong> Health.
<strong>Final</strong> <strong>Evaluation</strong><br />
<strong>Report</strong><br />
of the Queensl<strong>and</strong> Government’s<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong><br />
Dr Tom Meehan<br />
Ms Kathy Madson<br />
Ms Nicole Shepherd<br />
Dr Dan Siskind<br />
Department of Psychiatry (UQ)<br />
<strong>and</strong> Service <strong>Evaluation</strong> <strong>and</strong> Research Unit<br />
The Park, Centre for Mental Health<br />
November 2010
II<br />
Executive summary<br />
Since the 1990s, a range of housing models has<br />
emerged as an alternative to institutional care for those<br />
with high levels of psychiatric disability. ‘<strong>Support</strong>ed<br />
housing’ is one of the service options being promoted<br />
across Australia for those with more severe problems.<br />
A key factor in the success of supported housing<br />
has been the provision of ‘non-clinical’ support by<br />
visiting workers, typically employed through the nongovernment<br />
sector. This non-clinical support is aimed<br />
at assisting individuals to access services in their local<br />
community, manage day-to-day living activities <strong>and</strong><br />
sustain their tenancies. In Queensl<strong>and</strong>, supported<br />
housing has been made possible through a number<br />
of initiatives. One of these, the <strong>Housing</strong> <strong>and</strong> <strong>Support</strong><br />
<strong>Program</strong> (<strong>HASP</strong>), was established in 2006 to support<br />
individuals with psychiatric disability leaving acute<br />
<strong>and</strong> extended treatment mental health facilities.<br />
<strong>HASP</strong> is a cross-departmental initiative involving<br />
the collaboration of two government departments<br />
— Queensl<strong>and</strong> Health <strong>and</strong> the Department of<br />
Communities (<strong>Housing</strong> <strong>and</strong> Homelessness Services<br />
<strong>and</strong> Disability <strong>and</strong> Community Care Services).<br />
Each individual accessing <strong>HASP</strong> is provided with<br />
a ‘package’ of services consisting of mental health<br />
services, disability support services <strong>and</strong> normal<br />
community housing. <strong>HASP</strong> was designed to provide<br />
a stable home environment in the community for those<br />
with severe disability <strong>and</strong> increase the potential for<br />
individuals to maximise their inclusion in their<br />
chosen community.<br />
During 2010, a research team comprising of staff<br />
from the Park, Centre for Mental Health <strong>and</strong> the<br />
University of Queensl<strong>and</strong> was engaged to evaluate<br />
<strong>HASP</strong>. Qualitative <strong>and</strong> quantitative data were collected<br />
from a broad range of staff <strong>and</strong> clients to enable an<br />
assessment of the <strong>Program</strong> to be carried out.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Key fi ndings<br />
• Clients supported<br />
Since <strong>HASP</strong> commenced in 2006, some 204 clients<br />
have been offered a <strong>HASP</strong> package. Of these,<br />
153 were living in the community at the time of<br />
data collection (March–July 2010) <strong>and</strong> 80 of these<br />
consented to participate in the evaluation.<br />
• Overwhelming support for <strong>HASP</strong><br />
During our interviews with staff <strong>and</strong> clients we<br />
heard several accounts of the way in which <strong>HASP</strong><br />
had helped clients to move from a life fi lled with<br />
despair to one of hope <strong>and</strong> promise for the future.<br />
Indeed, 82.2% of clients indicated that involvement<br />
in <strong>HASP</strong> had helped them (or was currently helping<br />
them) to achieve their goals. Both clients <strong>and</strong> staff<br />
appreciated the holistic approach of <strong>HASP</strong> <strong>and</strong> noted<br />
that collaboration between the agencies involved<br />
was integral to the success of the <strong>Program</strong>.<br />
• Accommodation<br />
More than half of the <strong>HASP</strong> clients followed up<br />
(56%) were living in apartments <strong>and</strong> unit blocks,<br />
while the remainder were living in townhouses<br />
or detached houses. Satisfaction with housing<br />
was high, with almost 90% of clients claiming to<br />
be very satisfi ed/most satisfi ed with their housing.<br />
The majority of <strong>HASP</strong> tenancies have remained<br />
stable with 82.5% of individuals living in the original<br />
accommodation provided through <strong>HASP</strong>. Only 14 of<br />
the 80 clients interviewed (17.5%) had moved house<br />
since joining <strong>HASP</strong>. Eleven of these had moved once,<br />
one had moved twice <strong>and</strong> two had moved thrice.<br />
The reasons cited for moving included discord with<br />
neighbours <strong>and</strong> to be closer to family members.<br />
• Non-clinical support<br />
Non-clinical support is provided through a range<br />
of non-government agencies. These agencies<br />
were able to demonstrate success in reducing the<br />
amount of support provided to clients. The number<br />
of support hours provided each week decreased<br />
signifi cantly (p=.002) by 7.2 hours from an average<br />
of 27.6 hours on entry into <strong>HASP</strong>, to an average of<br />
20.4 hours at the follow-up time point.
• Community integration<br />
While eight of the 80 <strong>HASP</strong> clients followed up were<br />
in paid employment, clients worked an average<br />
of 18.06 hours per week. In addition to paid<br />
employment, 13 clients (16.2%) indicated that they<br />
participated in volunteer work. The mean number<br />
of hours spent on volunteer work was 8.15 hours per<br />
week (range = two to 24 hours per week). <strong>Final</strong>ly,<br />
eight clients (10%) indicated that they attended<br />
TAFE or other training programs. Over 40% of clients<br />
indicated that they would like paid employment as<br />
their main activity in the future. This suggests that<br />
there is some scope for clients <strong>and</strong> service providers<br />
to focus on employment as a long-term goal for<br />
those with a desire to work.<br />
• Changes in the need for inpatient care<br />
The average time in inpatient care decreased<br />
signifi cantly (p=0.001) from an average of<br />
227 days/per client in the 12 months prior to<br />
<strong>HASP</strong>, to an average of 18.9 days/per client in the<br />
12 months post-<strong>HASP</strong>. Moreover, the number of<br />
admissions also decreased signifi cantly (p=0.002)<br />
from an average of 1.22 admissions/per client in<br />
the 12 months prior to <strong>HASP</strong>, to an average of 0.66<br />
admissions/per client in the 12 months post-<strong>HASP</strong>.<br />
• Changes in functioning<br />
While improvements in functioning were not<br />
statistically signifi cant, the clients, as a group,<br />
did not deteriorate following entry into <strong>HASP</strong>.<br />
Indeed, the fi ndings indicate that over half of<br />
the clients (51%) demonstrated improvement<br />
in general functioning, while 40% produced<br />
improvement in clinical functioning in the<br />
12 months since joining <strong>HASP</strong>.<br />
• Changes in Mental Health Act status<br />
Restrictions placed on clients through the Mental<br />
Health Act had been signifi cantly relaxed since<br />
entering <strong>HASP</strong>. The proportion of clients on<br />
Involuntary Treatment Orders (ITOs) decreased<br />
from 46% to 22%, while the proportion of clients<br />
with voluntary status increased from 43% to 70%.<br />
This relaxation of the legal restrictions placed<br />
on clients suggests that client functioning <strong>and</strong><br />
compliance with treatment improved following<br />
access to <strong>HASP</strong>. It also demonstrates that efforts<br />
are being made by clinical services to reduce<br />
restrictions on clients where possible.<br />
• Cost – <strong>HASP</strong> versus alternative options<br />
Overall, the recurrent cost of keeping the ‘average’<br />
client in <strong>HASP</strong> for 12 months is approximately<br />
$74,000 less expensive than keeping the same<br />
client in a Community Care Unit (CCU) <strong>and</strong> $178,000<br />
less expensive than keeping the same client in an<br />
acute inpatient unit. The fi ndings suggest that one<br />
could maintain two clients in <strong>HASP</strong> for the cost of<br />
keeping one client in a CCU <strong>and</strong> almost four clients<br />
in <strong>HASP</strong> for the cost of keeping one client in an acute<br />
inpatient unit. However, programs such as <strong>HASP</strong><br />
should not be promoted as a substitute for the<br />
services of a CCU or acute inpatient unit. All of these<br />
treatment <strong>and</strong> housing options should be included<br />
in a comprehensive mental health program. <strong>Final</strong>ly,<br />
it should be noted that the costs provided here are<br />
based on recurrent costs only. Initial costs involved<br />
in selecting clients for the program, securing housing<br />
options <strong>and</strong> establishing infrastructure in the<br />
community to support each individual have not<br />
been considered in our estimates.<br />
• Overall quality of life<br />
An overall rating of quality of life was obtained<br />
by asking clients to rate their quality of life<br />
on a 10-point scale where ‘1’ was the worst quality<br />
of life possible <strong>and</strong> ‘10’ was the best quality of life<br />
possible. <strong>HASP</strong> clients provided a mean rating of<br />
almost ‘7’ out of a possible total score of 10. This<br />
high quality-of-life rating is in keeping with previous<br />
evaluations of clients living in supported housing<br />
in Queensl<strong>and</strong> (Project 300) <strong>and</strong> New South Wales<br />
(The <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> Initiative).<br />
Over 85% of clients were pleased about having<br />
accomplished something in the past month.<br />
These accomplishments included staying well,<br />
being able to stay out of hospital, making a new<br />
friend or getting a job or volunteer work. A further<br />
80% were happy that ‘things had gone their way’<br />
<strong>and</strong> were proud that someone had complimented<br />
them on something they had done (77%).<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
III
IV<br />
Executive summary<br />
Conclusion<br />
Given the focus on community care in national<br />
policy, the fi ndings have a number of implications<br />
for service provision. <strong>HASP</strong> is an excellent example<br />
of how government agencies can work together to<br />
improve the wellbeing of people with psychiatric<br />
disability. The program demonstrates that given<br />
adequate support, stable housing <strong>and</strong> good case<br />
management, the accommodation needs of people<br />
with severe psychiatric disability can be met through<br />
ordinary/normal housing in the community. Indeed,<br />
those involved in the planning of future resettlement<br />
programs are encouraged to consider the <strong>HASP</strong><br />
model. However, supported housing models such as<br />
<strong>HASP</strong> should not be promoted as a substitute for care<br />
settings such as Community Care Units (CCUs). A range<br />
of treatment <strong>and</strong> housing options should be included<br />
in a comprehensive service delivery system.<br />
Assessed on any measure, the fi ndings indicate that<br />
<strong>HASP</strong> has been as successful, if not more successful,<br />
than the majority of the resettlement programs<br />
reviewed. Community care within <strong>HASP</strong> appears to<br />
have an overall economic advantage over hospital<br />
care <strong>and</strong> no disadvantage for clients. Those who<br />
participated in the interviews expressed high levels<br />
of satisfaction <strong>and</strong> felt that <strong>HASP</strong> was instrumental<br />
in promoting their recovery.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
All of the clients in the evaluation demonstrated<br />
a strong preference for community living. The freedom<br />
<strong>and</strong> choice that community living offers appears to<br />
compensate for the increased responsibility associated<br />
with such living. Nonetheless, it is clear that while<br />
some clients made considerable advances in securing<br />
a future in the community, others had been less<br />
successful in taking advantage of the opportunities<br />
available to them. While service models continue to<br />
provide support, they must also allow for what Deegan<br />
(1992) calls the ‘dignity of risk <strong>and</strong> the right of failure’.<br />
Thus, the challenge for service providers is to fi nd<br />
the right balance between the provision of planned<br />
interventions for clients <strong>and</strong> ensuring that clients have<br />
the freedom to be self-determining individuals. Too<br />
much support may encourage dependency on support<br />
systems, while too little support may contribute to<br />
relapse <strong>and</strong> even homelessness (Cameron, Athurson<br />
& Worl<strong>and</strong>, 2008).
List of contents<br />
Executive summary __________________________ II<br />
Key fi ndings ..........................................................................................II<br />
Conclusion ........................................................................................... IV<br />
1 Introduction ____________________________ 1<br />
1.1 The <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong><br />
(<strong>HASP</strong>) .........................................................................................2<br />
1.2 <strong>Housing</strong> <strong>and</strong> supports –<br />
previous research ..............................................................5<br />
1.3 Current evaluation .........................................................11<br />
2 Method _______________________________ 13<br />
2.1 Design ......................................................................................13<br />
2.2 Participants .........................................................................14<br />
2.3 Data collection ..................................................................18<br />
2.4 Procedure ..............................................................................21<br />
2.5 Data analysis ......................................................................22<br />
3 The effectiveness of the collaborative<br />
process established across agencies ______ 24<br />
3.1 Collaboration between government<br />
agencies .................................................................................24<br />
3.2 Governance arrangements established<br />
to support ongoing development <strong>and</strong><br />
delivery of <strong>HASP</strong> ..............................................................26<br />
3.3 Perceptions of agency collaboration —<br />
Case Manager, support workers <strong>and</strong><br />
<strong>Support</strong>s Facilitators ...................................................30<br />
3.4 Section summary ............................................................31<br />
4 The process of providing clinical,<br />
non-clinical <strong>and</strong> housing services<br />
to clients ______________________________ 32<br />
4.1 Process of providing clinical services............32<br />
4.2 Process of providing non-clinical<br />
support services ..............................................................36<br />
4.3 Process of providing accommodation ...........42<br />
4.4 Section summary ............................................................46<br />
5 The opportunities available through<br />
the program for clients to maximise<br />
their recovery <strong>and</strong> participate in<br />
community life _________________________ 48<br />
5.1 Client perceptions of <strong>HASP</strong> <strong>and</strong><br />
how it supports their recovery .............................48<br />
5.2 Satisfaction with key life domains ...................49<br />
5.3 Involvement in vocational activities ...............49<br />
5.4 Involvement in activities...........................................50<br />
5.5 Number of friends ..........................................................50<br />
5.6 Satisfaction with the number<br />
of friends they have ......................................................50<br />
5.7 Depth of friendships ....................................................51<br />
5.8 Satisfaction with family<br />
relationships .......................................................................52<br />
5.9 Satisfaction with money ...........................................52<br />
5.10 Lack of money ....................................................................52<br />
5.11 Community involvement ...........................................53<br />
5.12 Client goals ..........................................................................54<br />
5.13 Section summary ............................................................55<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
V
VI<br />
List of contents<br />
6 The ability of the program to maintain<br />
clinical functioning <strong>and</strong> provide an<br />
acceptable quality of life for those<br />
supported by the program _______________ 56<br />
6.1 Readmissions to acute inpatient care ...........56<br />
6.2 Changes in functioning ..............................................56<br />
6.3 Clients who improved,<br />
stayed the same, or deteriorated ......................57<br />
6.4 Perceptions of change in client<br />
functioning – Case Managers versus<br />
support workers ...............................................................57<br />
6.5 Perceptions of future improvement<br />
in clients – Case Managers versus<br />
support workers ...............................................................58<br />
6.6 Changes in Mental Health Act (MHA)<br />
status ........................................................................................58<br />
6.7 Physical <strong>and</strong> mental health ....................................59<br />
6.8 Overall quality of life ....................................................59<br />
6.9 Emotional responses experienced...................60<br />
6.10 Section summary ............................................................61<br />
7 How do costs of providing care under <strong>HASP</strong><br />
compare with alternative care options? ____ 62<br />
7.1 Costs associated with<br />
Community Care ...................................... 62<br />
7.2 Comparing <strong>HASP</strong> with<br />
inpatient/residential alternatives ............ 63<br />
7.3 Cost of care pre <strong>and</strong> post-<strong>HASP</strong> ............... 63<br />
7.4 Section summary ..................................... 63<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
8 Discussion ____________________________ 64<br />
8.1 The effectiveness of the collaborative<br />
process established across agencies ............64<br />
8.2 The process of providing clinical,<br />
non-clinical <strong>and</strong> housing services<br />
to clients .................................................................................65<br />
8.3 The opportunities available through<br />
the program for clients to maximise<br />
their recovery <strong>and</strong> participate<br />
in community life.............................................................68<br />
8.4 The ability of the program to maintain<br />
clinical functioning <strong>and</strong> provide<br />
an acceptable quality of life for those<br />
supported by the program ......................................69<br />
8.5 <strong>Program</strong> costs ....................................................................70<br />
8.6 Conclusions .........................................................................70<br />
9 Recommendations ______________________ 71<br />
10 Reference list __________________________ 73<br />
Appendix 1<br />
<strong>HASP</strong> 2009–2010 Process fl owchart<br />
with timelines...................................................................................76
Section 1<br />
Introduction<br />
Since the 1970s, mental health policy in Australia has promoted the downsizing of<br />
‘st<strong>and</strong>-alone’ psychiatric hospitals <strong>and</strong> the decentralisation of mental health services<br />
into the broader community. The rationale for these reforms was based on the belief that<br />
community alternatives would provide a therapeutic <strong>and</strong> rehabilitation function such<br />
that individuals would move from higher to lower levels of dependence <strong>and</strong> eventually,<br />
to independence (Bachrach, 1989). Underpinning the process was the desire to provide<br />
a range of community supports that best suited the needs of people leaving hospital<br />
<strong>and</strong> also, new consumers with serious mental illness.<br />
There was an underlying belief that many of the<br />
services provided in the institution could be better<br />
provided in the community or in the individual’s own<br />
home (Bachrach, 1989). The movement towards the<br />
closure of psychiatric hospitals was driven in part by<br />
the philosophy of freedom, independence <strong>and</strong> the<br />
hope of providing a better quality of life for individuals<br />
with mental illness in the community (Meehan, 2007).<br />
Mental health policy in Queensl<strong>and</strong> has also been<br />
infl uenced by these broader trends in service reform.<br />
Over the past 20 years, a signifi cant number of<br />
individuals have been relocated to the community<br />
under hospital downsizing programs such as<br />
‘Project 300’ (Meehan et al, 2011). While many of these<br />
former long-stay clients are now elderly or deceased,<br />
a new group of individuals with severe disability has<br />
emerged. This group is made up of young, mostly male<br />
clients with a diagnosis of schizophrenia, frequently<br />
complicated by substance misuse (Meehan, 2007;<br />
Reul<strong>and</strong>, Schwarzfeld, & Draper, 2009). Many of these<br />
clients are too disabled or fearful to make <strong>and</strong> keep<br />
appointments at mental health centres <strong>and</strong> are at high<br />
risk of homelessness <strong>and</strong> frequent contact with police<br />
<strong>and</strong> other community agencies (Fry, O’Riordan, &<br />
Geanellos, 2002; Commonwealth of Australia, 2006).<br />
In Queensl<strong>and</strong>, a continuum of housing options has<br />
emerged to cater for the needs of those with more<br />
severe problems. These services range from 24-hour<br />
residential care (in the form of Community Care Units)<br />
through to independent living options. One of the<br />
initiatives in this continuum includes ‘supported’<br />
housing. Individuals are provided with public housing<br />
<strong>and</strong> are supported by visiting workers, typically<br />
employed through the non-government sector. This<br />
non-clinical support is aimed at assisting the individual<br />
to access required services in their local community,<br />
manage day-to-day living activities <strong>and</strong> sustain their<br />
tenancies (O’Malley & Croucher, 2005).<br />
One of the earliest supported housing models to be<br />
introduced in Queensl<strong>and</strong> was known as ‘Project 300’.<br />
The program was established in 1995 with the aim<br />
of relocating 300 individuals with severe psychiatric<br />
disability from the three existing psychiatric hospitals.<br />
In 2006, a similar supported housing initiative, known<br />
as the <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>), was<br />
established to support individuals who were unable<br />
to leave acute <strong>and</strong> extended treatment mental health<br />
facilities due to lack of housing <strong>and</strong> appropriate<br />
supports. This report focuses on the evaluation of the<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong>.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
1
2<br />
Section 1 Introduction<br />
1.1 The <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
The <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>) is an initiative under the Council of Australian Governments’ (COAG)<br />
National Action Plan on Mental Health 2006–2011. <strong>HASP</strong> is a cross-departmental initiative involving Queensl<strong>and</strong><br />
Health <strong>and</strong> the Department of Communities which includes both <strong>Housing</strong> <strong>and</strong> Homelessness Services <strong>and</strong><br />
Disability <strong>and</strong> Community Care Services (see Fig. 1.1).<br />
Fig. 1.1 <strong>HASP</strong> Service Provision Framework<br />
<strong>Housing</strong> <strong>and</strong><br />
Homelessness Services<br />
(HHS)<br />
<strong>Housing</strong> Services<br />
Stable accommodation<br />
The Queensl<strong>and</strong> Government Department of<br />
Communities is responsible for a wide range of human<br />
services that support people with a disability. The<br />
services provided include disability <strong>and</strong> community<br />
care services, housing <strong>and</strong> homelessness services,<br />
translating <strong>and</strong> interpreting services, sport <strong>and</strong><br />
recreation services, <strong>and</strong> community <strong>and</strong> individual<br />
support services. The overall aim of providing<br />
a number of services through one department is to<br />
enable easier access to government services <strong>and</strong><br />
information. Two key services within the Department<br />
of Communities are involved in supporting <strong>HASP</strong> clients.<br />
These are briefl y described below.<br />
i) Department of Communities —<br />
<strong>Housing</strong> <strong>and</strong> Homelessness Services (HHS)<br />
The services provided through the former Queensl<strong>and</strong><br />
Department of <strong>Housing</strong> are now provided under the<br />
Department of Communities through the division of<br />
<strong>Housing</strong> <strong>and</strong> Homelessness Services. <strong>Housing</strong> <strong>and</strong><br />
Homelessness Services provides accommodation<br />
for those clients accepted into <strong>HASP</strong>. Clients referred<br />
to <strong>HASP</strong> must be eligible for social housing. <strong>HASP</strong><br />
clients comprise an Interagency Priority Group,<br />
meaning they are the subject of inter-departmental<br />
or inter-governmental agreements, or are designated<br />
by the Queensl<strong>and</strong> Government for priority housing<br />
assistance.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
<strong>HASP</strong> Clients<br />
Queensl<strong>and</strong><br />
Health<br />
(QH)<br />
Mental Health<br />
Services<br />
Clinical <strong>Support</strong><br />
Disability <strong>and</strong> Community<br />
Care Services<br />
(DCCS)<br />
<strong>Program</strong> funding <strong>and</strong><br />
support services<br />
Non-clinical support<br />
Like other Queensl<strong>and</strong> Government-funded housing<br />
<strong>and</strong> support programs, capital funding for social<br />
housing under <strong>HASP</strong> enabled <strong>HASP</strong> clients to be<br />
designated for priority housing assistance. Once<br />
allocated to Government or community-managed<br />
long-term social housing, <strong>HASP</strong> clients become<br />
social housing tenants with the same rights <strong>and</strong><br />
responsibilities as other social housing tenants,<br />
for example by paying 25% of the household’s<br />
assessable income in rent.<br />
ii) The Department of Communities —<br />
Disability <strong>and</strong> Community Care Services (DCCS)<br />
DCCS has responsibility for funding, developing <strong>and</strong><br />
implementing, <strong>and</strong> monitoring all existing <strong>and</strong> new<br />
mental health programs delivered through nongovernment<br />
service providers.<br />
In addition to the service providers described,<br />
Queensl<strong>and</strong> Health provides a range of clinical support<br />
services to <strong>HASP</strong> clients. The primary role of Case<br />
Managers within <strong>HASP</strong> is to provide clinical support<br />
to the clients enrolled in <strong>HASP</strong>. Case Managers are<br />
also responsible for providing support <strong>and</strong> education<br />
to families, carers <strong>and</strong> disability support workers.<br />
In addition, they are responsible for consultation<br />
<strong>and</strong> liaison with primary health care providers with<br />
a focus on assessment <strong>and</strong> a collaborative approach<br />
to individual management.
1.1.1 <strong>HASP</strong> — Management Structure<br />
The overall management of <strong>HASP</strong> is carried out through<br />
the <strong>HASP</strong> Management Group which has senior<br />
representation from HHS, DCCS <strong>and</strong> QH. The group<br />
provides strategic leadership <strong>and</strong> operational direction<br />
for the program. Below the <strong>HASP</strong> Management Group<br />
is the <strong>HASP</strong> Operational Partnership (HOP) which also<br />
has representation from all key agencies. The <strong>HASP</strong><br />
Operational Partnership monitors implementation of<br />
the program <strong>and</strong> ongoing service provision. Members<br />
of HOP work collaboratively at a central offi ce level<br />
to facilitate the delivery of social housing assistance,<br />
clinical support <strong>and</strong> non-clinical support to individuals<br />
accepted into <strong>HASP</strong>. The HOP Group also actively<br />
promotes stakeholder collaboration <strong>and</strong> informationsharing<br />
at a local level to achieve positive outcomes for<br />
people who access <strong>HASP</strong>. <strong>Final</strong>ly, an interdepartmental<br />
group called the ‘<strong>HASP</strong> Interagency Panel’ examines<br />
applications for the program <strong>and</strong> endorses individuals<br />
to progress to the assessment <strong>and</strong> verifi cation phase<br />
of <strong>HASP</strong>. This panel has representatives from each of<br />
the government agencies involved.<br />
1.1.2 The aim of <strong>HASP</strong><br />
<strong>HASP</strong> is designed to provide a stable home<br />
environment in the community <strong>and</strong> increase the<br />
potential for individuals with psychiatric disability<br />
to maximise their inclusion in their chosen community.<br />
This is achieved through the provision of a coordinated<br />
framework of social housing <strong>and</strong> support, tailored to<br />
each individual’s needs. The suite of services offered<br />
through <strong>HASP</strong> refl ects the involvement of the three<br />
government agencies. Each individual accessing<br />
<strong>HASP</strong> is provided with a support ‘package’ of services<br />
consisting of mental health services, disability support<br />
services <strong>and</strong> community housing in keeping with their<br />
needs. Clinical services are provided by local mental<br />
health services, while non-clinical support is provided<br />
by a range of non-government agencies.<br />
1.1.3 Target Group for <strong>HASP</strong><br />
The target group for <strong>HASP</strong> includes individuals with<br />
a psychiatric disability who are current inpatients<br />
of acute/extended treatment mental health facilities<br />
<strong>and</strong> unable to be discharged due to homelessness<br />
or risk of homelessness. Those living in the community<br />
<strong>and</strong> who are homeless or at risk of homelessness<br />
<strong>and</strong> frequently require admission to an acute inpatient<br />
facility can also access <strong>HASP</strong>. The specifi c eligibility<br />
criteria established for <strong>HASP</strong> specify that individuals<br />
must be:<br />
over the age of 18 years<br />
an Australian citizen, or permanent resident<br />
of Australia<br />
living in Queensl<strong>and</strong><br />
diagnosed with a psychiatric illness<br />
(resulting in disability)<br />
currently or repeatedly housed<br />
in an inpatient care facility<br />
unable to be discharged due to homelessness<br />
or risk of homelessness<br />
does not own a home, rent privately or have a current<br />
<strong>Housing</strong> <strong>and</strong> Homelessness Services home<br />
has ongoing clinical needs that can be met by<br />
community mental health services<br />
requires non-clinical support to live successfully<br />
in the community<br />
willing <strong>and</strong> ready to transition to the community<br />
with the appropriate level of support<br />
committed to maintaining stable housing<br />
able to meet <strong>Housing</strong> <strong>and</strong> Homelessness Services<br />
eligibility criteria<br />
agreeable to participate in the program<br />
willing <strong>and</strong> able to provide informed consent.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
3
4<br />
Section 1 Introduction<br />
1.1.4 Securing <strong>HASP</strong> <strong>Support</strong> — The process<br />
The reader is referred to Appendix I for a schematic<br />
representation of the process. In brief, Queensl<strong>and</strong><br />
Health staff identify <strong>and</strong> nominate, for the program,<br />
individuals meeting the selection criteria described<br />
above. Applications are examined by the ‘<strong>HASP</strong><br />
Interagency Panel’ which endorses applications to<br />
progress to the assessment <strong>and</strong> verifi cation phase.<br />
Disability <strong>and</strong> Community Care Services (DCCS) then<br />
verifi es the person’s eligibility for DCCS services <strong>and</strong><br />
their non-clinical support requirements to live in the<br />
community. DCCS <strong>and</strong> housing coordinators engage<br />
with the person to:<br />
identify where they would like to live (location,<br />
type of housing, lifestyle needs, hobbies, etc)<br />
determine the level of ongoing support required<br />
select a funded non-government service provider<br />
engage with selected support provider (identify<br />
support needs, personal goals, develop support<br />
plans <strong>and</strong> select support workers)<br />
determine how they could best participate in the<br />
review of supports, goals <strong>and</strong> future plans.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
<strong>Housing</strong> <strong>and</strong> Homelessness Services (HHS) assesses<br />
the person’s housing <strong>and</strong> tenancy management needs<br />
<strong>and</strong> identifi es a suitable property to meet identifi ed<br />
needs. DCCS allocates funding to the person’s selected<br />
support agency which engages in the provision of<br />
support services to the person. All stakeholders work<br />
together to collaboratively develop <strong>and</strong> implement<br />
a plan to transition the individual to the community.<br />
Throughout the process, the individual is encouraged<br />
to make informed choices about:<br />
their preferred location <strong>and</strong> type of housing<br />
the NGO providing their support<br />
their household possessions<br />
personal goals <strong>and</strong> lifestyle<br />
the involvement of informal supporters.<br />
The actual move from hospital to the community<br />
is directed by each consumer. Some consumers<br />
transition slowly <strong>and</strong> gradually increase the amount<br />
of time they spend in the community until they are<br />
living there permanently. Others depart on the agreed<br />
date <strong>and</strong> do not return to the hospital again. While<br />
consumers are encouraged to commence living in<br />
their new homes as soon as possible, some took up to<br />
12 months to make the transition. It should be noted<br />
that in some of the more protracted transitions, issues<br />
outside the control of the consumer (e.g. Mental Health<br />
Act status), rather than the inability of the consumer to<br />
transition, were responsible for the delays.
1.2 <strong>Housing</strong> <strong>and</strong> supports –<br />
previous research<br />
In Australia, the inclusion of psychiatric disability<br />
in the Commonwealth Disability Services Act 1986<br />
brought into focus the distinction between illness<br />
<strong>and</strong> disability. It was noted that illness should be<br />
the domain of clinical interventions, while the<br />
disability component should become the concern<br />
of those skilled in the management of disability.<br />
Whiteford (1994, p.343) argues that no single agency<br />
should take complete responsibility for the lives<br />
of people with mental illness (as mental health has<br />
historically done). Whiteford outlined several reasons<br />
for this:<br />
access to social <strong>and</strong> disability programs available<br />
to people with other disabilities should be available<br />
to people with a mental disability. This is in keeping<br />
with equitable access <strong>and</strong> non-discrimination in<br />
service provision;<br />
mental health professionals can specialise in the<br />
provision of treatment <strong>and</strong> rehabilitation rather than<br />
the provision of services that can be provided more<br />
effectively or effi ciently by other agencies;<br />
mainstreaming people with mental illness into<br />
current social <strong>and</strong> disability services is likely<br />
to decrease marginalisation <strong>and</strong> stigmatisation;<br />
no single agency (including mental health) would<br />
have suffi cient resources to meet the broad range of<br />
services required by people with a mental disability.<br />
Thus disability support is provided on some<br />
assumptions about the desirability of moving care<br />
<strong>and</strong> treatment away from a focus on clinical concerns<br />
towards a broader community approach. The<br />
research evidence supporting greater involvement<br />
of the disability sector is increasing. Indeed, in<br />
Australia, funding provided to the non-government<br />
sector to support people with psychiatric disability<br />
has increased by 294% or $75 million since 1993<br />
(Commonwealth Department of Health <strong>and</strong> Ageing,<br />
2004).<br />
1.2.1 Services provided by disability support workers<br />
<strong>Support</strong> agencies work in collaboration with mainstream<br />
mental health services <strong>and</strong> tend to target people at<br />
the more severe end of the spectrum. They assist<br />
people to connect to mainstream social <strong>and</strong> disability<br />
services by linking them to community-based recreation<br />
<strong>and</strong> vocational services (Walter & Petr, 2006). While<br />
different models of disability support have developed,<br />
the interventions provided seem to be common across<br />
models. Warner <strong>and</strong> colleagues (1998) collected<br />
information on the services provided by support staff<br />
in a number of different support programs in the UK<br />
<strong>and</strong> Northern Irel<strong>and</strong> <strong>and</strong> found that service provision<br />
could be categorised into three domains — assisting<br />
clients ‘within the home’, ‘outside the home’, <strong>and</strong><br />
‘liaising’ on behalf of clients (Warner et al., 1998).<br />
Services offered within the home were classifi ed<br />
as being emotional or practical in nature, while those<br />
provided outside the home were classifi ed as social,<br />
practical <strong>and</strong> leisure based (Table 1.2.1).<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
5
6<br />
Section 1 Introduction<br />
Table 1.2.1 Summary of the services provided by disability support workers (Warner et al. 1998)<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
<strong>Support</strong> type Content<br />
Within the home (i) Emotional support Companionship, someone to talk to, watch TV with,<br />
planning <strong>and</strong> goal-setting<br />
(ii) Practical support Household tasks – cooking, cleaning, writing letters,<br />
claiming benefi ts, paying bills<br />
Outside the home (i) Social support Having a meal in a cafe or drink in a pub, going for walk<br />
in a garden or park, going to bingo, going to church,<br />
assessing local social networks<br />
(ii) Practical support Using public transport, shopping, visiting GP,<br />
mental health appointments, etc<br />
(iii) Leisure activities Taking part in sports – swimming, aerobics, bowling,<br />
fi shing, going to football games, etc<br />
Liaison (i) Liaison with agencies Working with statutory agencies, such as housing,<br />
mental health, disability services, support agency,<br />
employment<br />
(ii) Liaison with family Building relationships with family, friends <strong>and</strong><br />
other natural supports<br />
Other studies (Harrington-Godley et al., 1988;<br />
Mak & Gow, 1996; Clarkson et al., 1999; Lord &<br />
Hutchison, 2003) report a similar range of support<br />
interventions, including assistance with budgeting,<br />
personal hygiene, building social networks, promoting<br />
links to family/friends, providing psychological<br />
support, advocacy <strong>and</strong> advice. It is also clear that<br />
support workers provide a sense of psychological<br />
assurance for people with severe disability –<br />
they tend to be available at weekends <strong>and</strong> out of hours<br />
when health professionals cannot be contacted (Oliver<br />
et al., 1996). In effect, support services compensate<br />
for the lack of family networks <strong>and</strong> other natural<br />
support systems for those with psychiatric disability<br />
living in the community (Oliver et al., 1996). <strong>Support</strong><br />
workers are frequently expected to serve as ‘bridges’<br />
between the world of professional service providers<br />
<strong>and</strong> the world of clients (Wadsworth & Knight, 1996).<br />
It does appear that the services provided by disability<br />
staff <strong>and</strong> clinical staff are on a continuum of service<br />
provision, rather than being separate or parallel<br />
services. While there are some activities that are<br />
clearly the domain of clinical staff <strong>and</strong> some the<br />
domain of support staff, there is likely to be some<br />
overlap in service provision. For example, Case<br />
Managers <strong>and</strong> support workers are likely to engage<br />
in providing emotional support to clients, albeit<br />
at different levels.<br />
1.2.2 Outcomes for clients living in independent<br />
housing with support services<br />
While governments in Australia <strong>and</strong> overseas<br />
are promoting involvement of the non-government<br />
sector in the provision of support services to people<br />
with psychiatric disability, there has been limited<br />
evaluation of the services provided by the NGO sector.<br />
Notwithst<strong>and</strong>ing this, a small amount of literature<br />
has emerged from work carried out in North America,<br />
Engl<strong>and</strong> <strong>and</strong> Australia. The table below provides a<br />
summary of the key fi ndings from these evaluations.
Table 1.2.2 Outcomes for clients moving to supported accommodation — summary of research<br />
Author<br />
(Year) Country<br />
Mak & Gow<br />
(1996)<br />
Hong Kong<br />
Clarkson et al.<br />
(1999)<br />
Engl<strong>and</strong><br />
Anthony et al.<br />
(1999)<br />
USA<br />
Prince<br />
(2006)<br />
USA<br />
Morris et al.<br />
(2005)<br />
NSW, Aust.<br />
Desl<strong>and</strong>es<br />
& Kilner<br />
(1997)<br />
SA, Australia<br />
Carter<br />
(2008)<br />
VIC, Australia<br />
Meehan et al.<br />
(2011)<br />
QLD, Australia<br />
Sample<br />
(Follow-up<br />
period)<br />
N=64<br />
32 treatment<br />
& 32 controls<br />
(18 months)<br />
N=37<br />
(6 months)<br />
N=21<br />
(20 months)<br />
N=315<br />
(3 months)<br />
(HASI)<br />
N=100<br />
(12 months)<br />
(Individual<br />
Tenant <strong>Support</strong><br />
<strong>Program</strong>)<br />
N=32<br />
(24 months)<br />
(NEAMI)<br />
N=28<br />
(12 years)<br />
(Project 300)<br />
N=181<br />
6, 36 & 84<br />
months<br />
Details of support<br />
provided<br />
One ‘after-care’<br />
worker for the<br />
32 clients in<br />
treatment group<br />
35 hours of support<br />
per client per month<br />
(only 8 hours in<br />
direct contact)<br />
26 hours<br />
per month<br />
provided by<br />
a mixture of<br />
professional <strong>and</strong><br />
non-professional<br />
staff<br />
A range<br />
of programs –<br />
hours of contact<br />
not recorded<br />
Not stated –<br />
‘based on client<br />
needs’<br />
Not stated –<br />
‘provided support<br />
to tenants on<br />
a fl exible basis’<br />
(Up to 21 hours<br />
per week)<br />
Not stated –<br />
<strong>Support</strong><br />
‘client-directed’<br />
Each client<br />
received 20 hours<br />
per week<br />
(range = 0-86<br />
hours)<br />
Findings<br />
12.5% of treatment vs. 46.1% of control clients<br />
rehospitalised<br />
Control clients spent 1640 days longer<br />
in hospital than clients in treatment group<br />
No difference in symptoms<br />
No difference in overall functioning (GAF scores)<br />
Signifi cant decrease in depression <strong>and</strong> anxiety<br />
No changes in client satisfaction with services<br />
Social contacts decreased over study period<br />
10 of the 21 clients engaged in communitybased<br />
employment<br />
37% reduction in costs in follow-up year<br />
96.4% of time spent in community versus<br />
hospital<br />
<strong>Support</strong> hours decreased from an average<br />
of 33.9 to 26.2 per month by year 2<br />
<strong>Support</strong> services provided by Case Managers<br />
Services that enhanced daily structure<br />
decreased readmission<br />
Interventions more effective in individuals<br />
with 4 or more prior hospitalisations<br />
<strong>Support</strong> provided by NGOs<br />
Reduction in the need for inpatient care<br />
90% decrease in hospital days<br />
<strong>Support</strong> provided by NGOs, including service<br />
users, service providers <strong>and</strong> community-based<br />
organisations<br />
Project used a model of support based<br />
on Direct Care Workers<br />
Limited options for community integration<br />
<strong>Support</strong> provided by NGOs<br />
<strong>Program</strong> offered shared living arrangement<br />
where up to three clients shared<br />
The need for hospitalisation reduced<br />
<strong>Support</strong> provided by NGOs<br />
Reduction in hospital admissions<br />
Cheaper than other alternatives<br />
No change in symptoms <strong>and</strong> functioning<br />
Reduction in need for support over time<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
7
8<br />
Section 1 Introduction<br />
While there appears to be some consensus on the<br />
interventions to be provided by the non-government<br />
support sector, there are clear differences in the way<br />
in which these components are delivered. This makes<br />
it diffi cult to compare the outcomes of the different<br />
approaches described. As outlined, the intensity<br />
of support provided (i.e. hours of support) <strong>and</strong> the<br />
professional backgrounds of those providing the<br />
support vary among the studies. For example,<br />
clients in the study by Clarkson et al. (1999) received<br />
an average of 35 hours per month, while those in the<br />
study by Mak & Gow (1996) had only one worker for<br />
32 clients. It is also clear that the clients in the various<br />
studies differed in important ways. While some of the<br />
studies involved ‘new’ long-stay clients, others involved<br />
clients leaving psychiatric hospitals after many years of<br />
hospitalisation (e.g. Project 300).<br />
In many of the studies reviewed, support staff were<br />
employed directly by mental health services rather than<br />
separate support agencies. For example, in three of<br />
the studies (Oliver et al., 1996; Clarkson et al., 1999;<br />
Anthony et al., 1999), support services were provided<br />
via specially designated rehabilitation teams, led by<br />
professionally trained rehabilitation workers. This<br />
raises questions about the independence of the<br />
support agencies involved <strong>and</strong> their ability to provide<br />
a range of ‘alternate’ services based on their<br />
assessment of client needs. While it is acknowledged<br />
that all the agencies involved in the treatment of<br />
the client must cooperate, there needs to be some<br />
independence in decision-making around the services<br />
that agencies provide.<br />
Most of the studies relied on a single outcome measure<br />
– most employed the number of rehospitalisations over<br />
the study period. Those studies that did evaluate other<br />
domains, such as symptoms <strong>and</strong> clinical functioning,<br />
found that these components were unlikely to change<br />
despite an increase in service intensity. While there<br />
was a trend for general functioning (ADLs, self-care,<br />
work) to improve (Warner et al., 1998), the extent<br />
of this improvement in most of the studies reviewed<br />
did not reach signifi cance. Indeed, social networks<br />
tended to decline following the introduction of support<br />
workers; in that support staff replaced the role of family<br />
<strong>and</strong> friends.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Overall, there appears to be general agreement that<br />
the provision of disability support can be a useful<br />
adjunct to current treatment options, such as case<br />
management (Mak & Gow, 1996; Clarkson et al., 1999;<br />
Lord & Hutchison, 2003). However, a major limitation<br />
of the literature has been the lack of clarity regarding<br />
the active ingredients of disability support that lead<br />
to a reduction in admissions <strong>and</strong> improvements in<br />
general functioning <strong>and</strong> the quantity of support<br />
to be provided to maximise outcomes. For example,<br />
Prince (2006) demonstrated that support services<br />
that enhanced daily structure, service continuity,<br />
<strong>and</strong> provided symptom education, reduced the<br />
chances of readmission by 50%. However, most of<br />
these support services were provided by professionally<br />
trained workers who held tertiary qualifi cations in<br />
mental health (e.g. mental health nurses).<br />
1.2.3 Australian Studies — Overview<br />
The number of supported housing models in Australia<br />
has steadily increased over the past 10 years. While<br />
many of these have not been subjected to evaluation,<br />
a small number have <strong>and</strong> the main fi ndings from these<br />
are described below.<br />
The <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> Initiative — (NSW)<br />
The <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> Initiative (HASI)<br />
(Morris et al., 2005) is a jointly funded program<br />
provided by the Department of Health <strong>and</strong> Department<br />
of <strong>Housing</strong> in New South Wales. The program was<br />
designed to assist people with mental illness acquire<br />
accommodation, to maintain the tenancy of that<br />
accommodation, <strong>and</strong> to improve their quality of life.<br />
A primary objective of the program was to reduce the<br />
need for hospital admission. The program provides<br />
support in three areas — housing, disability support<br />
<strong>and</strong> clinical stability.<br />
<strong>Housing</strong> was provided by a combination of community<br />
housing agencies <strong>and</strong> the Department of <strong>Housing</strong>.<br />
A range of housing options were available, including<br />
units, townhouses <strong>and</strong> detached houses in the<br />
community. Properties were either leased or owned<br />
by the housing providers through a l<strong>and</strong>lord system.<br />
Disability support was provided by a range of NGOs,<br />
<strong>and</strong> focused on domestic, emotional, vocational,<br />
advocacy <strong>and</strong> living skills. Community integration<br />
was a major focus of the support provided. Some<br />
of the agencies linked clients into community-based
activities, while others tried to connect clients to<br />
existing disability support groups in their communities.<br />
The intensity of support provided to each client<br />
remains unclear as it was based on client needs <strong>and</strong><br />
the willingness of the individual to accept support.<br />
Stage one provided support to 100 people with<br />
complex mental health problems <strong>and</strong> high levels<br />
of disability. The majority had schizophrenia (71.9%)<br />
<strong>and</strong> almost all (86.4%) had been hospitalised prior<br />
to entering the program. One in 10 had been living<br />
in unsatisfactory accommodation, including boarding<br />
houses, crisis accommodation, tents, or squatting.<br />
The most signifi cant outcome was the reduction in the<br />
need for acute inpatient care. Prior to joining the HASI<br />
program, clients had a total of 12,486 days in hospital.<br />
This is compared with 1,461 days (or a 90% decrease)<br />
in the 12 months following the program (Morris et<br />
al., 2005). Cost-effectiveness analysis indicates that<br />
the cost per person was estimated for start-up at<br />
$110,337.88 <strong>and</strong> a recurrent annual cost of $57,530.<br />
This does not include a number of cost factors, such<br />
as the recurrent program management costs by the<br />
NSW Health Department, the cost to HASI participant,<br />
family <strong>and</strong> other services providers (such as GPs),<br />
or foregone costs because resources (such as<br />
management <strong>and</strong> housing stock) were spent on<br />
HASI rather than elsewhere.<br />
‘Project 300’ – (Queensl<strong>and</strong>)<br />
‘Project 300’ was established in Queensl<strong>and</strong> in 1995<br />
with the aim of relocating 300 long-stay clients who<br />
were resident in the three psychiatric hospitals in that<br />
state back to their community of origin or choice.<br />
An independent evaluation of the initiative found<br />
that the Project 300 ‘model’ was able to maintain<br />
a group of formerly institutionalised people in their<br />
chosen community. Days spent in the community<br />
remained high <strong>and</strong> most people were engaged in<br />
some form of structured activity outside the home.<br />
The cost of keeping individuals in the community<br />
was about one-third that of keeping the same<br />
individual in hospital (Meehan et al., 2011).<br />
Follow-up at seven years post-discharge to the<br />
community found that while the majority of people in<br />
the study remained unemployed, many were involved<br />
in community activities. While some individuals had<br />
made signifi cant progress, there was no evidence of<br />
systematic gains in general functioning for the group<br />
as a whole. The evidence of successful community<br />
tenure, notwithst<strong>and</strong>ing in many cases, a history of<br />
unsuccessful discharge prior to the introduction of<br />
Project 300, suggests that the support worker role<br />
actively contributed to successful community tenure.<br />
Indeed, follow-up found that 40% of those discharged<br />
had not required admission to inpatient care in the<br />
seven years since entering the program. This is a<br />
remarkable fi nding given that almost all of the clients<br />
in the program had been in hospital for the two years<br />
prior to entering the program.<br />
Individual Tenant <strong>Support</strong> <strong>Program</strong> –<br />
(South Australia)<br />
The Individual Tenant <strong>Support</strong> Scheme in South<br />
Australia was established in the inner-south region<br />
of Adelaide <strong>and</strong> was designed for people with<br />
long-term mental illness at risk of relapse through<br />
an accommodation/support crisis. The scheme, which<br />
was in place from November 1994 to November 1996,<br />
was designed to provide support to tenants on a<br />
fl exible basis. This was achieved through a partnership<br />
arrangement between service users, service providers<br />
<strong>and</strong> community-based organisations (Desl<strong>and</strong>es &<br />
Kilner, 1997). The project had the unexpected diffi culty<br />
of being able to recruit the minimum target of 15 tenants<br />
at any one time. The reason for the low referral rate is<br />
unclear, but could have been a consequence of inbuilt<br />
prejudices, which made it very diffi cult to create good<br />
working relationships across the different sectors<br />
(Desl<strong>and</strong>es & Kilner, 1997). The project used a model<br />
of support based on Direct Care Workers (DCWs), with<br />
each individual receiving up to 21 hours of support per<br />
week. The fi nal report was critical of some DCWs being<br />
more enabling than others <strong>and</strong> this may have restricted<br />
the manner in which DCWs interacted with tenants <strong>and</strong>,<br />
therefore, limited options for community integration.<br />
The report was generally descriptive <strong>and</strong> very little<br />
information was available on the background of these<br />
workers, other than that they were non-professionally<br />
trained staff employed for a minimum of four hours per<br />
week <strong>and</strong> received training <strong>and</strong> orientation.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
9
10<br />
Section 1 Introduction<br />
The NEAMI Community <strong>Housing</strong> <strong>Program</strong><br />
— (Victoria)<br />
This program offered shared living arrangements<br />
where up to three clients shared accommodation.<br />
Because the number of potential tenants was more<br />
than expected, clients had little choice about the<br />
individuals with whom they would share. Many<br />
households experienced diffi culties with sharing.<br />
<strong>Support</strong> workers invested signifi cant time in mediating<br />
disputes between tenants, <strong>and</strong> a number of clients<br />
relocated to other properties managed by NEAMI.<br />
Over time, NEAMI moved towards a policy of having<br />
no more than two tenants per property, adopting<br />
this position formally in 2002.<br />
Clinical staff from the psychiatric hospitals from<br />
which clients were discharged were nominated to<br />
‘follow’ the 30 clients, forming a community-based<br />
Mobile <strong>Support</strong> <strong>and</strong> Treatment Service. Funding for<br />
psychiatric disability support through NEAMI came<br />
from the mental health budget for clinical services.<br />
The decision by mental health to use its clinical<br />
services budget in this way was criticised by clinical<br />
staff, <strong>and</strong> consequently, the NEAMI Community<br />
<strong>Housing</strong> <strong>Program</strong> was established in an environment<br />
of industrial unrest.<br />
An evaluation commissioned by NEAMI in 1996 found<br />
that, of the 28 clients (19 men <strong>and</strong> nine women)<br />
discharged from the mental health service in 1995,<br />
all but one remained with NEAMI. Several clients<br />
had had brief hospital admissions after joining the<br />
program. NEAMI staff attributed the low number of<br />
readmissions to the responsiveness of clinical support<br />
available to clients (Cox, 1996).<br />
The NEAMI Community <strong>Housing</strong> <strong>Program</strong> has been<br />
effective in enabling a cohort of people with ongoing<br />
disability associated with mental illness to sustain<br />
tenancies <strong>and</strong> live in the community over a period<br />
of 12 years (Carter, 2008). In a recent follow-up study,<br />
Carter (2008) found that the fl exibility <strong>and</strong> duration<br />
of support provided by NEAMI was critical to the<br />
program’s success.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
NEAMI provides support that changes in response to<br />
clients’ changing needs, <strong>and</strong> continues for as long as<br />
is needed. <strong>Support</strong> is directed by priorities identifi ed<br />
by the client, enabling them to create their own<br />
recovery in their own way (Carter, 2008). Clients have<br />
access to support from familiar <strong>and</strong> responsive clinical<br />
services when they need it.<br />
1.2.4 Consumer perceptions of the services<br />
provided by support workers<br />
All of the studies reviewed suggest that consumers see<br />
non-professionally trained support workers as being<br />
more attuned to their everyday needs (Shepherd et al.,<br />
1994; Warner et al., 1998; Onyett & Smith, 2001) <strong>and</strong><br />
to be credible helpers with whom they can develop<br />
easy rapport (Beeforth et al., 1994; Meek, 1998). Many<br />
consumers see support workers as paid friends that<br />
provide a degree of social support (Harrington-Godley,<br />
1988; Meek, 1998). This in itself is an important factor<br />
since lack of social support has been found to be<br />
associated with rehospitalisation (Mak & Gow, 1996;<br />
Clarkson et al., 1999) <strong>and</strong> increased contact with the<br />
criminal justice system (Caton et al., 1993).<br />
1.2.5 Mental health staff perceptions<br />
of support worker involvement<br />
There is a paucity of research in this area. Two early<br />
studies from the UK suggested that mental health<br />
professionals were unhappy with the introduction<br />
of support workers <strong>and</strong> felt that they could potentially<br />
devalue professional roles <strong>and</strong> status (George, 1997;<br />
Murray et al., 1997). Although support agencies<br />
may provide services which cost less (Mak & Gow,<br />
1996), there was a perception that this may deprive<br />
vulnerable individuals of skilled interventions<br />
previously delivered by a regulated <strong>and</strong> professional<br />
workforce (Murray et al, 1997; Meek, 1998). However,<br />
Murray <strong>and</strong> colleagues (1997) concluded from a review<br />
of support services in the UK that greater involvement<br />
of non-professionally trained staff in service delivery<br />
would not necessarily sacrifi ce the effectiveness<br />
of care <strong>and</strong> that there would be clear advantages<br />
in terms of cost.
1.2.6 Section summary<br />
It is clear from the literature reviewed above that<br />
people with psychiatric disability require intensive,<br />
fl exible support over long periods of time. As noted<br />
by Perkins <strong>and</strong> Repper (2001, p.103), this support<br />
frequently involves ‘complex packages of care<br />
that focus on minimising symptoms, preventing<br />
relapse, optimising functioning in normal social<br />
roles, preventing admission to hospital, increasing<br />
skills <strong>and</strong> access to activities <strong>and</strong> relationships in<br />
the community’. A number of commentators (Oliver<br />
et al., 1996; George, 1997; Clarkson et al., 1999)<br />
suggest that many of these support functions could<br />
be met by the non-government sector using nonprofessionally<br />
trained disability support workers. The<br />
role of support workers is continually developing <strong>and</strong><br />
includes elements of supervision, skill development,<br />
<strong>and</strong> community integration, while encouraging hope<br />
<strong>and</strong> self-determination in the client. <strong>Support</strong> workers<br />
assist clients to live in the community <strong>and</strong> ensure that<br />
treatment outside hospital does not lead to increased<br />
risk for the client or the community. However, while<br />
clients value the services provided by support workers,<br />
mental health staff have mixed feelings about the<br />
introduction of a group than can provide services<br />
at a lower cost.<br />
Although disability support services are becoming<br />
an established part of mental health service provision<br />
in Australia <strong>and</strong> overseas, there is limited empirical<br />
evidence for the effectiveness of these services.<br />
An extensive review of the ‘support’ literature revealed<br />
a h<strong>and</strong>ful of studies that included some appraisal<br />
of disability support. The only consistent fi nding in all<br />
of the studies reviewed relates to rehospitalisation.<br />
Those clients in receipt of disability support services<br />
tend to have fewer readmissions to hospital <strong>and</strong><br />
fewer days in inpatient care once admission becomes<br />
necessary. Australian research has produced similar<br />
fi ndings. Morris <strong>and</strong> colleagues (2005), in a NSW<br />
study, found there was a 90% reduction in hospital<br />
bed days following the introduction of the support<br />
program. Meehan <strong>and</strong> colleagues (2011) found that<br />
40% of clients who could not be discharged prior<br />
to the introduction of the Project 300 <strong>Program</strong> in<br />
Queensl<strong>and</strong> had not required admission to hospital<br />
in the seven years since entering the program.<br />
1.3 Current evaluation<br />
In mid-2008, a submission from the Service <strong>Evaluation</strong><br />
& Research Unit located at the Park, Centre for<br />
Mental Health, in collaboration with the University<br />
of Queensl<strong>and</strong>, was successful in securing funding<br />
for the evaluation of <strong>HASP</strong>. The evaluation protocol<br />
was developed to include a comprehensive package<br />
of assessments to be undertaken with the clients <strong>and</strong><br />
the agencies involved in the program. The protocol<br />
involved the collection of data from both clients <strong>and</strong><br />
staff <strong>and</strong> included structured <strong>and</strong> semi-structured<br />
interviews, focus group interviews <strong>and</strong> self-completed<br />
questionnaires. While the Department of Communities<br />
— <strong>Housing</strong> <strong>and</strong> Homelessness Services (HHS) was<br />
the lead agency for the evaluation, all three agencies<br />
(<strong>Housing</strong> <strong>and</strong> Homelessness Services, Queensl<strong>and</strong><br />
Health, <strong>and</strong> Disability <strong>and</strong> Community Care Services)<br />
were represented through the <strong>Evaluation</strong> Steering<br />
Committee.<br />
While the evaluation team worked closely with the<br />
different government departments involved,<br />
it maintained its independent status <strong>and</strong> did not<br />
become unduly involved in the planning <strong>and</strong> decisionmaking<br />
processes. The focus of the evaluation team,<br />
therefore, remained the systematic evaluation of the<br />
resettlement process on the welfare of individual<br />
clients, rather than its impact on the service system<br />
as a whole. During the course of the evaluation,<br />
feedback was provided to the <strong>Evaluation</strong> Steering<br />
Committee, primarily through the dissemination<br />
of fi ndings in the form of progress reports, <strong>and</strong><br />
presentations targeted for policy-makers, service<br />
providers <strong>and</strong> care staff.<br />
1.3.1 Scope of evaluation<br />
The purpose of the evaluation was outlined in the<br />
Invitation to Offer Document (HPS001/09) which<br />
stated that the contractor will:<br />
‘Undertake an evaluation of the <strong>Housing</strong> <strong>and</strong><br />
<strong>Support</strong> <strong>Program</strong> to determine delivery <strong>and</strong> outcome<br />
effectiveness <strong>and</strong> effi ciencies, as well as to identify <strong>and</strong><br />
recommend opportunities for the future management<br />
of the <strong>Program</strong>.’<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
11
12<br />
Section 1 Introduction<br />
More specifi cally, the evaluation team was asked<br />
to focus on the following objectives:<br />
the effectiveness of the collaborative process<br />
established across agencies<br />
the process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
the opportunities available through the program<br />
for clients to maximise their recovery <strong>and</strong> participate<br />
in community life — the focus here will be on social,<br />
recreational, educational, <strong>and</strong> vocational activities<br />
in the community<br />
the ability of the program to maintain clinical<br />
functioning <strong>and</strong> provide an acceptable quality<br />
of life for those supported by the program.<br />
Key evaluation questions related to the above outcome<br />
objectives were also outlined in the Invitation to Offer<br />
Document. These included:<br />
1. Was an effective collaborative process established<br />
across agencies?<br />
2. Have effective governance arrangements been<br />
established to support ongoing development<br />
<strong>and</strong> delivery of <strong>HASP</strong>?<br />
3. To what extent has the program been effective<br />
in delivering timely <strong>and</strong> coordinated clinical,<br />
non-clinical <strong>and</strong> housing services to clients?<br />
4. Has <strong>HASP</strong> enhanced access to specialist <strong>and</strong><br />
generalist support services, including housing,<br />
mental health, disability <strong>and</strong> other human services<br />
through processes of partnership <strong>and</strong> planning?<br />
5. What are the costs <strong>and</strong> benefi ts of providing<br />
coordinated clinical <strong>and</strong> non-clinical support<br />
<strong>and</strong> appropriate housing to clients through <strong>HASP</strong>,<br />
compared with traditional forms of assistance?<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
6. What proportion of clients reported that<br />
participation in <strong>HASP</strong> has supported their recovery<br />
or that it will provide a basis for future recovery?<br />
7. Does <strong>HASP</strong> enhance the quality-of-life<br />
outcomes for clients?<br />
8. What proportion of <strong>HASP</strong> clients experienced<br />
improved functioning?<br />
9. Has there been a reduction in hospital admissions/<br />
presentations/duration of stay for clients of <strong>HASP</strong>?<br />
10. What proportion of <strong>HASP</strong> clients had sustained<br />
tenancies? Over what period?<br />
11. Where tenancies have ended have these been<br />
planned exits? What arrangements have been<br />
made for clients exiting <strong>HASP</strong>?<br />
12. What proportion of <strong>HASP</strong> clients of working age<br />
had an increase in participation in employment?<br />
13. Was there an increase in participation rates<br />
by <strong>HASP</strong> clients aged 18–30 in education<br />
<strong>and</strong> employment?<br />
14. Has there been a positive impact in the<br />
client’s community — with friends, community<br />
acceptance,participation in meaningful activities<br />
<strong>and</strong> reduction in stigma?<br />
1.3.2 Ethical considerations<br />
Ethical clearance for this evaluation was obtained from<br />
the relevant Human Research Ethics Committee in each<br />
Queensl<strong>and</strong> Health Service District. Every consumer<br />
participating in the evaluation was given a written<br />
explanation of the purpose of the evaluation <strong>and</strong> its<br />
focus on their experiences <strong>and</strong> views. All participants<br />
signed a form registering their consent to participate.<br />
In keeping with National Health & Medical Research<br />
Centre (NH&MRC) guidelines, no names or other<br />
identifying personal details of any participant will<br />
be reported in the presentation of fi ndings.
Section 2<br />
Method<br />
2.1 Design<br />
The study employed a multi-site, multi-method<br />
approach. Follow-up evaluation data were collected<br />
over a four-month period between March <strong>and</strong> June<br />
2010. The fi rst clients entered <strong>HASP</strong> in 2006 <strong>and</strong> as<br />
a consequence, some of the clients followed up had<br />
been in <strong>HASP</strong> for close to four years, while others<br />
(e.g. those who entered <strong>HASP</strong> in early-2010) had been<br />
in the program for only two to three months<br />
(see Table 2.1 below).<br />
Quantitative <strong>and</strong> qualitative data were collected from<br />
consumers <strong>and</strong> the staff of the government agencies<br />
involved (QH, HHS, <strong>and</strong> DCCS) <strong>and</strong> the NGO support<br />
agencies. The overall approach was designed to<br />
address the evaluation questions outlined previously.<br />
As such, data collection focused on perceptions<br />
of <strong>HASP</strong>, inter-agency communication <strong>and</strong> working<br />
relations, <strong>and</strong> the outcomes for consumers.<br />
Fig. 2.1 Overview of evaluation components<br />
Consumers<br />
Domains assessed:<br />
1. Perceptions of <strong>HASP</strong><br />
2. Perceptions of<br />
<strong>Housing</strong><br />
3. Perceptions<br />
of <strong>Support</strong>s<br />
4. Quality of Life<br />
5. Functioning <strong>and</strong><br />
Symptom data<br />
derived from CIMHA<br />
<strong>Evaluation</strong> of the <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
Mental Health<br />
Domains assessed:<br />
1. Perceptions of <strong>HASP</strong><br />
2. Interactions with<br />
support services<br />
3. Interactions with<br />
<strong>Housing</strong> services<br />
While some data were collected as a ‘one-off’, data<br />
concerning consumer functioning were downloaded<br />
from the Consumer Integrated Mental Health<br />
Application (‘CIMHA’), a computerised information<br />
system maintained by Queensl<strong>and</strong> Health. This<br />
application enabled the evaluation team to assess<br />
changes in consumer functioning pre <strong>and</strong> post-entry<br />
into <strong>HASP</strong>.<br />
By assessing measures on individuals at different<br />
stages of the program, the clients acted as their own<br />
controls. <strong>Final</strong>ly, data concerning the number<br />
of support hours allocated to each individual on entry<br />
into <strong>HASP</strong> <strong>and</strong> at the follow-up assessment were<br />
also collected to provide an estimate of the cost of<br />
supporting individuals through <strong>HASP</strong>. This provided<br />
a means of comparing <strong>HASP</strong> with alternate inpatient<br />
<strong>and</strong> residential rehabilitation programs. An overview<br />
of the evaluation components is provided in Fig. 2.1.<br />
Disability Services<br />
Domains assessed:<br />
1. Perceptions of <strong>HASP</strong><br />
2. Interactions with<br />
Mental Health<br />
3. Provision of<br />
support services<br />
<strong>Housing</strong><br />
Domains assessed:<br />
1. Perceptions of <strong>HASP</strong><br />
2. Interactions with<br />
MH services<br />
3. Interactions with<br />
support services<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
13
14<br />
Section 2 Method<br />
2.2 Participants<br />
As noted, data were collected from a range of key<br />
individuals <strong>and</strong> groups associated with <strong>HASP</strong>. The<br />
clients involved in <strong>HASP</strong> formed the cohort of primary<br />
interest. Other key groups included clinical staff,<br />
support workers/staff, <strong>Support</strong>s Facilitators <strong>and</strong><br />
housing providers. An overview of each sample is<br />
provided below.<br />
2.2.1 Client sample<br />
<strong>HASP</strong> commenced as a ‘pilot’ program in 2006 with<br />
80 places being made available over the 2006–2007<br />
fi nancial year. All individuals entering <strong>HASP</strong> in the<br />
2006–2007 year had existing recurrent funding<br />
arrangements in place either through Disability<br />
Services or Queensl<strong>and</strong> Health. Their accommodation<br />
needs were met by the former Department of <strong>Housing</strong><br />
(now known as <strong>Housing</strong> <strong>and</strong> Homelessness Services).<br />
Since <strong>HASP</strong> commenced in 2006, 194 places have<br />
been funded through the program (Table 2.1).<br />
However, since 10 new clients were selected to fi ll<br />
the vacancies created by those who left the program,<br />
a total of 204 clients have been offered <strong>HASP</strong><br />
packages over the four years (2006–2010).<br />
Table 2.2 Clients enrolled in the study<br />
Total clients<br />
funded through<br />
<strong>HASP</strong> (n=204)<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Clients unavailable<br />
to the evaluation<br />
204 26 withdrawn from program<br />
14 in transition – not living in<br />
community<br />
6 deceased<br />
1 in High Secure Unit<br />
1 in Medium Secure Unit<br />
1 in CCU<br />
1 in nursing home<br />
1 in hospital (physical health)<br />
Clients available but unwilling/<br />
unable to participate<br />
45 refused to participate<br />
19 too unwell to participate<br />
7 have intellectual/cognitive<br />
problems – unable to<br />
participate<br />
2 living in remote location<br />
51 Unavailable 73 Unable/unwilling<br />
to participate<br />
Of these, 153 were living in the community at the time<br />
of the evaluation (March–July 2010) <strong>and</strong> 80 of these<br />
were enrolled in the study (Table 2.1).<br />
Table 2.1 Funded places <strong>and</strong> clients living<br />
in the community<br />
Year Number<br />
of <strong>HASP</strong><br />
places<br />
<strong>HASP</strong><br />
clients<br />
living in the<br />
community<br />
at time of<br />
evaluation<br />
Clients enrolled<br />
in the evaluation<br />
204 204 – 51 = 153 153 – 73 = 80 80<br />
Clients<br />
enrolled<br />
in the<br />
evaluation<br />
2006–2007 80 64 26 (40.6%)<br />
2007–2008 40 33 18 (54.5%)<br />
2008–2009 40 34 21 (61.8%)<br />
2009–2010 34 22 15 (68.2%)<br />
Total 194 153 80 (51.6%)<br />
Of the 153 clients available for inclusion in the<br />
evaluation, 73 of these were unable or unwilling<br />
to be involved in the evaluation. The reasons for this<br />
are summarised in the table below.<br />
80
2.2.1.2 Clients unavailable to participate<br />
As noted above, 51 of the 204 clients (25.0%) who<br />
entered <strong>HASP</strong> were unavailable to the evaluation.<br />
The reasons for this are discussed below.<br />
(i) Clients who have left <strong>HASP</strong><br />
Twenty-six of the 204 clients allocated a <strong>HASP</strong> place<br />
were subsequently withdrawn from the program. Of<br />
these, 13 failed to transition/move to the community<br />
<strong>and</strong> three moved into private accommodation after<br />
joining the <strong>HASP</strong>. Two moved interstate <strong>and</strong> three<br />
others were unable to adapt to life in the community<br />
<strong>and</strong> returned to 24-hour care. Two breached their<br />
forensic orders <strong>and</strong> one was withdrawn due to<br />
poor physical health. <strong>Final</strong>ly, two refused to accept<br />
support services despite having an obvious need<br />
for such services.<br />
(ii) Clients in transition<br />
Clients who were spending less than four nights per<br />
week in the community at the time of follow-up were<br />
considered to be ‘in transition’ <strong>and</strong> not included<br />
in the study (as they were spending more time in<br />
hospital than in the community). Using this criterion,<br />
14 clients (6.8%) were treated as being in transition<br />
to the community. There was wide variation in the<br />
duration of time spent in transition. One client has<br />
been in transition for over three years <strong>and</strong> two others<br />
have been in transition for over 12 months (due to<br />
complications with forensic orders). The remainder<br />
have been in transition for less than 12 months. The<br />
average time in transition was 163 days (i.e. the time<br />
between allocation of a house by HHS <strong>and</strong> the date<br />
of discharge to the community).<br />
(iii) Clients deceased<br />
Six of the 204 clients (2.9%) were deceased by<br />
the time of evaluation. Two died by suicide <strong>and</strong> two<br />
others died from cardiac-related conditions. One client<br />
died from a physical health problem <strong>and</strong> the cause<br />
of death for the remaining client is currently being<br />
investigated.<br />
(iv) Clients in other healthcare facilities<br />
Five of the clients had been admitted to a range<br />
of other facilities by the time the evaluation team<br />
conducted the follow-up assessment. While one<br />
had committed an offence requiring admission to<br />
a High Secure Unit, none were in prison (or had been<br />
in prison since discharge). One was in hospital for<br />
physical health problems <strong>and</strong> one had been admitted<br />
to a nursing home.<br />
2.2.1.3 Clients available to participate but unable/<br />
unwilling to participate<br />
Of the 153 clients eligible to participate in the<br />
evaluation, 73 of these were unable or unwilling to<br />
participate. The reasons for this are discussed below.<br />
(i) Clients who refused to participate<br />
Of the 153 remaining clients, 45 (29.4%) refused<br />
to participate in the evaluation. This is a relatively<br />
large proportion of the cohort. The reasons for nonparticipation<br />
are speculative. The evaluation team<br />
gained access to clients through their support agency<br />
– in keeping with ethical considerations. While the<br />
majority of support agencies were willing to assist<br />
in recruiting clients, some were less motivated to<br />
promote the evaluation to their clients.<br />
(ii) Clients who were too unwell to participate<br />
Nineteen clients (n=19) were too unwell to participate.<br />
Seven of these were receiving care in acute inpatient<br />
units at the time of data collection. In addition, 12<br />
clients were considered by their support agency/Case<br />
Manager to be too unwell to complete the interview/<br />
questionnaire <strong>and</strong> these were not approached to<br />
be involved.<br />
(iii) Clients unable to complete questionnaire<br />
The support agencies for seven of the clients felt<br />
that these clients would be unable to complete the<br />
questionnaire or participate in an interview. The<br />
evaluation team accepted this advice <strong>and</strong> these clients<br />
were not invited to participate.<br />
(iv) Clients in remote areas<br />
Two clients were living in remote locations in north<br />
Queensl<strong>and</strong> <strong>and</strong> these proved too diffi cult to reach.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
15
16<br />
Section 2 Method<br />
2.2.1.4 Demographic profi le of clients enrolled<br />
in the evaluation<br />
While 204 clients accessed <strong>HASP</strong>, data were available<br />
for 80 of these. The majority of the 80 clients enrolled<br />
in the evaluation were male (76%) <strong>and</strong> 72% (n=58)<br />
had completed year 10 or higher. While two clients<br />
(2.5%) had obtained a TAFE certifi cate, none of the<br />
80 clients had attended university.<br />
Table 2.3 Profi le of clients in study (n=80)<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
The majority had a diagnosis of schizophrenia<br />
(89%) <strong>and</strong> 61 (78.2%) were single/never married.<br />
The majority were born in Australia (90%) <strong>and</strong><br />
eight of the 80 clients (10%) were Indigenous<br />
(see Table 2.3 below).<br />
Characteristic Clients enrolled in evaluation (n=80)<br />
Gender Male 61 (76.2%)<br />
Female 19 (23.7%)<br />
Education Did not complete year 10 22 (27.5%)<br />
Year 10 <strong>and</strong> higher 58 (72.5%)<br />
Marital status Single/Never Married 63 (78.7%)<br />
In a committed relationship 9 (11.2%)<br />
Separated/Divorced 7 (8.7%)<br />
Spouse deceased 1 (1.2%)<br />
Country of birth Australia 70 (87.5%)<br />
Other 10 (12.5%)<br />
Background Aboriginal or Torres Strait Isl<strong>and</strong>er 8 (10.0%)<br />
Other 72 (90.0%)<br />
Diagnosis Schizophrenia 71 (88.7%)<br />
Other 9 (11.3%)
2.2.1.5 Clinical staff — sample<br />
Forty (n=40) of the Case Managers who provided<br />
services to <strong>HASP</strong> clients completed the Case Manager<br />
Questionnaire. Attempts were made to ensure that<br />
Case Managers were drawn from rural <strong>and</strong> remote<br />
locations <strong>and</strong> in proportion to the number of <strong>HASP</strong><br />
clients in each location. It should be noted that while<br />
the fi nal sample represents approximately 50% of<br />
Case Managers providing services to <strong>HASP</strong> clients<br />
(some Case Managers provide services for up to<br />
three <strong>HASP</strong> clients), participants were not r<strong>and</strong>omly<br />
selected. As such, generalisation of fi ndings to the<br />
broader Case Manager group requires a degree<br />
of caution.<br />
Approximately half of the respondents were from the<br />
greater Brisbane area, with signifi cant representation<br />
also from the Gold Coast, Townsville <strong>and</strong> Cairns.<br />
Approximately 61% were female <strong>and</strong> 23.7% were<br />
between 31–40 years. The average length of time that<br />
Case Managers had been working in mental health<br />
was 12 years <strong>and</strong> they had been involved with <strong>HASP</strong><br />
clients for an average of 2.4 years. Approximately half<br />
(52.6%) were nurses <strong>and</strong> 21.1% were occupational<br />
therapists. Social workers <strong>and</strong> psychologists made up<br />
the remainder of the sample.<br />
2.2.2 <strong>Support</strong> services – sample<br />
Fifty-eight (n=58) support workers completed the<br />
support worker Questionnaire. It should be noted<br />
that while the fi nal sample represents approximately<br />
35% of the total number of support workers providing<br />
services to <strong>HASP</strong> clients (some support workers<br />
provide services for up to three <strong>HASP</strong> clients),<br />
the fi nal sample was not r<strong>and</strong>omly selected. Again,<br />
generalisation of fi ndings to the broader support<br />
worker group should be carried out with a degree<br />
of caution.<br />
Approximately 60% of those who completed the<br />
questionnaire were female <strong>and</strong> approximately half<br />
(53.4%) were between 30 to 50 years (24% were below<br />
30 years <strong>and</strong> 22.6% were above 50 years). More than<br />
half (56.1%) had worked as a support worker for one<br />
to three years (26.3% worked less than a year <strong>and</strong><br />
17.6% worked more than three years). Almost 63% had<br />
prior experience working with people who had mental<br />
illness prior to joining their present support agency.<br />
This experience was gained from previous employment<br />
in aged care, as youth workers, <strong>and</strong> in communitybased<br />
mental health support centres. Others had<br />
experienced mental illness themselves or had<br />
a sibling or family member with mental illness.<br />
Approximately 78% had some form of qualifi cation<br />
for their role as a support worker. The most common<br />
qualifi cation was Cert III or Cert IV in Mental Health<br />
(non-clinical) offered through TAFE or a similar training<br />
facility. Others had completed or were completing<br />
courses in social work, psychology, mental health<br />
nursing or training in mental health fi rst-aid. The modal<br />
number of clients supported by each support worker<br />
was two <strong>and</strong> the average hours spent with all their<br />
<strong>HASP</strong> clients was 11.9 hours. The average hours spent<br />
with all their mental health clients (including <strong>HASP</strong><br />
clients) was 29.35 hours.<br />
2.2.3 <strong>Support</strong>s Facilitators<br />
Nineteen (n=19) <strong>Support</strong>s Facilitators participated<br />
in interviews <strong>and</strong> 10 of these completed the <strong>Support</strong>s<br />
Facilitator Questionnaire. Nine of the 10 were female<br />
<strong>and</strong> 60% were 31–50-years-old. Each facilitator<br />
supported an average of 8.5 clients <strong>and</strong> the average<br />
time spent with each <strong>HASP</strong> client per week was<br />
3.3 hours.<br />
2.2.4 <strong>Housing</strong> <strong>and</strong> Homelessness Services — sample<br />
Twenty-six (n=26) HHS staff from 14 <strong>Housing</strong> Service<br />
Centres across Queensl<strong>and</strong> participated in either<br />
individual or group interviews. These interviews<br />
enabled staff to describe, in their own words, how they<br />
perceived their role in the program. The interviews<br />
enabled them to discuss their relationship with the<br />
other agencies, concerns with the process of providing<br />
housing under <strong>HASP</strong>, <strong>and</strong> suggestions for future<br />
initiatives such as <strong>HASP</strong>.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
17
18<br />
Section 2 Method<br />
2.3 Data collection<br />
As outlined, data were collected from a number of key<br />
agencies involved with the program. These included:<br />
(i) clients who entered the program since 2006,<br />
(ii) support staff who provide non-clinical support<br />
to these clients,<br />
(iii) clinical staff who provide case management<br />
services, <strong>and</strong><br />
(iv) staff from <strong>Housing</strong> <strong>and</strong> Homelessness Services<br />
who provide accommodation.<br />
1) Data collected directly from consumers:<br />
a. Consumers completed a modifi ed version of<br />
the Wisconsin Quality of Life Index (Becker et al.,<br />
1993). This measure was developed in the USA<br />
to assess quality of life in individuals with severe<br />
mental illness. A number of domains that contribute<br />
to quality of life are assessed. These include<br />
ratings of mental <strong>and</strong> physical functioning, work<br />
<strong>and</strong> vocational outcomes, contact with family <strong>and</strong><br />
friends, community activities <strong>and</strong> overall quality of<br />
life. In addition to this information, the evaluation<br />
team added a number of domains concerning<br />
consumer perception of the interventions delivered<br />
by mental health <strong>and</strong> disability support services.<br />
The scale was completed by the consumer in the<br />
presence of the research assistant or through<br />
an interview with the research assistant for<br />
those participants who had diffi culty reading/<br />
underst<strong>and</strong>ing the questionnaire.<br />
b. In addition to this scale data, in-depth interviews<br />
were conducted with 15 consumers. These<br />
interviews were designed to gain consumer insights<br />
into how they perceived their recovery <strong>and</strong> the<br />
components of <strong>HASP</strong> that helped in this recovery.<br />
These interviews enabled participants to describe,<br />
in their own words, the factors (housing, clinical<br />
support, non-clinical support, etc) that they believe<br />
were important in their recovery.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
2) Data collected from support services<br />
a. Data on the level of support provided (i.e. hours of<br />
support/week) was sought from support agencies<br />
for two time-points; at the time the consumer<br />
entered <strong>HASP</strong> <strong>and</strong> at the time the consumer was<br />
interviewed. Information concerning the ‘actual’<br />
hours provided, rather than the hours funded,<br />
was collected <strong>and</strong> used in the evaluation.<br />
(There may be some variation between the<br />
hours provided <strong>and</strong> the hours funded as support<br />
agencies can increase or decrease levels of<br />
support to meet client needs).<br />
b. <strong>Support</strong> workers were asked to complete a scale<br />
designed by the evaluation team to assess the<br />
support worker role, support worker involvement<br />
in treatment decisions, <strong>and</strong> general comments<br />
on the program. Fifty-eight (n=58) support<br />
workers from across the state returned completed<br />
questionnaires.<br />
c. In addition to the above data, in-depth interviews<br />
were conducted with a sub-sample of 11 support<br />
workers to gain insights into the issues confronting<br />
support workers caring for people with psychiatric<br />
disability. These interviews explored how support<br />
workers perceived their role, their preparation <strong>and</strong><br />
training for the role, their relationship with<br />
other service providers, such as Case Managers,<br />
the day-to-day challenges of providing care, how<br />
decisions are made concerning the activities<br />
carried out with/for clients, <strong>and</strong> what, if anything,<br />
is required to improve their contribution to the<br />
recovery of the clients in <strong>HASP</strong>.<br />
3) Data collected from <strong>Support</strong>s Facilitators<br />
a. In-depth interviews were conducted with<br />
19 <strong>Support</strong>s Facilitators to gain insights<br />
into the issues confronting this group. These<br />
interviews explored how <strong>Support</strong>s Facilitators<br />
perceive their role, how decisions are made about<br />
their work, their relationship with other players,<br />
such as support agencies <strong>and</strong> Queensl<strong>and</strong> Health<br />
staff, the day-to-day challenges, <strong>and</strong> what, if<br />
anything, is required to improve their contribution<br />
to the <strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong>. In addition,<br />
10 <strong>Support</strong>s Facilitators completed the <strong>Support</strong>s<br />
Facilitator Questionnaire.
4) Data collected from mental health services<br />
a. Case Managers involved with <strong>HASP</strong> were<br />
also identifi ed <strong>and</strong> asked to complete a brief<br />
questionnaire to assess their perceptions of the<br />
program, current concerns, <strong>and</strong> future concerns<br />
for the program. Forty (n=40) completed<br />
questionnaires were returned for inclusion<br />
in the evaluation.<br />
b. In-depth interviews were also conducted with<br />
31 clinical staff employed in community <strong>and</strong><br />
inpatient services (such as Community Care Units).<br />
The interviews were designed to gain insights<br />
into the issues confronting clinical staff employed<br />
in these positions. The interviews explored how<br />
clinical staff perceived their role, how decisions<br />
were made about their work, their relationship<br />
with other players such as support agencies<br />
<strong>and</strong> housing staff, the day-to-day challenges,<br />
<strong>and</strong> what, if anything, was required to improve<br />
their contribution to <strong>HASP</strong>.<br />
c. In-depth interviews were also conducted with<br />
10 Service Integration Coordinators (SIC).<br />
The interviews were designed to gain insights<br />
into the issues confronting staff employed in<br />
these positions. The interviews explored how<br />
SICs perceived their role, how decisions were<br />
made about their work, their relationship with<br />
other players such as support agencies <strong>and</strong><br />
housing staff, the day-to-day challenges, <strong>and</strong><br />
what, if anything, was required to improve their<br />
contribution to <strong>HASP</strong>.<br />
5) Data relating to accommodation<br />
a. An assessment of the living environment for each<br />
participant was also carried out. An Environmental<br />
Assessment Scale used in the evaluation of<br />
Project 300 was employed to assess individual<br />
satisfaction with accommodation. The scale<br />
covers a number of domains, such as comfort,<br />
safety, proximity to transport <strong>and</strong> shops, building<br />
security, privacy, available space, etc.<br />
b. Feedback about access to <strong>and</strong> allocation<br />
of accommodation <strong>and</strong> living environments<br />
for <strong>HASP</strong> clients was also obtained through<br />
in-depth interviews <strong>and</strong> focus group discussions<br />
with <strong>Housing</strong> <strong>and</strong> Homelessness Services staff in<br />
Service Centres offi ces across Queensl<strong>and</strong>. Twentysix<br />
(n=26) staff from 14 <strong>Housing</strong> Service Centres<br />
across the state participated in these interviews.<br />
6) Data relating to costs<br />
a. The total number of support hours provided on<br />
a weekly basis to each individual was collected<br />
to estimate the cost of maintaining clients in the<br />
community. In addition to support costs, the<br />
costs for case management/GP services <strong>and</strong><br />
accommodation were estimated <strong>and</strong> included<br />
in the model to provide an estimated annual cost<br />
for maintaining individuals in the community<br />
under <strong>HASP</strong>.<br />
7) Data relating to consumer outcomes – CIMHA Data<br />
a. The collection of routine outcomes data is now<br />
m<strong>and</strong>ated for all publicly funded mental health<br />
consumers in Queensl<strong>and</strong>. Three measures —<br />
The Life Skills Profi le (LSP), the Health of the Nation<br />
Outcome Scales (HoNOS), <strong>and</strong> the Mental Health<br />
Index (MHI) — are collected by the consumer’s Case<br />
Manager at admission <strong>and</strong> discharge from mental<br />
health services <strong>and</strong> every 91 days for continuing<br />
care clients. This information is entered into the<br />
Consumer Integrated Mental Health Application<br />
(‘CIMHA’), a database maintained by Queensl<strong>and</strong><br />
Health. Of the 80 clients consenting to be involved<br />
in the evaluation, 77 provided consent for their<br />
CIMHA data to be used for the purpose of the<br />
evaluation. Clients were not asked a reason for<br />
refusing access to their CIMHA data, but two of the<br />
clients outlined that they would be embarrassed<br />
if people could see how unwell they had been<br />
in the past.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
19
20<br />
Section 2 Method<br />
To summarise, a large quantity of both qualitative <strong>and</strong> quantitative data was collected from consumers<br />
<strong>and</strong> the service providers that support these consumers. An overview of the data collected is provided<br />
in the table below.<br />
Table 2.4 Overview of data collected<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Target Group Data collected<br />
Consumers 80 Clients completed Wisconsin Quality-of-Life Scale in the presence<br />
of a Research Assistant (RA).<br />
Department of Communities –<br />
Funded NGOs<br />
Department of Communities –<br />
Disability <strong>and</strong> Community<br />
Care Services<br />
Department of Communities –<br />
Funded NGOs<br />
12 Clients participated in face-to-face interviews with RA<br />
Data relating to support hours collected from <strong>Support</strong> Agencies<br />
Data relating to client functioning (n=77) downloaded from CIMHA<br />
(3 clients refused access to their CIMHA data)<br />
58 <strong>Support</strong> workers completed support worker Questionnaire<br />
11 <strong>Support</strong> workers participated in face-to-face interviews<br />
19 <strong>Support</strong>s Facilitators in 12 DCCS Offi ces participated in interviews<br />
10 <strong>Support</strong>s Facilitators completed the <strong>Support</strong>s Facilitator Questionnaire<br />
19 <strong>Support</strong>s Facilitators in 12 DCCS Offi ces participated in interviews<br />
10 <strong>Support</strong>s Facilitators completed the <strong>Support</strong>s Facilitator Questionnaire<br />
Queensl<strong>and</strong> Health 40 Case Managers completed Case Manager Questionnaire<br />
Department of Communities —<br />
<strong>Housing</strong> <strong>and</strong> Homelessness<br />
Services<br />
31 QH clinical staff participated in face-to-face interviews<br />
10 Service Integration Coordinators participated in interviews<br />
26 HHS staff in 14 <strong>Housing</strong> Service Centres across Queensl<strong>and</strong><br />
participated in interviews
2.4 Procedure<br />
2.4.1 Clients – procedure for data collection<br />
Initial contact with clients was through their support agency. All <strong>HASP</strong> clients were approached by support staff<br />
<strong>and</strong> invited to participate in the evaluation. Clients were informed about the evaluation <strong>and</strong> provided with details<br />
of what their involvement would entail. Those interested in being involved completed a ‘consent to be contacted’<br />
form <strong>and</strong> this was then mailed to the evaluation team. The evaluation team then made contact with the client<br />
to arrange a time for interview. At this initial meeting the client was again provided with information about the<br />
project, <strong>and</strong> fully informed consent in writing was obtained. Having obtained consent, the client was invited to<br />
complete the Wisconsin Quality of Life Index. Eighty clients participated in this component of the evaluation.<br />
In addition to providing consent to be involved in the evaluation, each client was also asked to provide consent<br />
for the evaluation team to access his/her data in CIMHA <strong>and</strong> 77 of the 80 did so. Having identifi ed the date that<br />
each individual entered <strong>HASP</strong>, it was possible to obtain the outcomes data from CIMHA for clients at 12 months<br />
<strong>and</strong> three months prior to entering <strong>HASP</strong> <strong>and</strong> for three months <strong>and</strong> 12 months post-entry into <strong>HASP</strong> (Table 2.5).<br />
We also examined data at 24 months post-entry into <strong>HASP</strong>, but the number of clients with completed measures<br />
was too small to be useful in the study.<br />
Table 2.5 Overview of data collection time-points (CIMHA D=data)<br />
Time 1 Time 2 Time 3 Time 4<br />
Clients enter <strong>HASP</strong><br />
12 months-pre 3 months-pre 3 months-post 12 months-post<br />
In addition to the above data, a sub-group of consumers was invited to participate in in-depth interviews with<br />
a member of the research team. These individuals were selected on their ability to contribute to an interview<br />
<strong>and</strong> their willingness to discuss their views of <strong>HASP</strong>. Both of these criteria were assessed through observations<br />
made by the research assistant during the completion of the Wisconsin Quality of Life Index <strong>and</strong> in subsequent<br />
discussions with support agency staff.<br />
2.4.2 Clinical staff – procedure for data collection<br />
The name of the Case Manager responsible for each consumer was obtained directly from consumers during<br />
their initial interview with the research assistant (described above). Case Managers were then contacted directly<br />
by a research assistant <strong>and</strong> invited to complete a brief questionnaire (i.e. Case Manager Questionnaire).<br />
This questionnaire invited Case Managers to comment on their perceptions of <strong>HASP</strong> <strong>and</strong> their interactions<br />
with support <strong>and</strong> housing staff.<br />
Case Managers were asked to provide general information about the program — no information concerning<br />
any individual client was collected from Case Managers. The questionnaire was sent to Case Managers via<br />
mail or email.<br />
In addition, a sub-group of 31 clinical staff participated in focus group discussions <strong>and</strong> individual interviews<br />
with a member of the research team. These individuals were selected on their willingness to contribute to<br />
an interview <strong>and</strong> their experience of working with <strong>HASP</strong> clients. A member of the research team also conducted<br />
individual interviews with 10 Service Integration Coordinators from across Queensl<strong>and</strong>. These individuals were<br />
contacted via email <strong>and</strong> invited to be involved in the evaluation. None of the Service Integration Coordinators<br />
contacted refused to be involved.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
21
22<br />
Section 2 Method<br />
2.4.3 <strong>Support</strong> Staff — procedure for data collection<br />
Information from support workers was collected<br />
through the <strong>HASP</strong> Coordinator at each <strong>Support</strong> Agency.<br />
The Coordinator distributed the support worker<br />
Questionnaire to relevant support workers (i.e. those<br />
working with <strong>HASP</strong> clients). Again, no information<br />
concerning any individual client was collected from<br />
support workers. The questionnaire was general in<br />
nature <strong>and</strong> invited support workers to rate perceptions<br />
of <strong>HASP</strong> <strong>and</strong> their role in the care process.<br />
In addition, a sub-group of support workers was<br />
invited to participate in in-depth interviews with<br />
a member of the research team. These support workers<br />
were selected on their experience as a support<br />
worker (i.e. more than 12 months’ experience) <strong>and</strong><br />
their willingness to contribute to an interview. The<br />
names of support workers meeting the selection<br />
criteria were provided to the evaluation team by the<br />
agency manager. Individuals were then contacted by<br />
the evaluation team <strong>and</strong> invited to participate in an<br />
interview. Attempts were made to ensure that support<br />
workers from rural <strong>and</strong> urban areas were included<br />
in the sample.<br />
2.4.4 <strong>Support</strong>s Facilitators —<br />
procedure for data collection<br />
In-depth interviews were also conducted with<br />
19 <strong>Support</strong>s Facilitators to gain insights into the<br />
issues confronting this group. These <strong>Support</strong>s<br />
Facilitators were selected from across the state.<br />
In addition, 10 <strong>Support</strong>s Facilitators completed the<br />
<strong>Support</strong>s Facilitator Questionnaire. Questionnaires<br />
were left with every <strong>Support</strong>s Facilitator interviewed<br />
<strong>and</strong> they were asked to return the completed<br />
questionnaire to the evaluation team (anonymously)<br />
in the reply-paid enveloped provided. Ten of the<br />
19 <strong>Support</strong>s Facilitators returned completed<br />
questionnaires.<br />
2.4.5 <strong>Housing</strong> <strong>and</strong> Homelessness Services —<br />
procedure for data collection<br />
Data from <strong>Housing</strong> <strong>and</strong> Homelessness Services staff<br />
were collected using individual interviews <strong>and</strong> or focus<br />
group interviews. Questionnaire data was not collected<br />
due to the small number of HHS staff involved with<br />
<strong>HASP</strong>. Twenty-six (n=26) HHS staff from 14 <strong>Housing</strong><br />
Service Centres across Queensl<strong>and</strong> participated in<br />
either individual or group interviews.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
2.5 Data analysis<br />
2.5.1 Scale data<br />
The outcome of interest in the present study was<br />
the impact of <strong>HASP</strong> on the community adjustment of<br />
clients following entry into the program. As outlined,<br />
client outcomes data was downloaded from CIMHA<br />
<strong>and</strong> entered into the electronic statistical package —<br />
SPSS for Windows (Version 14). Following cleaning <strong>and</strong><br />
checking of the data for errors, items in each scale were<br />
recoded in the direction outlined by the developers of<br />
the individual scales. Sub-scale <strong>and</strong> total scale scores<br />
were computed <strong>and</strong> used in the analysis of data from<br />
that point onwards. Descriptive statistics (means,<br />
st<strong>and</strong>ard deviations, etc) were used to summarise the<br />
data. Repeated measures analyses of variance (ANOVA)<br />
were used to explore change on the different scales over<br />
the study period (i.e. 12 months, three months prior to<br />
<strong>HASP</strong> <strong>and</strong> three months <strong>and</strong> 12 months post-<strong>HASP</strong>).<br />
Given that a large number of tests were performed,<br />
Bonferroni correction of the alpha level was carried<br />
out to adjust for risk of Type I error (i.e. declaring a<br />
difference when one does not exist).<br />
2.5.2 Focus group <strong>and</strong> interview data<br />
The individual interviews enabled the participants<br />
to describe, in their own words, how they felt about<br />
a topic specifi c to the program. It is diffi cult to estimate<br />
the actual number of individuals to be included in<br />
interviews prior to commencing data collection.<br />
One usually continues data collection until a point<br />
of ‘saturation’ has been achieved (Rice <strong>and</strong> Ezzy,<br />
1999). This is the point where no new information is<br />
forthcoming <strong>and</strong> it would be pointless to continue<br />
interviewing new people beyond this point. It is<br />
common practice when reporting qualitative fi ndings<br />
to provide a section of the transcript (i.e. verbatim<br />
text) to support a given theme. It should be noted that<br />
generalisations cannot be made to a broader population<br />
of individuals from interviews (with a sample of the<br />
broader population). Nonetheless, while fi ndings can<br />
only be generalised to those interviewed, fi ndings are<br />
likely to have relevance for the broader study group.<br />
For example, if loneliness is a recurrent theme in the<br />
interviews with the majority of those interviewed,<br />
it is likely that loneliness is an issue for all people<br />
in the program.
All focus group discussions <strong>and</strong> individual interviews<br />
were audio-taped <strong>and</strong> transcribed by a research<br />
assistant for analysis. All transcriptions were then<br />
checked for errors against the taped version to ensure<br />
an accurate <strong>and</strong> authentic reproduction. Content<br />
analysis (Morse & Field, 1996) was then employed<br />
to guide analysis of the transcripts. The transcripts<br />
were reviewed several times to generate units of<br />
information that referred to common themes of the<br />
program. The fi ndings were then discussed with other<br />
members of the evaluation team who had read the<br />
transcripts. Agreement was then reached on the fi nal<br />
set of themes.<br />
2.5.3 Discussion of fi ndings<br />
As noted, the evaluation team was asked to investigate<br />
four key areas/objectives of interest. These included:<br />
the effectiveness of the collaborative process<br />
established across government agencies<br />
the process of providing clinical, non-clinical <strong>and</strong><br />
housing services to clients<br />
the opportunities available through the program<br />
for clients to maximise their recovery <strong>and</strong> participate<br />
in community life. The focus here will be on social,<br />
recreational, educational <strong>and</strong> vocational activities<br />
in the community<br />
the ability of the program to maintain clinical<br />
functioning <strong>and</strong> provide an acceptable quality<br />
of life for those supported by the program.<br />
In addition, we were asked to examine the cost<br />
of maintaining the program <strong>and</strong> how this compares<br />
with other residential <strong>and</strong> non-residential programs.<br />
Each objective is discussed in separate sections<br />
of the report as follows:<br />
Section 3 examines the effectiveness of the<br />
collaborative process established across government<br />
agencies <strong>and</strong> the governance arrangements<br />
established to support ongoing development <strong>and</strong><br />
delivery of <strong>HASP</strong>.<br />
Section 4 explores the process of providing clinical,<br />
non-clinical <strong>and</strong> housing services to clients <strong>and</strong> the<br />
extent to which <strong>HASP</strong> has been effective in delivering<br />
timely <strong>and</strong> coordinated clinical, non-clinical <strong>and</strong><br />
housing services.<br />
Section 5 examines the opportunities available<br />
through the program for clients to maximise their<br />
recovery <strong>and</strong> participate in community life. The main<br />
focus of this section is client involvement in social,<br />
recreational, educational <strong>and</strong> vocational activities<br />
in the community.<br />
Section 6 assesses the ability of the <strong>HASP</strong><br />
to maintain clinical functioning <strong>and</strong> provide<br />
an acceptable quality of life for those supported<br />
by the program<br />
Section 7 provides an assessment of the cost<br />
of maintaining the program <strong>and</strong> how this compares<br />
with other residential <strong>and</strong> non-residential programs.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
23
24<br />
Section 3<br />
The effectiveness of the collaborative process<br />
established across agencies<br />
The main issues discussed in this section of the report include the effectiveness of the<br />
governance arrangements established to support ongoing development <strong>and</strong> delivery<br />
of <strong>HASP</strong>, <strong>and</strong> the extent to which the program has been effective in delivering timely<br />
<strong>and</strong> coordinated clinical, non-clinical <strong>and</strong> housing services to clients. These issues are<br />
addressed, in large part, through the interview data collected from the staff <strong>and</strong> clients<br />
who participated in the individual interviews.<br />
3.1 Collaboration between government agencies<br />
There was overwhelming support for <strong>HASP</strong>.<br />
This support came from both staff <strong>and</strong> clients:<br />
We’re very pro <strong>HASP</strong>, I think I have to say that. Those<br />
individuals who have been fortunate enough to get<br />
a <strong>HASP</strong> package have gone really well <strong>and</strong> we think<br />
it’s a good process. Of course, like all processes,<br />
it can be refi ned <strong>and</strong> improved, but we’d hate to see<br />
it disappear.<br />
CCU worker<br />
Both clients <strong>and</strong> staff appreciated the holistic<br />
approach of <strong>HASP</strong>. It was identifi ed that the<br />
collaboration between the agencies enabled the<br />
program to meet the needs of individuals <strong>and</strong> assist<br />
them to adapt to life in the community:<br />
The best thing about <strong>HASP</strong> is the support. And<br />
the fact of being able to set myself up… if I had no<br />
support I would, oh mate… I’d be in that hospital<br />
quick as! Yeah it’s totally changed my life!<br />
Female client<br />
<strong>and</strong><br />
<strong>HASP</strong> is just fantastic… there are people living now<br />
in the community that would still be in hospital if it<br />
wasn’t for the agencies working together… working<br />
at providing the things that people want <strong>and</strong> need to<br />
keep them in the community.<br />
Case Manager<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
The majority of those who contributed to the<br />
evaluation (staff <strong>and</strong> clients) felt that an effective<br />
process of collaboration had been established<br />
between the different government <strong>and</strong> nongovernment<br />
agencies involved in <strong>HASP</strong>:<br />
…in terms of a network between agencies, <strong>and</strong> that<br />
is part of <strong>HASP</strong>, I think that is a great thing, <strong>and</strong> it’s<br />
a great thing for the clients, because generally there<br />
is more than one focus in their life <strong>and</strong> that involves<br />
other agencies, they need a house, they need health<br />
<strong>and</strong> support, so it allows them to have a team that<br />
works together, rather than giving them this, <strong>and</strong><br />
they have to sort the rest out on their own, <strong>and</strong><br />
that’s really hard, so I think that certainly that part<br />
of <strong>HASP</strong> is great.<br />
Metropolitan <strong>Support</strong>s Facilitator<br />
<strong>Housing</strong>, Health <strong>and</strong> us, we work really closely<br />
with XX, the agency that currently has the funds,<br />
we have respect for one another’s roles, <strong>and</strong> there’s<br />
a willingness of people to get together <strong>and</strong> work to<br />
achieve the best outcome for the person.<br />
Regional <strong>Support</strong>s Facilitator
However, it was clear that the development of a close<br />
working alliance between agencies took time <strong>and</strong><br />
effort to achieve. In some districts, relationships were<br />
diffi cult to develop <strong>and</strong> a lot of effort was required to<br />
establish these:<br />
We’ve tried to work really hard with the mental<br />
health unit to develop relationships so there is more<br />
trust between Disability Services <strong>and</strong> Queensl<strong>and</strong><br />
Health, <strong>and</strong> I have to say I think it has improved<br />
over the last three years or so, but that would be our<br />
biggest challenge <strong>and</strong> we’ve got some processes<br />
now in place that certainly help.<br />
NGO Service Coordinator<br />
The challenge for any program requiring interagency<br />
collaboration is to determine which agency is<br />
responsible for specifi c components of the program.<br />
Failure to do this can lead to misunderst<strong>and</strong>ings <strong>and</strong><br />
disputes between agency staff:<br />
We’ve sort of sat down <strong>and</strong> nutted out who’s<br />
responsible for what step in the whole process <strong>and</strong><br />
who takes the lead in certain parts, because in the<br />
early days it was a turf war… probably too strong<br />
a term, but there were some misunderst<strong>and</strong>ings<br />
in terms of whose responsibility was which, so we<br />
really had to do almost a formal process here…<br />
to determine joint underst<strong>and</strong>ing of what the<br />
process would involve <strong>and</strong> who takes responsibility<br />
<strong>and</strong> who does the communicating <strong>and</strong> all that sort<br />
of stuff, it just didn’t fl ow easily at all, for the fi rst<br />
couple of years…<br />
Regional <strong>Support</strong>s Facilitator<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
25
26<br />
Section 3 The effectiveness of the collaborative process<br />
established across agencies<br />
3.2 Governance arrangements established to support ongoing development<br />
<strong>and</strong> delivery of <strong>HASP</strong><br />
While those interviewed felt that the level of<br />
collaboration between the agencies was satisfactory,<br />
a number of concerns relating to the governance of<br />
<strong>HASP</strong> were identifi ed. These included (i) communication<br />
fl ows, (ii) the nomination process, <strong>and</strong> (iii) ongoing<br />
review of support packages.<br />
3.2.1 Communication fl ows<br />
Participants from all agencies highlighted problems<br />
arising from poor communication between the agencies,<br />
<strong>and</strong> individuals within agencies. This is not surprising<br />
given the complexity of the agencies involved with<br />
<strong>HASP</strong>. A range of barriers to good communication<br />
was identifi ed by those interviewed.<br />
These are discussed below.<br />
Moving between treating teams<br />
Clients transitioning to the community are likely to<br />
move between a number of care coordinators <strong>and</strong><br />
Case Managers. Case mangers can often be diffi cult<br />
to reach as they are often away from their desks <strong>and</strong><br />
many do not work st<strong>and</strong>ard 9–5 hours. In addition,<br />
some have days off mid-week, while others work<br />
across different services:<br />
In most cases, Qld Health are good, but if they<br />
change staff, <strong>and</strong> we don’t know who is in the new<br />
role, <strong>and</strong> it comes to <strong>HASP</strong> verifi cations <strong>and</strong> all of<br />
a sudden the person who did it last year, has been<br />
asked not to do it, <strong>and</strong> you think, oh, I had a great<br />
contact last year, now who do I ring? So it can be<br />
a little bit disjointed at the start of picking that piece<br />
of work up.<br />
Regional <strong>Support</strong>s Facilitator<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Agency structure<br />
All of the organisations involved with <strong>HASP</strong> have<br />
hierarchical structures that make it diffi cult to fi nd the<br />
right person to talk to when a crisis situation occurs.<br />
Even within the NGOs sector, there can be several<br />
layers between the person who works directly with the<br />
client <strong>and</strong> the manager or coordinator who liaises with<br />
the government agencies. Respondents appreciated<br />
having an identifi ed responsible contact at each<br />
agency, especially in the initial stages of moving<br />
a client into <strong>HASP</strong>:<br />
I think what worked well was to have that one<br />
person contact. And we found that out recently too,<br />
to have that liaison person— ‘Who do you contact?<br />
Oh you contact this person’. If you’re having<br />
problems with Dept of <strong>Housing</strong>, contact this person.<br />
If you’re having problems with the NGO, not getting<br />
one, or DSQ — contact this person. So that worked<br />
really well having that one contact person <strong>and</strong> to<br />
know who it was…sometimes we wouldn’t know<br />
who it was!<br />
Rural mental health facility staff member<br />
In some areas, the Service Integration Coordinator acts<br />
as a ‘bridge across the silos’ so as to bring the relevant<br />
stakeholders together:<br />
Health, <strong>Housing</strong> <strong>and</strong> MHS, we meet regularly, email<br />
regularly <strong>and</strong> talk regularly on the phone. It makes<br />
things run smoothly, for example one of the clients<br />
went up north, <strong>and</strong> when she came back, I knew<br />
before she was coming, so I got back in touch with<br />
the Case Manager, <strong>and</strong> we were able to manage it<br />
all very smoothly. If there are any issues, like with<br />
neighbours or anything, <strong>Housing</strong> will contact me<br />
very early in the confl ict <strong>and</strong> we set up a round-table<br />
meeting <strong>and</strong> talk over the problem, <strong>and</strong> talk with<br />
the client <strong>and</strong> we are able to sort things out before<br />
things go too far.<br />
Service Integration Coordinator
Importance of the <strong>Support</strong>s Facilitator Role<br />
There was a perception amongst all stakeholder<br />
groups that the move within DCCS to change the<br />
<strong>Support</strong>s Facilitator role as described in the reforms<br />
outlined in ‘Growing Stronger’ (2007–2011), may<br />
impact on communication <strong>and</strong> accountability:<br />
And I think the other thing with Disability Services<br />
is where you had a dedicated bunch of <strong>Support</strong>s<br />
Facilitators, now it appears it’s the same team that<br />
we deal with for all our other clients who have also<br />
taken a <strong>HASP</strong> client as well. So we don’t seem to<br />
have that dedicated bunch of <strong>Support</strong>s Facilitators.<br />
I don’t know how that will work because we don’t<br />
know the [other] <strong>Support</strong>s Facilitators very well<br />
so that’s a rough start. Whereas before there was<br />
a core group of <strong>Support</strong>s Facilitators who were<br />
involved with <strong>HASP</strong>.<br />
<strong>Housing</strong> Offi cer<br />
3.2.2 The nomination process<br />
A number of issues concerning the nomination process<br />
were raised amongst the different stakeholders<br />
interviewed. These included exp<strong>and</strong>ing the eligibility<br />
criteria, the arduous application process, the due<br />
date of applications, <strong>and</strong> the length of time between<br />
nomination <strong>and</strong> allocation of housing.<br />
Exp<strong>and</strong>ing the eligibility criteria<br />
Staff from both <strong>Housing</strong> <strong>and</strong> Homelessness Service<br />
<strong>and</strong> DCCS felt that there would be benefi ts from<br />
broadening the criteria to include those with diffi cult<br />
tenancies. There was a perception that inclusion of<br />
this group in <strong>HASP</strong> would provide early intervention<br />
<strong>and</strong> possibly prevent loss of housing <strong>and</strong> the<br />
subsequent need for hospitalisation:<br />
To also help those people who may already be<br />
tenants of Queensl<strong>and</strong> <strong>Housing</strong> <strong>and</strong> they’re facing<br />
eviction, <strong>and</strong> we have to say, ‘oh, we can’t have you<br />
in <strong>HASP</strong>, because you’re not eligible’ we have to have<br />
people completely decompensate, get re-admitted,<br />
at huge cost to the taxpayer, <strong>and</strong>, then we might be<br />
able to nominate you for <strong>HASP</strong>. I mean, I mean it’s<br />
insane, because we’re putting the ambulance down<br />
the bottom, rather than the fence on top in that<br />
regard, when we do have unspent (funds).<br />
<strong>Support</strong>s Facilitator<br />
Arduous application process<br />
Many people noted the arduous nature of completing<br />
the paperwork to nominate clients for <strong>HASP</strong>. The<br />
number of forms to be completed <strong>and</strong> the amount<br />
of supporting documentation required were diffi cult<br />
for some services to organise. Even relatively simple<br />
requirements, such as the need for a birth certifi cate<br />
in certain circumstances to apply for housing, can<br />
generate a number of phone calls <strong>and</strong> visits to a<br />
client’s home to locate such a document. In smaller<br />
teams, it can be diffi cult to fi nd an occupational<br />
therapist to do an assessment <strong>and</strong> get all the<br />
paperwork prepared:<br />
Unfortunately it does fall back to the allied health<br />
teams — certainly in our workplace — in completing<br />
the whole application, which everyone will know<br />
is a massive document ’cos not only is it the <strong>HASP</strong><br />
application <strong>and</strong> the allied health reports that come<br />
with it, it’s also the DS application as well, so we<br />
normally have a relatively short timeframe to do that<br />
<strong>and</strong> it’s an enormous amount of work on top of all of<br />
our clinical duties.<br />
Mental Health Worker<br />
Due date of applications<br />
Applications are usually due at the end of January.<br />
Districts usually have an earlier timeframe for local<br />
processing applications so that they are ready for the<br />
January deadline. The period mid-December to mid-<br />
January is a time when many staff take leave, <strong>and</strong> some<br />
services operate on reduced staffi ng numbers over the<br />
Christmas <strong>and</strong> New Year period. It has been suggested<br />
that the due date for applications could be brought<br />
forward, possibly to the end of November, to alleviate<br />
this problem.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
27
28<br />
Section 3 The effectiveness of the collaborative process<br />
established across agencies<br />
Length of time between nomination<br />
<strong>and</strong> allocation of housing<br />
An important issue for all participants is the length<br />
of time between the submission of the application<br />
<strong>and</strong> the client actually moving into the community.<br />
Many mental health workers described how clients<br />
fi nd this extremely frustrating <strong>and</strong> a major source<br />
of stress:<br />
I would say that there perhaps needs to be a quicker<br />
processing <strong>and</strong> turning around so that once you<br />
get the package there’s a…there are movements<br />
straight away…because otherwise it becomes a bit<br />
like pie in the sky <strong>and</strong> it’ll never happen, kind of<br />
thing. And I think that’s what’s happened in a few<br />
cases where it’s been such a long drawn out process<br />
that people have actually gone ‘oh stuff it’. And I’m<br />
talking about consumers actually disengaging <strong>and</strong><br />
saying ‘uhh, you know you promise the world, but<br />
you come up with nothing, I’m not interested’.<br />
Mental Health Worker<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
3.2.3 Ongoing review of support packages<br />
It was identifi ed that a regular review of support<br />
packages was required to ensure that the support<br />
provided by NGOs was in keeping with client needs.<br />
The <strong>HASP</strong> process fl owchart suggests that <strong>Support</strong>s<br />
Facilitators (SFs) in regional offi ces provide a review<br />
‘when required’. However, it is unclear how this will<br />
work in the future given the changes to the <strong>Support</strong>s<br />
Facilitator role under the reforms outlined in<br />
‘Growing Stronger’ (2007–2011).<br />
Until recently, <strong>Support</strong>s Facilitators were able to<br />
review the level of support being provided <strong>and</strong> ask<br />
or alterations in support (increase or decrease)<br />
if deemed necessary:<br />
The beauty of the role of the <strong>Support</strong>s Facilitator<br />
is I can go in <strong>and</strong> ask really hard questions, <strong>and</strong><br />
if they hate me, it doesn’t matter, I can come in as<br />
the Big Bad wolf, <strong>and</strong> say “Well… what’s stopping<br />
you going <strong>and</strong> doing your shopping, by yourself?”<br />
whereas the support services saying it, or Qld<br />
Health saying it, [clients] can get a bit ‘oh, I don’t<br />
like you, <strong>and</strong> I’m not talking to you anymore’. You<br />
don’t want to have them in that position, so I mean,<br />
that has been one of my roles here at times,<br />
is getting called in as the Big Bad Wolf to say ‘No,<br />
that is not happening’. Like people wanting to get<br />
driven all over the place <strong>and</strong> all that sort of stuff,<br />
because I can go in <strong>and</strong> say ‘No, sorry, that is not<br />
the purpose of this expenditure’.<br />
Regional <strong>Support</strong>s Facilitator
Accountability<br />
There was a perception among <strong>Support</strong>s Facilitators<br />
that there needs to be more accountability <strong>and</strong><br />
transparency around the levels of support provided.<br />
<strong>Support</strong>s Facilitators cited situations where support<br />
shifts/hours were not being fi lled <strong>and</strong> were asking<br />
who was overseeing the process:<br />
Say someone gets verifi ed for 30 hours a week,<br />
that’s really nice, but they may not need 30 hours<br />
a week ongoing, but there is no mechanism in place<br />
whereby we really look at that regularly, like how<br />
much support is a person using, are they being over<br />
supported, making them more dependant, <strong>and</strong> are<br />
we entrapping them?<br />
<strong>Support</strong>s Facilitator<br />
There were also concerns around the transfer of clients<br />
between agencies. It was pointed out that under<br />
‘block’ funding it was much more diffi cult for clients<br />
to move from one agency to another. The agency<br />
transferring the client keeps the funding for that client<br />
so that the receiving agency has to have enough<br />
funding capacity to support the new client. As a result,<br />
it can be diffi cult for clients on large packages to move<br />
between agencies.<br />
Care Planning<br />
Care planning is an important component in the<br />
provision of a coordinated approach to the delivery<br />
of services. A number of stakeholders noted that<br />
some clients can have three care plans — a transition<br />
plan, a plan developed by clinical services <strong>and</strong> a plan<br />
developed by the support agency:<br />
We have a situation where some of the clients have<br />
three care plans – I know that sounds unusual <strong>and</strong><br />
it would be better if we had one… <strong>and</strong> all used that<br />
as a reference point. It appears that each provider<br />
prefers to have their own plan<br />
Case Manager<br />
It was suggested by a number of the staff interviewed<br />
that it would be much more effective for each individual<br />
to have a single care plan which is developed with input<br />
from all stakeholders including the client. This care plan<br />
should be used to guide interventions with the client<br />
<strong>and</strong> be reviewed <strong>and</strong> updated on a regular basis —<br />
at least every three months.<br />
Transport costs<br />
Approximately two-thirds of clients indicated that<br />
their support agency/support workers provide them<br />
with transport. The payment of support agencies/<br />
workers for this service does raise some concerns.<br />
In some situations, it was noted that the client pays<br />
the support worker directly for the transport. In others,<br />
support workers transport clients free of charge <strong>and</strong><br />
claim the cost in their annual tax return as a work<br />
related deduction. <strong>Final</strong>ly, some agencies take<br />
funding from the client’s <strong>HASP</strong> package to fund<br />
transport costs. Clarity needs to be provided on the<br />
most appropriate approach for managing transport<br />
costs/reimbursement.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
29
30<br />
Section 3 The effectiveness of the collaborative process<br />
established across agencies<br />
3.3 Perceptions of agency collaboration —<br />
Case Manager, support workers <strong>and</strong> <strong>Support</strong>s Facilitators<br />
One of the questions included in the surveys<br />
completed by Case Managers (n=40), support<br />
workers (n=58) <strong>and</strong> <strong>Support</strong>s Facilitators (n=10)<br />
asked about their perceptions of how well the<br />
government agencies work together.<br />
Participants were asked to rate the statement<br />
‘Agencies such as <strong>Housing</strong> <strong>and</strong> Homelessness<br />
Services, Disability <strong>and</strong> Community Mental Health<br />
Services work well together to support <strong>HASP</strong> clients’.<br />
Their responses are summarised below (Fig. 3.1).<br />
Fig. 3.1 Agencies work well together to support<br />
<strong>HASP</strong> clients<br />
Percent<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Legend<br />
Strongly<br />
agree<br />
Almost 63% of Case Managers <strong>and</strong> 52% of support<br />
workers <strong>and</strong> 90% of <strong>Support</strong>s Facilitators agreed that<br />
all the agencies worked well to support <strong>HASP</strong> clients.<br />
In response to open-ended questions, Case Managers<br />
identifi ed that communication between all key<br />
stakeholders was of paramount importance <strong>and</strong><br />
in most instances it works well.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Agree<br />
Case<br />
Managers<br />
Neither<br />
<strong>Support</strong><br />
workers<br />
Disagree<br />
Strongly<br />
disagree<br />
<strong>Support</strong>s<br />
Facilitators<br />
3.3.1 Factors impacting on the ability of<br />
Case Managers, support workers <strong>and</strong><br />
<strong>Support</strong>s Facilitators to work with clients<br />
Clinical <strong>and</strong> support staff were also asked to respond<br />
to the statement ‘There are things that I would like<br />
to do for my <strong>HASP</strong> clients, but I am unable to’. The<br />
responses from the groups are compared in the<br />
graph below.<br />
Fig. 3.2 Ability of staff to work with <strong>HASP</strong> clients<br />
Percent<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Legend<br />
Strongly<br />
agree<br />
Agree<br />
Case<br />
Managers<br />
Neither<br />
<strong>Support</strong><br />
workers<br />
Disagree<br />
Strongly<br />
disagree<br />
<strong>Support</strong>s<br />
Facilitators<br />
Overall, 29% of case mangers <strong>and</strong> 44% of support<br />
workers agreed that there were things they wanted<br />
to do for their clients, but were unable to provide these.<br />
In the additional comments received, Case Managers<br />
highlighted the impact of time constraints, increased<br />
workload <strong>and</strong> lack of staffi ng on their ability to provide<br />
more support to their <strong>HASP</strong> clients. Some of them<br />
noted that the <strong>HASP</strong> clients were at the severe end<br />
of the disability scale <strong>and</strong> that many of these required<br />
additional support with medication supervision,<br />
emotional support <strong>and</strong> symptom management.<br />
Others noted that many clients had physical conditions<br />
that required signifi cant time <strong>and</strong> attention.
<strong>Support</strong> workers highlighted issues with transport,<br />
lack of money, <strong>and</strong> lack of motivation in their clients.<br />
Lack of motivation in clients was mentioned by<br />
most of the support workers. Some support workers<br />
described how they frequently try to encourage clients<br />
to exercise, become involved in the community, <strong>and</strong><br />
introduce clients to a new hobby/activity, but the<br />
clients showed little or no motivation.<br />
3.3.2 Case Manager <strong>and</strong> <strong>Support</strong>s Facilitator<br />
views of <strong>HASP</strong> support<br />
Case Managers <strong>and</strong> <strong>Support</strong>s Facilitators were asked<br />
to rate the statement ‘client needs are currently met<br />
through <strong>HASP</strong>’. (The statement was rated in the<br />
negative, <strong>and</strong> responses have been reversed).<br />
It should be noted that there were only 10 <strong>Support</strong>s<br />
Facilitators who responded to this question.<br />
Fig. 3.1.3 Client needs are currently met by <strong>HASP</strong><br />
Percent<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Legend<br />
Strongly<br />
agree<br />
Agree<br />
Case<br />
Managers<br />
Neither<br />
<strong>Support</strong>s<br />
Facilitators<br />
Disagree<br />
Strongly<br />
disagree<br />
Some 58% of Case Managers agreed that client needs<br />
are currently met through <strong>HASP</strong>. However, only 40%<br />
of <strong>Support</strong>s Facilitators agreed with the statement.<br />
Case Managers reported that <strong>HASP</strong> had met most of<br />
their clients’ needs, although some reported that basic<br />
domestic, self-care <strong>and</strong> budget management skills<br />
were lacking in many <strong>HASP</strong> clients. Some of the Case<br />
Managers commented that most support workers were<br />
excellent <strong>and</strong> provided ‘assistance to a group of people<br />
with severe problems on a daily basis’.<br />
However, there were some who were perceived as not<br />
being consistent in their approach to service provision.<br />
Some tended to have considerable sick leave <strong>and</strong><br />
others seemed ‘to do too much for the clients which<br />
may give rise to dependency’.<br />
3.4 Section summary<br />
All of those interviewed expressed very positive views<br />
of <strong>HASP</strong>. The overall model of having key government<br />
agencies (HHS, DCCS, <strong>and</strong> QH) <strong>and</strong> NGOs working<br />
in collaboration appears to be effective in providing<br />
the infrastructure to support community adaptation<br />
for individuals with psychiatric disability. However,<br />
it is clear that government agencies come to the<br />
project with different philosophies, different<br />
backgrounds <strong>and</strong> underst<strong>and</strong>ings of what constitutes<br />
the most effective approach for providing mental<br />
health <strong>and</strong> support services. While those interviewed<br />
felt that collaboration between the agencies had<br />
improved over time, there were a number of issues<br />
around the governance of the program that require<br />
attention. These issues include communication<br />
between agencies <strong>and</strong> individuals, the nomination<br />
process for entry into <strong>HASP</strong>, <strong>and</strong> ongoing review of<br />
support packages.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
31
32<br />
Section 4<br />
The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
This section of the report examines service provision <strong>and</strong> the extent to which <strong>HASP</strong><br />
has been effective in delivering timely <strong>and</strong> coordinated clinical, non-clinical <strong>and</strong> housing<br />
services. The costs <strong>and</strong> benefi ts of providing coordinated clinical <strong>and</strong> non-clinical support<br />
<strong>and</strong> appropriate housing to clients through <strong>HASP</strong> are also examined.<br />
4.1 Process of providing clinical services<br />
Clinical services within <strong>HASP</strong> are largely provided by Case Managers employed through Queensl<strong>and</strong> Health.<br />
(Only a small proportion of the <strong>HASP</strong> clients had a GP as their primary mental health provider). Forty Case<br />
Managers responded to a questionnaire which gathered data on their background <strong>and</strong> perceptions of <strong>HASP</strong>.<br />
A greater proportion of Case Managers from Queensl<strong>and</strong> Health’s Metro North <strong>and</strong> Metro South Districts<br />
responded to the questionnaire. This is in keeping with the greater proportion of <strong>HASP</strong> clients settled<br />
in these regions.<br />
Fig. 4.1.1 Location of Case Managers<br />
Percent<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
Metro<br />
North<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Metro<br />
South<br />
Cairns<br />
Gold<br />
Coast<br />
Sunshine<br />
Coast<br />
Toowoomba<br />
Townsville<br />
Central<br />
Queensl<strong>and</strong><br />
Approximately 61% of those who completed the questionnaire were female <strong>and</strong> 31.6% were in the 41–50 age group.<br />
The average length of time they had been employed in the mental health fi eld was 12 years <strong>and</strong> they had been<br />
working in the role for an average of 5.7 years. They had been working with <strong>HASP</strong> for 2.4 years. The group was<br />
made up of nurses (52.6%), occupational therapists (21.1%), social workers (18.4%) <strong>and</strong> psychologists (7.9%).<br />
4.1.1 Number of Case Managers in the past 12 months<br />
Stability in service provider was also assessed. Clients were asked to outline the number of Case Managers they<br />
had had in the previous 12 months. As outlined in the graph below, only 6% of clients had the same Case Manager<br />
for the entire 12 months. While 43% had two Case Managers, 31% had three Case Managers in the previous<br />
12 months. However, it should be noted that some clients may have had two or more Case Managers due to<br />
their permanent Case Manager taking annual leave, etc.<br />
Fig. 4.1.2 Number of changes in Case Manager in past 12 months<br />
Percent<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
One<br />
Two<br />
Three<br />
Four<br />
Five<br />
Six<br />
Seven
4.1.2 Client perceptions of support received from case manger<br />
We invited clients to rate a number of statements concerning their interactions with their Case Manager.<br />
These cover areas such as perceptions of Case Manager role, Case Manager underst<strong>and</strong>ing of client,<br />
amount of time spent with Case Manager, <strong>and</strong> medications (see Table below).<br />
Table 4.1 Client perceptions of support received from Case Manager<br />
Statement Strongly<br />
Agree %<br />
a. I can get in contact with my Case Manager<br />
if I have a problem.<br />
b. My Case Manager helps me<br />
with my symptoms.<br />
c. My Case Manager helps me to<br />
function better.<br />
d. My Case Manager underst<strong>and</strong>s<br />
my problems.<br />
Agree<br />
%<br />
Neither<br />
%<br />
Disagree<br />
%<br />
Strongly<br />
Disagree %<br />
41.6 47.2 5.6 5.6 –<br />
18.3 43.7 18.3 16.9 2.8<br />
21.1 43.7 19.7 14.1 1.4<br />
31.4 47.1 8.6 11.4 1.4<br />
e. My Case Manager treats me with respect. 34.7 55.6 2.8 4.2 2.8<br />
f. I would like my Case Manager to spend<br />
more time with me.<br />
12.5 29.2 27.8 20.8 9.7<br />
g. I know what my medications are for. 45.1 46.5 1.4 5.6 1.4<br />
h. I know the side-effects of my medications. 30.6 44.4 8.3 12.5 4.2<br />
Overall, while there was considerable dispersion in the data, responses indicate that clients hold positive views<br />
of their Case Manager. Most clients (89%) indicated that they could get in contact with their Case Manager if they<br />
had a problem <strong>and</strong> 62% believed that their Case Manager helped them with their symptoms. Over 78% of clients<br />
felt that their Case Manager understood their problems, <strong>and</strong> 91% claimed to know what their medications were<br />
used for. While over 40% of clients wanted their Case Manager to spend more time with them, over 30% felt that<br />
they had enough time with their Case Manager.<br />
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Section 4 The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
4.1.3 Case Manager involvement with <strong>Support</strong> Services<br />
A key focus of the evaluation was the working relationship <strong>and</strong> coordination between service providers.<br />
Case Managers (n=40) were asked to rate a number of statements concerning their interactions with support<br />
workers (Table 4.2 below). These statements related to information transfer, perceptions of support worker<br />
contribution, support worker involvement in the development of care plans, <strong>and</strong> issues around recovery.<br />
Table 4.2 Case Manager interactions with support workers<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Statement Strongly<br />
Agree<br />
(%)<br />
a. <strong>Support</strong> workers give me as much information<br />
as I need.<br />
b. I am comfortable questioning support workers<br />
about information they give me.<br />
c. I would like to have more say in the support<br />
services provided to <strong>HASP</strong> clients.<br />
d. I feel that support workers should have more<br />
training to be able to work effectively with<br />
<strong>HASP</strong> clients.<br />
e. I wish that I knew more about the concept<br />
of ‘recovery’.<br />
f. I generally engage support workers<br />
in the development of treatment plans<br />
for <strong>HASP</strong> clients.<br />
g. <strong>Support</strong> workers have an important role<br />
to play in the treatment planning process.<br />
h. I ensure that support workers are familiar<br />
with treatment goals for each <strong>HASP</strong> client.<br />
i. Generally, I fi nd that support workers are<br />
familiar with the principles of ‘recovery’.<br />
j. <strong>Housing</strong> staff are easy to contact when I need<br />
to discuss client accommodation issues.<br />
Agree<br />
(%)<br />
Neither<br />
(%)<br />
Disagree<br />
(%)<br />
Strongly<br />
Disagree<br />
(%)<br />
30.0 47.5 17.7 5.0 –<br />
37.5 50.0 12.5 – –<br />
20.0 35.0 42.5 2.5 –<br />
40.0 42.5 12.5 5.0 –<br />
7.5 15.0 25.0 40.0 12.5<br />
22.5 57.5 17.5 2.5 –<br />
37.5 55.0 7.5 – –<br />
30.0 60.0 10.0 – –<br />
7.5 52.5 25.0 15.0 –<br />
10.0 32.5 35.0 15.0 7.5<br />
k. I value the support worker role. 55.0 40.0 5.0 – –<br />
l. I trust the information support workers give me. 37.5 50.0 10.0 2.5 –<br />
m. I wish that I knew more about the rehabilitation<br />
of people with psychiatric disability.<br />
– 15.0 42.5 25.0 17.5
In general, Case Managers expressed positive views<br />
of support workers <strong>and</strong> the services they provide.<br />
Over half of the Case Managers (55%) wanted a greater<br />
say in the support services provided to <strong>HASP</strong> clients.<br />
In addition, 82.5% of Case Managers felt that support<br />
workers should have more training to be able to work<br />
effectively with <strong>HASP</strong> clients. Ninety-fi ve percent<br />
outlined that they valued the support worker role<br />
<strong>and</strong> that support workers have a valuable role to play<br />
in the treatment planning process (92%). <strong>Final</strong>ly,<br />
42% of Case Managers felt that housing staff were<br />
easy to contact when they need to discuss client<br />
accommodation needs.<br />
4.1.4 Client views of clinical service provision<br />
As outlined previously, 12 clients participated in<br />
individual interviews to assess their perceptions of<br />
the program. Clients expressed mostly positive views<br />
of their Case Manager. Most linked improvement in<br />
their mental health to skills of their Case Manager:<br />
I still have contact with her. Yep. And she’s the only<br />
one that I ever really, umm, made any progress<br />
<strong>and</strong> things just progressed from — from when I met<br />
her <strong>and</strong> I just got weller <strong>and</strong> weller <strong>and</strong> it was with<br />
her support.<br />
There was also a perception that clients have some<br />
say in the amount of contact they have with their<br />
Case Manager. Most clients get a visit from their Case<br />
Manager once every two weeks. As clients improve,<br />
the frequency of visits tends to decrease:<br />
My Case Manager pops around <strong>and</strong> asks me how<br />
I’m going <strong>and</strong> do I need anything. She said ‘How<br />
often do you want me to come around?’, I just sort<br />
of said, oh probably once a month’s fi ne.<br />
Regional male client<br />
4.1.5 <strong>Support</strong> staff views of clinical service provision<br />
Consistency in Case Manager was seen as important<br />
for continuity of care. Having a regular Case Manager<br />
seemed to reduce confusion <strong>and</strong> provide a more stable<br />
approach to clinical service provision:<br />
We’ve got some long-term Case Managers though<br />
here in XX (town), that certainly helps, a lot of<br />
our <strong>HASP</strong> individuals have maintained their Case<br />
Manager for two or three years, <strong>and</strong> that always<br />
helps to have that consistency there.<br />
Regional <strong>Support</strong>s Facilitator<br />
<strong>Support</strong> workers expressed a desire to have more<br />
contact with Case Managers <strong>and</strong> felt that they had<br />
a lot to offer since they spend much more time with<br />
clients than any other group. However, some felt<br />
uncomfortable discussing clients in the co-ordination<br />
meetings:<br />
Yeah, I would defi nitely like a bit more of a chat with<br />
the Case Manager <strong>and</strong> stuff – ’cos the care<br />
co-ordination meetings…it’s just like once every three<br />
months…. I just don’t necessarily think that there’s<br />
that sort of cohesiveness that there needs to be for<br />
people to be able to effectively work together. You<br />
know it’s all well <strong>and</strong> good us meeting every three<br />
months, but yeh, you know it’s…I guess we’re all<br />
looking at it from different angles as well …<br />
I’m the one who’s going to see the client on a day-today<br />
basis <strong>and</strong> see him in his home environment <strong>and</strong><br />
everything. I know him better than anyone else.<br />
Metropolitan support worker<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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Section 4 The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
4.2 Process of providing non-clinical<br />
support services<br />
Each client returning to the community received a<br />
package of care consisting disability/lifestyle support<br />
services in keeping with their needs. Fifty-two nongovernment<br />
organisations from across the state have<br />
been engaged to provide these disability support<br />
services to all of the clients in <strong>HASP</strong>. (It should be<br />
noted that 32 agencies provide services to the subsample<br />
of 80 clients enrolled in the evaluation).<br />
4.2.1 Preparation for role as <strong>HASP</strong> support worker<br />
<strong>Support</strong> workers were asked about their level of<br />
training for their role as a support worker. Almost<br />
40% indicated that they required more training<br />
for their role as a support worker.<br />
Fig. 4.2.1 Perceptions of training for role<br />
as a support worker<br />
Percent<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Strongly<br />
agree<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Agree<br />
Neither<br />
<strong>Support</strong> workers<br />
Disagree<br />
Strongly<br />
disagree<br />
Thirty-four support workers provided details of<br />
the additional training that they felt was required.<br />
The topics suggested were categorised under<br />
fi ve key areas:<br />
(i) information/training on clinical issues —<br />
(psychiatric conditions, symptoms,<br />
medications, side-effects).<br />
(ii) skill development in strategies to deal<br />
with behaviours, such as anger, aggression,<br />
substance misuse, etc.<br />
(iii) information/skills for dealing with crisis situations,<br />
such as self-harm, suicide <strong>and</strong> self-neglect.<br />
(iv) training in basic counselling skills <strong>and</strong><br />
interventions to promote client motivation<br />
(e.g. motivational interviewing).<br />
(v) information/training in the concept of recovery<br />
<strong>and</strong> how this could be applied when working<br />
with <strong>HASP</strong> clients.
4.2.2 Client perceptions of the amount of ‘help’ they receive from support workers<br />
Clients (n=80) were asked to consider a number of activities <strong>and</strong> rate the amount of assistance they receive<br />
from support workers for each activity. Three response options were available — ‘a lot of help’, ‘some help’<br />
<strong>and</strong> ‘no help’ (see Table below).<br />
Table 4.2.1 Rating of help received from support workers<br />
Activity<br />
Amount of help clients receive<br />
from support workers<br />
A lot of<br />
help %<br />
Some<br />
help %<br />
No<br />
help %<br />
a. Personal hygiene/care (e.g. showering, brushing teeth) 10.4 3.9 85.7<br />
b. Diet (food purchasing <strong>and</strong> preparation) 10.4 40.3 49.3<br />
c. Exercise 20.8 36.4 42.8<br />
d. Taking medication 24.7 23.4 51.9<br />
e. Cooking 15.6 29.9 54.5<br />
f. Cleaning 19.5 44.2 36.3<br />
g. Shopping 37.7 37.7 24.6<br />
h. Laundry 15.6 32.5 51.9<br />
i. Transportation (i.e. getting to places) 50.6 27.3 22.1<br />
j. Budgeting /banking 20.7 32.5 46.8<br />
k. Use of community services (e.g. library, Centrelink) 24.7 50.6 24.7<br />
l. Making appointments 23.4 59.7 16.9<br />
m. Social /community activities 28.6 48.1 23.4<br />
n. Accessing training or education 15.1 28.8 56.2<br />
o. Finding work (paid or unpaid) 17.3 25.3 57.3<br />
p. Acts as a companion 35.1 48.1 16.9<br />
The results indicate that clients continue to require considerable assistance with basic chores, such as cooking,<br />
cleaning, shopping <strong>and</strong> making appointments. Over 50% indicated that they receive a ‘lot of help’ from support<br />
workers with transport. Shopping was the next activity with high input from support workers, with almost<br />
38% of clients indicating that they required a ‘lot of help’ with shopping. <strong>Final</strong>ly, 35% of clients felt that<br />
support workers offer a lot of help in providing companionship to clients.<br />
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Section 4 The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
Turning to low support activities, 86% of clients indicated that they required ‘no help’ with hygiene.<br />
Other activities for which clients required ‘no help’ included fi nding work (57%), accessing education (56%),<br />
cooking (54%) <strong>and</strong> taking medications (52%).<br />
It should be noted that the list of activities was rather task-orientated <strong>and</strong> support workers provide a range<br />
of emotional support <strong>and</strong> advocacy interventions that were not captured.<br />
4.2.3 <strong>Support</strong> worker involvement in decision-making around service provision<br />
From our previous evaluation of the ‘Project 300’ <strong>Program</strong>, we found that the services provided by support<br />
workers were instrumental in maintaining clients in their chosen community (Meehan et al., 2011). However,<br />
for support workers to be effective, they must be engaged in decision-making around key aspects of the<br />
services provided. The Table below provides support worker ratings of their involvement in decision-making<br />
around client care.<br />
Table 4.2.2 <strong>Support</strong> worker involvement in decision-making (n=58)<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Statement Strongly<br />
Agree<br />
(%)<br />
a. From my interactions with Case Managers<br />
I feel that I have an important role in the<br />
treatment process.<br />
b. Case Managers have given me as much<br />
information as I have needed.<br />
c. I am comfortable questioning Case<br />
Managers about advice they give me.<br />
d. I would like to have more say in the<br />
services that my <strong>HASP</strong> clients/receive.<br />
e. I need more training to be able to work<br />
effectively with my <strong>HASP</strong> clients.<br />
f. I often wish that I knew more about mental<br />
illness when I talk with Case Managers.<br />
g. I am asked to be involved when the<br />
treatment plans for my <strong>HASP</strong> clients are<br />
being developed.<br />
h. I am familiar with the principles<br />
of ‘recovery’.<br />
i. I am familiar with the treatment goals<br />
for each of my <strong>HASP</strong> clients.<br />
j. I need more training in the concept of<br />
‘recovery’.<br />
k. It is often harmful to have too high<br />
expectations for clients.<br />
Agree<br />
(%)<br />
Neither<br />
(%)<br />
Disagree<br />
(%)<br />
Strongly<br />
Disagree<br />
(%)<br />
31.0 48.3 13.8 5.2 1.7<br />
17.2 37.9 19.0 19.0 6.9<br />
19.0 58.6 8.6 12.1 1.7<br />
15.5 46.5 32.8 5.2 –<br />
8.7 37.9 24.1 27.6 1.7<br />
6.9 32.8 20.7 36.2 3.4<br />
3.4 31.0 19.0 34.5 12.1<br />
25.9 60.3 6.9 6.9 –<br />
24.1 65.6 6.9 1.7 1.7<br />
3.4 34.5 37.9 19 5.2<br />
22.4 34.5 19.0 17.2 6.9
<strong>Support</strong> workers felt, as a result of their interactions<br />
with Case Managers, that they had an important role<br />
to play in the treatment process. However, just over<br />
half (54%) agreed that Case Managers had provided<br />
them with as much information as they needed. Six in<br />
every 10 support workers expressed a desire to have<br />
a greater say in the services provided to <strong>HASP</strong> clients.<br />
Almost half (45%) felt that they needed more training<br />
to be able to work effectively with their <strong>HASP</strong> clients.<br />
Only one-third of support workers indicated that they<br />
were involved in developing treatment plans for clients.<br />
4.2.4 Client satisfaction with the activities provided<br />
by support workers<br />
Overall, 85% of clients were satisfi ed/very satisfi ed<br />
with the activities that support workers do for/with<br />
them. Most highlighted the important role played by<br />
support workers <strong>and</strong> acknowledged that they would<br />
not be able to survive in the community without the<br />
interventions provided by support workers (Fig. 4.2.2).<br />
Fig. 4.2.2 Satisfaction with support workers<br />
Percent<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Very<br />
satisfied<br />
Satisfied<br />
Neither<br />
Satisfaction with support workers<br />
Dissatisfied Very<br />
Dissatisfied<br />
A small number of clients were dissatisfi ed with<br />
support workers/agencies for not providing transport.<br />
They felt that they should not have to pay for support<br />
workers to transport them to places of interest. Others<br />
outlined that they had no time to themselves because<br />
support workers were constantly ‘coming <strong>and</strong> going’.<br />
4.2.5 Lack of support <strong>and</strong> activities<br />
Clients were asked to consider the amount of support<br />
provided to them <strong>and</strong> indicate how frequently did lack<br />
of support prevent them from doing things that they<br />
would like to do. Three response options were available<br />
— ‘almost always’, ‘sometimes’ <strong>and</strong> ‘never’. Responses<br />
are provided in the graph below.<br />
Fig. 4.2.3 Lack of support <strong>and</strong> activities<br />
Percent<br />
50<br />
45<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
Never<br />
Sometimes<br />
Prevented from doing activities<br />
Almost always<br />
The fi ndings indicate that 16% of clients felt that lack<br />
of support prevented them from doing things that they<br />
would like to do. However, a much larger proportion<br />
(47%) indicated that lack of support prevented them<br />
from doing things ‘sometimes’.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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Section 4 The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
4.2.6 Changes in support workers in the<br />
past 12 months<br />
Clients were again asked to provide information about<br />
the number of different support workers that they had<br />
had in the past 12 months. Almost one-third had no<br />
change in support staff in the previous 12 months<br />
(this was 6% for Case Managers). However, one client<br />
claimed to have had eight changes of support worker<br />
in the past 12 months (see Fig. 4.2.4).<br />
Fig. 4.2.4 Change in support workers during the past<br />
12 months<br />
Percent<br />
40<br />
30<br />
20<br />
10<br />
0<br />
No<br />
Change<br />
One<br />
Two<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Three<br />
Four<br />
Five<br />
Six<br />
Seven Eight<br />
Change in support workers in past 12 months<br />
4.2.7 Change in support intensity (support hours)<br />
between entry into <strong>HASP</strong> <strong>and</strong> follow-up<br />
Data concerning the number of hours of disability<br />
support allocated to each client, on a weekly basis,<br />
was collected from support agencies. <strong>Support</strong><br />
agencies were asked to provide the number of hours<br />
of support allocated to each <strong>HASP</strong> client for two timepoints<br />
— when they commenced in <strong>HASP</strong>, <strong>and</strong> again<br />
at the time of follow-up (Mar–July 2010). Change<br />
in the weekly support hours was assessed using<br />
Paired t-tests. Data for this variable was available for<br />
56 clients across the two time-points (see Table below).<br />
Table 4.2.3 Change in support hours provided over<br />
study period (n=56)<br />
Weekly<br />
support hours<br />
on entry into<br />
<strong>HASP</strong> (n=56)<br />
Mean = 27.62<br />
(sd. = 15.78)<br />
(range = 3.0<br />
to 87.5)<br />
Weekly<br />
support hours<br />
at follow-up<br />
(n=56)<br />
Mean = 20.49<br />
(sd. = 14.06)<br />
(range= 0<br />
to 77.0)<br />
Test<br />
statistic<br />
Paired<br />
t = – 4.46,<br />
df = 55,<br />
p=.001<br />
There was a statistically signifi cant decrease in the<br />
number of hours of disability support provided each<br />
week (Paired t= – 4.46, p=.002). <strong>Support</strong> hours<br />
provided each week decreased by an average of 7.13<br />
hours from a mean of 27.6 hours on entry into <strong>HASP</strong><br />
to a mean of 20.4 hours at the follow-up time-point.<br />
Indeed, the range in support provided decreased<br />
from 3–87.5 hours on entry into <strong>HASP</strong> to 0–77 hours<br />
at follow-up.
4.2.8 Amount of support required in the future<br />
Clients were asked to think about the amount of<br />
support they currently receive from their support<br />
workers <strong>and</strong> indicate the amount of support they<br />
would require in the next 12 months. The options<br />
were ‘more support’, ‘less support’ or the ‘same<br />
amount of support’. The responses are summarised<br />
in the graph below.<br />
Fig. 4.2.5 Perceptions of support required<br />
in the future<br />
Percent<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
More<br />
Same<br />
Amount of support in future<br />
Less<br />
Over one-third (37%) indicated that they would require<br />
more support in the next 12 months, while almost<br />
one-fi fth (19%) felt that they would require the same<br />
level of support that they currently receive. However,<br />
over 40% felt that they would require less support in<br />
the future.<br />
4.2.9 Client perceptions of non-clinical<br />
support services<br />
Clients were very satisfi ed by the support services<br />
provided by the NGO sector. They felt that their<br />
success in community living was, in part, attributed<br />
to their support agency. There was a perception that<br />
support agencies encouraged clients to participate<br />
in community activities:<br />
Since my last time in hospital, I’ve been here [in<br />
own home] for two years now, I haven’t had a<br />
hospitalisation yet, <strong>and</strong> there was one year I was in<br />
hospital nine times. I was pretty lost <strong>and</strong> since then,<br />
being involved with [XX support agency], they pushed<br />
me along, to get back…got me back to being involved<br />
in the community, be my friend, <strong>and</strong> helping me feel<br />
a lot better about my life now.<br />
Male consumer<br />
It is clear that while support workers assist clients<br />
with a number of activities necessary for daily living,<br />
they also provide social support to many clients:<br />
No I wouldn’t be able to do it without the support<br />
workers. Just the social interaction, like having a<br />
cuppa, talking about the day’s events <strong>and</strong> what I’m<br />
doing for the next week. Even to just watch a DVD<br />
or share a meal it’s just the social side of it… Yeah…<br />
So that’s very important.<br />
Female consumer<br />
4.2.10 Case Manager perceptions<br />
of non-clinical support services<br />
Case Managers were appreciative of the support<br />
provided by the NGO sector. There was a perception<br />
that <strong>HASP</strong> in general, <strong>and</strong> the input from support<br />
workers in particular, had resulted in a more stable<br />
lifestyle for clients. Refl ecting on the benefi ts of the<br />
program, a Case Manager detailed how <strong>HASP</strong> had<br />
assisted one of his clients:<br />
It seems to take a signifi cant load off, because<br />
the client is a much more stable, gets an awful lot<br />
of input from the NGO that is working with him…<br />
they put a lot of work in with training, job training<br />
<strong>and</strong> social skills training, the client has actually<br />
gone from someone who was an alcoholic, drugusing<br />
street person, to someone who is settled in<br />
a unit, <strong>and</strong> is going out regularly to a place where<br />
he is doing some proper type work, cut down on<br />
the alcohol, got rid of the drugs, cleaned himself<br />
up, so that takes away a lot of stuff, we’d normally<br />
be chasing him, he’s on a depot, <strong>and</strong> he comes<br />
in on the dot, every two weeks, instead of being<br />
chased all around the place, it’s vastly improved his<br />
lifestyle, <strong>and</strong> the way he mixes in the community,<br />
he’s got much more stuff he does outside now, than<br />
he used to, so I think it’s good.<br />
Case Manager<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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Section 4 The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
4.3 Process of providing accommodation<br />
The downsizing of state hospitals <strong>and</strong> the shift to<br />
community care for people with mental illness have<br />
raised questions about how to best accommodate<br />
people with mental illness in the community<br />
(Carling & Ridgway, 1987; Burdekin, 1993; Queensl<strong>and</strong><br />
Department of <strong>Housing</strong>, 2000). The importance of<br />
housing <strong>and</strong> its contribution to wellbeing cannot be<br />
overstated (Carling, 1995). A living situation that feels<br />
like home is a primary source of stability <strong>and</strong> security<br />
in the lives of all people — those with or without a<br />
mental illness. Indeed, much time <strong>and</strong> physical effort<br />
are spent establishing <strong>and</strong> maintaining one’s preferred<br />
living space (i.e. home) in the community.<br />
The provision of housing for people with mental illness<br />
is currently undergoing signifi cant change, with three<br />
essential principles now increasingly recognized —<br />
consumer choice (Ridgway, 1988); normal integrated<br />
housing (Hogan & Carling, 1992); <strong>and</strong> fl exible,<br />
integrated support (Carling, 1990). These principles<br />
form the basis for the ‘new paradigm’ approach<br />
promoted in the USA by Ridgway <strong>and</strong> Zepple (1990)<br />
(see Table below).<br />
Table 4.3.1 Changes in the way housing is considered<br />
Old Paradigm New Paradigm<br />
Residential treatment<br />
setting<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
A home<br />
Staff control Client control<br />
Grouping by disability Social integration<br />
Learning in transitory/<br />
preparatory settings<br />
Learning in permanent<br />
settings<br />
St<strong>and</strong>ard service Individualised service<br />
Least restrictive<br />
environment<br />
(independence)<br />
Most facilitative<br />
environment (supports)<br />
The housing provided should also encourage the<br />
development of skills associated with normal social<br />
roles <strong>and</strong> exposure to <strong>and</strong> participation in the life<br />
of that community. Moreover, the housing option<br />
should include the provision of individualised support<br />
services <strong>and</strong> skills training that occur in the person’s<br />
home. These support services should be fl exible<br />
to meet the changing needs of the individual.<br />
4.3.1 <strong>Housing</strong> within <strong>HASP</strong><br />
The provision of accommodation to <strong>HASP</strong> clients<br />
is managed by the Department of Communities –<br />
<strong>Housing</strong> <strong>and</strong> Homelessness Services (HHS). Every<br />
effort was made to ensure that each client entering<br />
<strong>HASP</strong> was provided with accommodation in keeping<br />
with their needs. All clients received an ‘establishment<br />
grant’ of $5,000 from Disability <strong>and</strong> Community Care<br />
Services to buy white goods <strong>and</strong> other furnishings<br />
required to establish their new home in the community.<br />
The majority of <strong>HASP</strong> clients were living in mediumsized<br />
unit blocks. While 37% of residences had one<br />
bedroom, 45% had two bedrooms <strong>and</strong> 15% contained<br />
three bedrooms (Fig. 4.3.1).<br />
Figure 4.3.1 Type of accommodation provided<br />
Percent<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Unit<br />
in large<br />
block<br />
Unit<br />
in med<br />
block<br />
Unit Townhouse Duplex<br />
in small<br />
block<br />
Type of housing<br />
House<br />
(Note on Unit Blocks: Small Block = up to 6 Units;<br />
Medium block = 7-16 Units; Large Block = More than<br />
16 Units)
4.3.2 Living arrangements<br />
The majority of <strong>HASP</strong> clients (80%) lived on their own.<br />
However, 22% felt that they would like to live with a<br />
roommate or friend in the future. Four clients were still<br />
in hospital (in transition – spending more than four<br />
nights in their own home) when they were interviewed.<br />
Indeed, seven individuals (8.7%) outlined that they<br />
would like to live in a mental health unit/hospital<br />
in the future.<br />
Fig. 4.3.2 Current living arrangements<br />
<strong>and</strong> desires for future living<br />
Percent<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Alone<br />
Friend<br />
Legend Current<br />
situation<br />
4.3.3 Features of housing<br />
Some 91% outlined that public transport was<br />
convenient <strong>and</strong> 94% felt safe in their present<br />
accommodation. In addition, 91% claimed to<br />
have suffi cient space <strong>and</strong> 90% were comfortable<br />
in their accommodation. Overall, 87% rated their<br />
accommodation as being highly appealing/appealing<br />
(see Fig. 4.3.3).<br />
Fig. 4.3.3 Rating of housing<br />
Percent<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Highly<br />
appealing<br />
With Parents Partner Hospital<br />
their<br />
children<br />
Appealing<br />
In the<br />
future<br />
Neutral<br />
Attractiveness of housing<br />
Other<br />
Unatttractive<br />
4.3.4 Overall satisfaction with housing.<br />
Satisfaction with housing was high with almost<br />
90% of <strong>HASP</strong> clients claiming to be very satisfi ed/<br />
mostly satisfi ed with their housing (Fig. 4.3.4).<br />
Fig. 4.3.4 Rating of satisfaction with housing<br />
Percent<br />
70<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Very<br />
satisfied<br />
Mostly<br />
satisfied<br />
Neutral<br />
Satisfaction with housing<br />
Mostly Extremely<br />
dissatisfied dissatisfied<br />
4.3.5 Clients who had moved since joining <strong>HASP</strong><br />
Fourteen of the 80 clients (17.5%) had moved house<br />
since joining <strong>HASP</strong>. Eleven of these had moved once,<br />
one had moved twice <strong>and</strong> two had moved thrice. There<br />
were three main reasons cited for moving — noise from<br />
neighbours <strong>and</strong> or unable to get along with neighbours<br />
(n=8), dislike of the area in which they lived (n=3), <strong>and</strong><br />
to be closer to family (n=3).<br />
4.3.6 Client perceptions of their accommodation<br />
From interviews with clients it became clear that<br />
housing forms an important component of their<br />
recovery. The fi ndings support previous work by<br />
Baker & Douglas (1990) which suggests that clients<br />
who remained in adequate <strong>and</strong> appropriate housing<br />
improved, while those in poor housing remained<br />
the same or deteriorated in their level of functioning.<br />
Similarly, clients who moved from poor-quality housing<br />
to better housing improved in their global functioning.<br />
The authors concluded that the quality of housing<br />
had a clear impact on the outcomes for people with<br />
mental illness.<br />
It is clear from the interviews with <strong>HASP</strong> consumers<br />
that housing provides a feeling of security <strong>and</strong> a place<br />
of ‘asylum’ where, as one client put it, ‘my home is<br />
my escape from the madness of the world’. Three key<br />
themes emerged: housing — essential for recovery;<br />
a sense of home; <strong>and</strong> a sense of freedom.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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Section 4 The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
<strong>Housing</strong> — essential for recovery<br />
There was a perception among those interviewed that<br />
stable housing formed a key element of the recovery<br />
process. Most believed that housing provided stability<br />
<strong>and</strong> had far greater implications than simply providing<br />
a roof over one’s head:<br />
I don’t think people realise how much<br />
accommodation changes your life. I’d still be using<br />
speed if I didn’t have this house, it’s changed my<br />
life. Just having responsibility <strong>and</strong> just the good<br />
feeling of coming home, <strong>and</strong> you’ve got a nice house<br />
to come home to <strong>and</strong>, you’re not behind in your<br />
rent, or, stuff like that, it’s massive, a lot of people<br />
take it for granted…I was on <strong>and</strong> off the streets<br />
for eight years.<br />
40-year-old male consumer<br />
When I got the <strong>HASP</strong> package I was so happy, I got<br />
a br<strong>and</strong> new property <strong>and</strong> I’ve got it for 10 years,<br />
<strong>and</strong> 10 years after that, I asked housing. I don’t<br />
know where I’d be if I hadn’t got this, it came at the<br />
right time – I got out of hospital, ready to get a job.<br />
34-year-old female consumer<br />
A sense of ‘home’<br />
Almost all of the clients interviewed indicated that<br />
they felt their new accommodation in the community<br />
was ‘home’:<br />
Yes, I consider this to be my home now.<br />
51-year-old male<br />
Yeh, I feel at home with myself <strong>and</strong> my cat <strong>and</strong> my<br />
painting. Sometimes the neighbours get a bit agro,<br />
not with me, but with each other.<br />
46-year-old female consumer<br />
Two clients suggested that it was home only for the<br />
short-term, <strong>and</strong> these clients indicated that the home<br />
in which they grew up, <strong>and</strong> which was still owned by<br />
a family member (usually a parent) would always be<br />
their ‘real’ home.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
A sense of freedom<br />
There was also agreement among those interviewed<br />
that they could do ‘their own thing’ in their new home<br />
in the community. The responses are further indication<br />
of positive adaptation — indicating that clients<br />
perceive themselves as having real choices available<br />
to them in the community:<br />
Yes, I can do what I want to do, because I want to,<br />
not because I have to.<br />
24-year-old male consumer<br />
…moving to this house has been the best thing that<br />
has ever happened to me, I feel independent <strong>and</strong><br />
free, <strong>and</strong> even though I’ve got the support workers,<br />
I can go outside <strong>and</strong> do my garden, I can mow my<br />
own lawn now… everything has just fallen so well<br />
into place. But yes, so moving into this house, it’s<br />
just like being given some other second chance.<br />
I haven’t been back to hospital since 2006, so that’s<br />
good, <strong>and</strong> [my psychiatrist] said to me that I might<br />
not have to go to hospital again.<br />
55-year-old female consumer<br />
While some clients acknowledged their freedom, they<br />
also expressed reservations about the responsibilities<br />
associated with independent living, including an<br />
acknowledged respect for property –<br />
You can do what you want to a point — you don’t<br />
go wrecking the place or anything.
4.3.7 <strong>Housing</strong> in <strong>HASP</strong> — comparison with international st<strong>and</strong>ards<br />
The <strong>Support</strong>ed <strong>Housing</strong> Approach in the United States has developed a framework for assessing accommodation<br />
provided to individuals with psychiatric disability (Carling, 1995). The key principles for this are outlined below.<br />
We assessed the provision of housing in <strong>HASP</strong> against these principles (Table below).<br />
Table 4.3.2 International principles in the provision of housing<br />
Principles <strong>HASP</strong> <strong>Housing</strong><br />
1. <strong>Housing</strong> is a home rather than a residential treatment service. ✓<br />
2. The housing is based on what the consumer rather than the mental health worker<br />
considers to be appropriate.<br />
3. Consumers are seen as normal community members rather than mental health<br />
program residents.<br />
4. There is a shift in the locus of control from mental health worker/staff to client. ✓<br />
5. There is social integration rather than grouping people by disability. ✓<br />
6. Training <strong>and</strong> support is offered in vivo permanent settings rather than<br />
transitional, preparatory settings.<br />
7. Individualised fl exible support is offered rather than st<strong>and</strong>ardised levels<br />
of service in short-term settings.<br />
8. The environment which best facilitates development is sought rather than the<br />
least restrictive <strong>and</strong> most independent.<br />
While the housing provided to <strong>HASP</strong> clients clearly meets the principles described, care must be taken to ensure<br />
that there is no erosion of the principles with the passage of time. For example, in the case of principle ‘4’, it would<br />
be very easy for control of the housing environment to gradually shift from client to staff.<br />
✓<br />
✓<br />
✓<br />
✓<br />
✓<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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Section 4 The process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
4.4 Section summary<br />
Case Managers were held in high regard by clients.<br />
Many clients attributed improvements in their health<br />
to their Case Manager. Indeed, over 60% of clients<br />
believed that their Case Manager had helped them<br />
with their symptoms. Consistency in the same Case<br />
Manager was valued by clients <strong>and</strong> support staff.<br />
However, only 6% of clients had the same Case<br />
Manager for the entire 12 months prior to interview.<br />
Notwithst<strong>and</strong>ing this, most clients (89%) indicated<br />
that they could get in contact with their Case Manager<br />
if they had a problem. Over 78% of clients felt that<br />
Case Managers understood their problems <strong>and</strong><br />
91% claimed to know what their medications were<br />
used for.<br />
Both Case Managers <strong>and</strong> support workers expressed<br />
satisfaction with the collaborative working<br />
relationships they had developed. Ninety-fi ve percent<br />
of Case Managers outlined that they valued the<br />
support worker role <strong>and</strong> 92% felt that support workers<br />
had a valuable role to play in the treatment planning<br />
process. However, support workers raised concerns<br />
about Case Manager involvement in <strong>HASP</strong> <strong>and</strong> felt<br />
that Case Managers could play a greater role in the<br />
overall program. Reasons highlighted for the perceived<br />
lack of involvement included the high caseloads that<br />
some Case Managers were expected to carry <strong>and</strong> the<br />
presence of support workers in the lives of the clients.<br />
Case Managers carried out their role in the knowledge<br />
that support workers would contact them should they<br />
observed changes in client functioning. This fi nding<br />
supports earlier work in New South Wales that found<br />
Case Managers had less involvement with clients<br />
supported by NGOs due to the auxiliary services<br />
provided by support workers (Muir et al., 2006).<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Thirty-two different support agencies (n=32) provide<br />
services to the 80 clients enrolled in the evaluation.<br />
All of these agencies have different levels of<br />
experience in the provision of support to individuals<br />
with mental illness. Nonetheless, consumers see the<br />
interventions provided by support workers as being<br />
instrumental in maintaining them in their chosen<br />
community. Overall, 85% of clients were satisfi ed/very<br />
satisfi ed with the activities that support workers do<br />
for/with them.<br />
<strong>Support</strong> workers felt, as a result of their interactions<br />
with Case Managers, that they had an important role<br />
to play in the treatment process. However, just over<br />
half (54%) agreed that Case Managers had provided<br />
them with as much information as they needed. Six in<br />
every 10 support workers expressed a desire to have<br />
a greater say in the services provided to <strong>HASP</strong> clients.<br />
Only one-third of support workers indicated that they<br />
were involved in developing care plans for clients.<br />
However, in most support agencies this task<br />
is managed by the <strong>Support</strong>s Coordinator who passes<br />
on relevant information to the support workers.<br />
The training of support workers was raised by Case<br />
Managers (<strong>and</strong> support workers themselves). Both<br />
groups felt that support workers required more<br />
training in a range of areas so as to be more effective<br />
in the provision of services to clients with complex<br />
needs. Almost half of the support workers (45%) who<br />
participated felt that they needed more training to be<br />
able to work effectively with their <strong>HASP</strong> clients.<br />
<strong>Final</strong>ly, the level of support required by clients seems<br />
to decrease with the passage of time. <strong>Support</strong> hours<br />
provided each week decreased by an average of 7.13<br />
hours from a mean of 27.6 hours on entry into <strong>HASP</strong><br />
to a mean of 20.4 hours at the follow-up time-point.
The majority of <strong>HASP</strong> clients (76%) lived on their own.<br />
However, 22% felt that in the future, they would like<br />
to live with a roommate or friend. The evaluation team<br />
notes that while <strong>HASP</strong> clients are not prevented from<br />
sharing a house should they prefer this option, they<br />
are unable to share the support services they receive.<br />
It may be worth exploring how the program can better<br />
facilitate shared accommodation for a small sub-group<br />
of clients who may prefer this option.<br />
Fourteen of the 80 clients in our sample moved<br />
accommodation since joining <strong>HASP</strong>. Eleven of these<br />
moved once, one moved twice <strong>and</strong> two moved thrice.<br />
There were three main reasons cited for moving —<br />
noise from neighbours <strong>and</strong> or unable to get along with<br />
neighbours (n=8), dislike of the area in which they<br />
lived (n=3), <strong>and</strong> to be closer to family (n=3). While this<br />
could be viewed as a negative for the program, it is<br />
reassuring that clients can ask to be relocated to a new<br />
neighbourhood <strong>and</strong> relocation appears to be feasible<br />
when the need occurs.<br />
Themes that emerged from the interviews with clients<br />
suggest that stable housing plays an important role<br />
in one’s recovery. Clients viewed their housing as<br />
being important in providing stability <strong>and</strong> it offered<br />
a platform from which to undertake other elements<br />
of the recovery process (fi nding a job, etc). Two other<br />
themes included a ‘sense of freedom’ <strong>and</strong> a ‘sense<br />
of home’.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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48<br />
Section 5<br />
The opportunities available through the program for clients<br />
to maximise their recovery <strong>and</strong> participate in community life<br />
The focus here was on social, recreational, educational<br />
<strong>and</strong> vocational activities in the community<br />
This section of the report discusses how client participation in <strong>HASP</strong> has supported their<br />
recovery. In addition, overall functioning is discussed in terms of the proportion of clients<br />
experiencing improved functioning, the need for hospital admission following entry into<br />
<strong>HASP</strong>, <strong>and</strong> the proportion of clients that have sustained tenancies since entry into <strong>HASP</strong>.<br />
5.1 Client perceptions of <strong>HASP</strong><br />
<strong>and</strong> how it supports their recovery<br />
There was overwhelming support for the program<br />
from the clients who we interviewed. Many provided<br />
examples of how <strong>HASP</strong> had helped them to reconnect<br />
with their community:<br />
It felt good coming back to my home town <strong>and</strong><br />
stuff… bit like that…after being away for so long…<br />
to get back into the community, like you need<br />
a leg up sort of thing. <strong>HASP</strong> was just great.<br />
Consumer who had spent 18 months in a long stay unit<br />
One of the key aspects of the program was the support<br />
provided by support services. <strong>Support</strong> workers were<br />
perceived as providing support, motivating clients<br />
to achieve more from life <strong>and</strong> linking clients into the<br />
community:<br />
The <strong>HASP</strong> support workers… well they’re here to<br />
egg me on, bit of support, <strong>and</strong> bit more courage<br />
to get going because, you know I’m on pretty strong<br />
medication, but it has dropped, but they sort of egg<br />
me on for exercise <strong>and</strong> get me out in the community<br />
<strong>and</strong> talking to people.<br />
Male consumer<br />
Each client entering <strong>HASP</strong> received an establishment<br />
grant of $5,000 to buy ‘white’ goods <strong>and</strong> enable<br />
clients to pay for phone connection etc. This practical<br />
component of <strong>HASP</strong> was recognised by many of those<br />
interviewed:<br />
<strong>HASP</strong> has helped me a great deal, it’s brought me<br />
a fridge, a washing machine, furniture, TV, that was<br />
the $5,000 for the household stuff. Yes, I bought<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
a br<strong>and</strong> new washing machine <strong>and</strong> a br<strong>and</strong> new<br />
fridge, the lounge suite <strong>and</strong> the TV cabinet <strong>and</strong> me<br />
bed <strong>and</strong> the lawnmower, it’s just sort of set me right<br />
up, so I would have been sort of buggered without<br />
it. It’s been great.<br />
Male consumer<br />
There was also a view that <strong>HASP</strong> was instrumental in<br />
assisting family members to cope with the burden of<br />
caring for a loved one. Families frequently struggle in<br />
the caring role because they may have to give up work<br />
to support their loved one.<br />
I’ve seen <strong>HASP</strong> clients helped so much. Like I’m<br />
working with a young fellow now… <strong>and</strong> I mean his<br />
mother had to give up work <strong>and</strong> everything to try<br />
<strong>and</strong> look after him <strong>and</strong> we’ve come on board <strong>and</strong><br />
the family’s so happy — I mean she’s saying ‘oh now<br />
I can try <strong>and</strong> get my life back together <strong>and</strong> try <strong>and</strong><br />
go back to work <strong>and</strong> all that’ So we aren’t only…the<br />
<strong>HASP</strong> packages aren’t only helping the client it’s<br />
helping their families <strong>and</strong> extended family <strong>and</strong> that,<br />
those that are normally stuck with the responsibility<br />
of caring for someone.<br />
Regional support worker<br />
It should be noted that this is not an isolated case.<br />
Clients provided numerous accounts of how <strong>HASP</strong><br />
has helped them to move from a life fi lled with despair<br />
<strong>and</strong> isolation to one of hope <strong>and</strong> stable living in their<br />
own home.
5.2 Satisfaction with key life domains<br />
Much of the questionnaire data collected as part of<br />
the evaluation supports the views expressed above.<br />
Clients were asked to rate their satisfaction with a<br />
number of life domains on a seven-point scale ranging<br />
from 1 = ‘very dissatisfi ed’ to 7 = ‘very satisfi ed’ (thus<br />
a higher score represents higher levels of satisfaction).<br />
The items focused on a number of different domains,<br />
such as the way clients spend their time, their housing,<br />
mental health services they receive, the services they<br />
receive from the support agency, the neighbourhood<br />
as a place to live, personal safety, <strong>and</strong> access to<br />
transportation (see Fig. below).<br />
Fig. 5.1 Satisfaction with life domains<br />
Score<br />
7<br />
6<br />
5<br />
4<br />
3<br />
2<br />
1<br />
Spend<br />
time<br />
<strong>Housing</strong><br />
Neighbourhood<br />
<strong>Support</strong> agency<br />
Mental health<br />
service<br />
Transport<br />
Domain (1 = least satisfied to 7 = most satisfied)<br />
Personal<br />
safety<br />
The participants rated all domains as being positive,<br />
with many of the domains rated close to ‘6’ (out of a<br />
possible score of ‘7’). They were most satisfi ed by the<br />
services provided by the relevant support agency<br />
(mean score = 6.05) <strong>and</strong> least satisfi ed by the way<br />
they spent their time (mean score = 5.37).<br />
5.3 Involvement in vocational activities<br />
Clients were asked to outline their involvement<br />
in fi ve activity areas — paid employment, volunteer work,<br />
TAFE/study, Clubhouse/Rehab, <strong>and</strong> craft/leisure. Clients<br />
who claimed to have no involvement in any of these<br />
activities were classifi ed as having ‘no structured activity’<br />
(Fig. 5.2). While eight of the 80 clients interviewed (10.0%)<br />
were in paid employment, the hours worked ranged from<br />
four to 60 per week with a mean of 18.06 hours worked<br />
per week. One client had two part-time jobs that required<br />
him to work 60 hours per week. They worked in industry/<br />
factories (three), construction (two), pamphlet delivery<br />
(two), <strong>and</strong> newspaper delivery (one).<br />
In addition to paid employment, 13 (16.2%) clients<br />
indicated that they participated in volunteer work<br />
(such as bookshop, garden centre, shop assistant,<br />
sorting clothes with St Vincent de Paul, etc). The mean<br />
number of hours spent on volunteer work was 8.15 hours<br />
(range= two to 24 hours). <strong>Final</strong>ly, eight clients (10%)<br />
indicated that they attended TAFE <strong>and</strong> other training<br />
programs. On average, clients spent 7.81 hours per week<br />
in education (range = one to 28 hours).<br />
Fig. 5.2 Main activity of <strong>HASP</strong> clients<br />
Percent<br />
60<br />
40<br />
20<br />
0<br />
Paid<br />
employ<br />
Legend Current<br />
situation<br />
Volunteer TAFE/<br />
Training<br />
Clubhouse/<br />
Rehab<br />
Desire<br />
for future<br />
Craft/<br />
Leisure<br />
No<br />
structured<br />
activity<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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Section 5 The opportunities available through the program for clients<br />
to maximise their recovery <strong>and</strong> participate in community life<br />
Clients were asked to describe what they would like<br />
to have as their main activity. A large proportion<br />
(43.4%) indicated that they would like paid employment<br />
as their main activity in the future. This suggests that<br />
there is considerable scope for clients to focus on<br />
employment. Another 21% outlined that they would<br />
like to have craft/hobbies as their main activity.<br />
5.4 Involvement in activities<br />
Clients were also asked to rate how they felt about their<br />
level of involvement in the activities described above.<br />
They were asked to indicate whether they were engaged<br />
in activities ‘less than they would like’, ‘more than they<br />
would like’, <strong>and</strong> ‘as much as they wanted to be’.<br />
Overall, 60% of clients were happy with their<br />
engagement in activities. However, almost one-third<br />
of the clients indicated that they would like to be<br />
involved in activities more than they were at present.<br />
Further analysis of this data indicated that 67% of<br />
those who wanted more activities were the same group<br />
that indicated they wanted employment as their main<br />
activity (see graph below).<br />
Fig. 5.3 Client perceptions of level of engagement<br />
in activities<br />
Percent<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Less than<br />
I would like<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
More than<br />
I would Like<br />
Involvement in activities<br />
As much<br />
as I like<br />
5.5 Number of friends<br />
The number of friends one has can be one indicator<br />
of community integration. We asked clients to tell<br />
us about the number of people that they would call<br />
friends. While 7% of <strong>HASP</strong> clients claimed to have<br />
‘no friends’, over one-third indicated that they had<br />
more than fi ve friends. It is clear from the information<br />
collected that many clients included family members<br />
as their friends.<br />
Fig. 5.4 Number of friends<br />
Percent<br />
40<br />
30<br />
20<br />
10<br />
0<br />
None<br />
1–2 friends<br />
3–5 friends<br />
Number of friends<br />
5.6 Satisfaction with the number<br />
of friends they have<br />
The majority of clients were either very satisfi ed<br />
or moderately satisfi ed with the number people they<br />
called friends.<br />
Fig. 5.5 Satisfaction with number of friends<br />
Percent<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Very<br />
satisfied<br />
Moderately<br />
satisfied<br />
Neither<br />
Satisfaction with number of friends<br />
More than<br />
5 friends<br />
Moderately Very<br />
dissatisfied dissatisfied
5.7 Depth of friendships<br />
We explored ‘depth’ of friendships by asking <strong>HASP</strong> clients additional questions around key areas, such as support<br />
from friends if they were sick or feeling lonely (see table below). Note that clients were asked not to include<br />
support workers <strong>and</strong> mental health staff when considering the statements.<br />
While 86% of the <strong>HASP</strong> clients claimed to have between one to fi ve friends, 39% of the sample felt confi dent that<br />
they would be able to fi nd someone to ‘put them up’ if they needed somewhere to stay for a few days. However,<br />
45% felt that they would have trouble fi nding someone to drive them to hospital if they were ill. Indeed, over<br />
one-fi fth of clients indicated that they did not have ‘one person they could trust’.<br />
Table 5.1 Depth of friendships<br />
Statement Completely<br />
True %<br />
If I needed a place to stay for a few days,<br />
I could easily fi nd someone to put me up.<br />
If I was sick <strong>and</strong> needed someone to drive<br />
me to a doctor/hospital, I would have<br />
trouble fi nding someone.<br />
If I had to go into hospital for a couple of<br />
weeks, I could fi nd someone to look after<br />
my house (water plants, feed pet).<br />
When I need help to deal with a personal<br />
problem, I know someone I can turn to.<br />
When I feel lonely, there is someone I can<br />
call or talk to.<br />
There is at least one person in my life that<br />
I can trust.<br />
Somewhat<br />
True %<br />
Somewhat<br />
False %<br />
Completely<br />
False %<br />
38.7% 24.0% 10.7% 26.7%<br />
44.6% 12.2% 12.2% 31.1%<br />
37.2% 18.4% 8.2% 36.2%<br />
44.0% 28.0% 5.3% 22.7%<br />
60.8% 18.9% 4.1% 16.2%<br />
61.6% 16.4% 6.8% 15.1%<br />
The fi ndings indicate that over one-third of those who completed the survey had poor support from family <strong>and</strong><br />
friends. For example, 36% outlined that if they needed a place to stay for a few days, they would not be able<br />
to fi nd someone to put them up.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
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Section 5 The opportunities available through the program for clients<br />
to maximise their recovery <strong>and</strong> participate in community life<br />
5.8 Satisfaction with family relationships<br />
Most of the clients were satisfi ed with the relationships<br />
they had been having with their families. While<br />
15% were very dissatisfi ed with family relationships,<br />
65% were moderately satisfi ed to very satisfi ed<br />
(Fig. 5.6).<br />
Fig. 5.6 Satisfaction with family relationships<br />
Percent<br />
40<br />
30<br />
20<br />
10<br />
0<br />
5.9 Satisfaction with money<br />
Access to suffi cient money <strong>and</strong> control over money are<br />
important factors in being able to maintain life in the<br />
community. Overall, <strong>HASP</strong> clients were satisfi ed with<br />
the amount of money they had to spend. Moreover,<br />
they were also happy with the level of control they had<br />
over their money (Fig. 5.7).<br />
Fig. 5.7 Satisfaction with amount of money<br />
<strong>and</strong> control over money<br />
Percent<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Very<br />
satisfied<br />
Very<br />
satisfied<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Moderately<br />
satisfied<br />
Neither<br />
Satisfaction with your family<br />
Moderately<br />
satisfied<br />
Legend Amount<br />
of money<br />
Neither<br />
Control<br />
over money<br />
Moderately Very<br />
dissatisfied dissatisfied<br />
Moderately Very<br />
dissatisfied dissatisfied<br />
The high satisfaction rating provided by clients<br />
for ‘control over their money’ is unusual given that<br />
51 of the 80 clients in the study (63%) had their<br />
fi nances managed by the Public Trustee.<br />
5.10 Lack of money<br />
The issue of clients not having suffi cient money<br />
to achieve their goals was also explored. Clients<br />
were asked to consider how often the lack of money<br />
prevented them from doing things that they would like<br />
to do. Some 75% of clients indicated that the lack of<br />
money prevented them from doing things frequently/<br />
sometimes (Fig. 5.8).<br />
Fig. 5.8 How often does lack of money<br />
stop you from doing things?<br />
Percent<br />
40<br />
30<br />
20<br />
10<br />
0<br />
Never<br />
Sometimes<br />
Lack of money<br />
Frequently
5.11 Community involvement<br />
Clients were also asked to consider a number of activities that relate to community involvement <strong>and</strong> outline<br />
if they had participated in the named activity in the past month. The results are provided in the table below.<br />
Table 5.2 Activities carried out in the past month<br />
Activity ‘YES’ Did anyone help you?<br />
Number (%)<br />
a. Gone for a walk 63 (78.7%) <strong>Support</strong> worker/family<br />
b. Gone to a movie or play 58 (72.0%) Family/friends<br />
c. Watched TV or DVD/video 75 (93.7%) Self<br />
d. Played a sport 31 (38.7%) <strong>Support</strong> workers<br />
e. Gone to a social club 32 (40.0%) Family/friends<br />
f. Gone to church 22 (27.5%) Self<br />
g. Gone to a library 36 (45.0%) <strong>Support</strong> workers<br />
h. Gone to a coffee shop 48 (60.0%) Family/friends<br />
i. Gone ‘window’ shopping 35 (43.7%) Family/<strong>Support</strong> workers<br />
j. Played a computer game (e.g. Wii) 20 (25.0%) <strong>Support</strong> workers<br />
k. Gone to a friend’s place 30 (37.5%) Friends<br />
The highest-ranked activity was watching TV, which was carried out by over 93% of individuals. Eighty-fi ve<br />
percent claimed to have gone to a movie or a play in the past month. Going to church (27.5%) <strong>and</strong> playing a sport<br />
(38.7%) were low-participation activities. Clients received assistance with these activities from either support<br />
workers or family members.<br />
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Section 5 The opportunities available through the program for clients<br />
to maximise their recovery <strong>and</strong> participate in community life<br />
5.12 Client goals<br />
Clients were asked to provide their main goal (i.e. What is your main goal at the moment?). A range of goals<br />
was provided <strong>and</strong> these were categorised under four main themes that seemed to cover the content (Table below).<br />
The most commonly mentioned goal concerned work <strong>and</strong> ‘getting a job’. Of the 56 consumers who provided<br />
a response to this question, 15 made comments that related to fi nding a job.<br />
Table 5.3 The main goal of clients at follow-up<br />
Themes Examples of Content<br />
Finding<br />
a Job/Training<br />
(n=15)<br />
Staying<br />
Healthy<br />
(n=12)<br />
Travel<br />
(n=10)<br />
Family<br />
Contact<br />
(n=8)<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Further my education <strong>and</strong> get a job<br />
Get a job <strong>and</strong> get married<br />
Get a job <strong>and</strong> make some money<br />
Eat well <strong>and</strong> exercise<br />
Get a stronger body<br />
Stay out of hospital<br />
Keep the illness under control<br />
Go to America<br />
Visit Engl<strong>and</strong><br />
Have a holiday in Cairns<br />
Get a girlfriend <strong>and</strong> get married<br />
Get my family back together<br />
See more of my daughter<br />
Get part-time work<br />
To fi nd work<br />
Do a TAFE course<br />
Become a support worker<br />
Get fi t<br />
To fi nd happiness <strong>and</strong> joy in my life<br />
Stay alive<br />
Leave it all behind me <strong>and</strong> move on<br />
Visit family up north<br />
Get a car<br />
Get my ‘learners’ <strong>and</strong> a car<br />
Get the family up to visit<br />
Write a letter to mum<br />
Clients were asked if being involved with <strong>HASP</strong> had helped them to work towards their goals. Of the 73 clients<br />
who completed this question, 60 (82.2%) indicated that involvement in <strong>HASP</strong> had helped them to achieve<br />
their goals.
5.13 Section summary<br />
During our interviews with clients (<strong>and</strong> staff) we heard<br />
accounts of the way that <strong>HASP</strong> had helped clients to<br />
move from a life fi lled with despair <strong>and</strong> isolation to<br />
one of hope. All of the individuals (staff <strong>and</strong> clients)<br />
felt that the housing <strong>and</strong> support provided through<br />
<strong>HASP</strong> were essential in promoting recovery for clients.<br />
The clients were asked to consider a number of life<br />
domains. They were most satisfi ed by the services<br />
provided by their support agency (mean score = 2.05)<br />
<strong>and</strong> least satisfi ed by the way they spent their time<br />
(mean score = 1.37). We further explored the way in<br />
which clients spent their time. While eight of the<br />
80 <strong>HASP</strong> clients (10.0%) were in paid employment,<br />
the hours worked ranged from four to 60 per week<br />
with a mean of 18.06 hours worked per week. One<br />
client had two part-time jobs which required him<br />
to work 60 hours per week. Most worked as factory<br />
h<strong>and</strong>s, in construction or on paper delivery jobs.<br />
A large proportion of clients (43.4%) indicated that<br />
they would like paid employment as their main activity<br />
in the future. This suggests that there is considerable<br />
scope for clients to focus on employment. Another<br />
21% outlined that they would like to have craft/<br />
hobbies as their main activity.<br />
While 86% of the <strong>HASP</strong> clients claimed to have<br />
between one to fi ve friends, 39% of the sample<br />
outlined that they would be able to fi nd someone<br />
to ‘put them up’ if they needed somewhere to stay for<br />
a few days. In addition, 44% felt that they would have<br />
trouble fi nding someone to drive them to hospital if<br />
they were ill. Indeed, over one-fi fth of clients indicated<br />
that they did not have ‘one person they could trust’.<br />
Access to suffi cient fi nance <strong>and</strong> control over that<br />
money are important factors in being able to maintain<br />
life in the community. Overall, <strong>HASP</strong> clients were<br />
satisfi ed with the amount of money they had.<br />
Moreover, they expressed high levels of satisfaction<br />
with the amount of control they had over their money.<br />
This was somewhat surprising given that 51 of the<br />
80 clients in the study (63%) had their fi nances<br />
managed by the Public Trustee. Indeed, having their<br />
fi nances managed by the Public Trustee enabled some<br />
clients to purchase goods <strong>and</strong> services that they could<br />
never previously afford. By way of example, one client<br />
was able to save enough money to have a holiday in<br />
Cairns, while another outlined how he was able to<br />
buy a racing bicycle. Nonetheless, three-quarters<br />
of clients indicated that the lack of money prevented<br />
them from doing things they wanted to do either<br />
‘frequently’/‘sometimes’.<br />
Clients provided a range of goals. These were<br />
categorised into four themes — staying healthy,<br />
fi nding a job, travel <strong>and</strong> connecting with family.<br />
Eighty-two percent indicated that involvement<br />
in <strong>HASP</strong> had helped them (or was currently helping<br />
them) to achieve their goals.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
55
56<br />
Section 6<br />
The ability of the program to maintain clinical functioning <strong>and</strong> provide<br />
an acceptable quality of life for those supported by the program<br />
This section of the report explores factors related to clinical functioning <strong>and</strong> how these<br />
are maintained under <strong>HASP</strong>. Factors such as changes in clinical functioning, medication use,<br />
physical health, client goals, participation in meaningful activities, employment, level of<br />
independence <strong>and</strong> the need for inpatient care are discussed.<br />
6.1 Readmissions to acute<br />
inpatient care<br />
The need for readmission to acute care is one indicator<br />
of how well a program can maintain clinical functioning<br />
in individuals with high levels of disability. Of the<br />
80 clients in our sample, admission data (number<br />
of admissions <strong>and</strong> length of stay) were available for<br />
70 clients at 12 months prior to entering <strong>HASP</strong> <strong>and</strong><br />
12 months post-entry into <strong>HASP</strong>. While 61 of the<br />
70 clients for which data were available (87.1%)<br />
required time in hospital in the 12 months prior to<br />
<strong>HASP</strong>, 41 of these clients spent the entire 12 months<br />
in hospital prior to entry into <strong>HASP</strong>. However, following<br />
entry into <strong>HASP</strong>, only 26 clients (37.1%) required time<br />
in hospital in the 12 months post-<strong>HASP</strong>.<br />
The average time in inpatient care for each individual<br />
in the 12 months prior to <strong>HASP</strong> decreased signifi cantly<br />
from an average of 227 days to an average of<br />
18.9 days in the 12 months post-<strong>HASP</strong>. This reduction<br />
in inpatient bed days was statistically signifi cant<br />
(paired t = 10.44, p=0.001). <strong>Final</strong>ly, the number of<br />
admissions also decreased signifi cantly from an<br />
average of 1.22 admissions in the 12 months prior to<br />
<strong>HASP</strong>, to an average of .66 admissions per individual<br />
in the 12 months post-<strong>HASP</strong> (paired t = 3.22,<br />
p=0.002).<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
6.2 Changes in functioning<br />
As noted earlier, ‘outcomes’ data were obtained from<br />
the Queensl<strong>and</strong> Health Information System ‘CIMHA’<br />
for the 77 clients who provided written consent for<br />
their data to be used for the evaluation. (Three clients<br />
refused to provide consent for their outcomes data<br />
to be used in this way). Having identifi ed the date<br />
that each individual entered <strong>HASP</strong>, it was possible to<br />
obtain the outcomes data from CIMHA for clients at 12<br />
months <strong>and</strong> three months prior to entering <strong>HASP</strong> <strong>and</strong><br />
for three months <strong>and</strong> 12 months after entering <strong>HASP</strong>.<br />
The mean scores for the both the Life Skills Profi le<br />
(LSP) <strong>and</strong> the Health of the Nation Outcome Scales<br />
(HoNOS) are summarised in the graph below. The LSP<br />
provides a measure of general life skills functioning,<br />
while the HoNOS provides an assessment of disability<br />
<strong>and</strong> clinical functioning. There was a considerable<br />
amount of missing data for the 77 clients. HoNOS data<br />
were available for 33 of the 77 clients across all four<br />
time-points, while LSP data were available for 17 of the<br />
77 clients across all four time-points.<br />
Fig. 6.1 Changes in functioning<br />
Score<br />
20<br />
15<br />
10<br />
5<br />
0<br />
Legend<br />
HoNOS (n=33)<br />
12<br />
months<br />
pre<br />
3<br />
months<br />
pre<br />
LSP (n=17)<br />
3<br />
months<br />
post<br />
12<br />
months<br />
post<br />
Overall, the clients, as a group, demonstrated<br />
improvement in functioning as indicated by the lower<br />
mean scores (lower scores on these scales indicate
etter functioning). However, while these changes/<br />
improvements approached signifi cance, they were<br />
not statistically signifi cant.<br />
6.3 Clients who improved, stayed the<br />
same, or deteriorated<br />
While some of the clients improved, others remained<br />
the same or deteriorated. Identifying the proportion<br />
of clients in each of these groups is a useful method<br />
of assessing outcomes. To identify those in the three<br />
categories (improved, remain the same, deteriorated)<br />
we added the two-scale scores pre-<strong>HASP</strong> (i.e. the<br />
score for HoNOS at 12 months pre <strong>and</strong> three months<br />
pre) <strong>and</strong> subtracted the combined score from the two<br />
measures post-<strong>HASP</strong>. This provided a range of ‘change’<br />
scores. We then calculated the st<strong>and</strong>ard deviation for<br />
the change scores. One st<strong>and</strong>ard deviation around the<br />
mean was used to differentiate between clients in each<br />
of the groups. Thus, clients with a total scale score<br />
greater than .5 of a st<strong>and</strong>ard deviation above the mean<br />
were classifi ed as having highly deteriorated (since<br />
a higher score represented more severe problems).<br />
Those with scores less than .5 of a st<strong>and</strong>ard deviation<br />
below the mean were classifi ed as having improved,<br />
while those with scores ± .5 of a st<strong>and</strong>ard deviation<br />
around the mean were classifi ed as having remained<br />
the same. The data for each category is summarised<br />
in the Table below.<br />
Table 6.1 Proportion of clients who improved,<br />
stayed the same, or deteriorated<br />
Group Proportion<br />
of clients who<br />
improved, stayed<br />
the same or<br />
deteriorated<br />
Life Skills Profile<br />
(LSP Data)<br />
Proportion<br />
of clients who<br />
improved, stayed<br />
the same or<br />
deteriorated<br />
Health of the<br />
Nation Outcomes<br />
(HoNOS Data)<br />
Improved 51.0% 42.9%<br />
Stable 19.6% 33.3%<br />
Deteriorated 29.4% 23.8%<br />
It is clear from the data that just over half of the clients<br />
in the study group improved on measures of their life<br />
skills performance, while 43% showed improvement<br />
on clinical functioning.<br />
6.4 Perceptions of change in client<br />
functioning — Case Managers versus<br />
support workers<br />
Case Managers (n=40) <strong>and</strong> support workers (n=58)<br />
were asked to indicate their level of agreement with<br />
the statement ‘the functioning of <strong>HASP</strong> clients has<br />
improved in the past six months’. The responses<br />
for both groups are compared in the graph below.<br />
Fig. 6.2 Change in client functioning —<br />
past six months versus next six months<br />
Percent<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Legend<br />
Strongly<br />
agree<br />
Agree<br />
Case<br />
Managers<br />
Neither<br />
<strong>Support</strong><br />
workers<br />
Disagree<br />
Strongly<br />
disagree<br />
Sixty-two percent (62%) of Case Managers agreed that<br />
the functioning of <strong>HASP</strong> clients had improved over the<br />
past six months. This is compared with 69% of support<br />
workers who believed that the functioning of <strong>HASP</strong><br />
clients had improved over the past six months.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
57
58<br />
Section 6 The ability of the program to maintain clinical functioning <strong>and</strong> provide<br />
an acceptable quality of life for those supported by the program<br />
6.5 Perceptions of future improvement<br />
in clients — Case Managers versus<br />
support workers<br />
Case Managers <strong>and</strong> support workers were also asked<br />
to consider the statement ‘the functioning of <strong>HASP</strong><br />
clients will continue to improve in the next six months’<br />
(graph below).<br />
Fig. 6.3 Change in client functioning —<br />
past six months versus next six months<br />
Percent<br />
100<br />
80<br />
60<br />
40<br />
20<br />
0<br />
Legend<br />
Strongly<br />
agree<br />
Sixty-six percent (66%) of Case Managers indicated<br />
that the functioning of their <strong>HASP</strong> clients would continue<br />
to improve in the future. In contrast, 81% of support<br />
workers believed that the functioning of <strong>HASP</strong> clients<br />
would continue to improve in the future.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Agree<br />
Case<br />
Managers<br />
Neither<br />
<strong>Support</strong><br />
workers<br />
Disagree<br />
Strongly<br />
disagree<br />
The support workers who felt that clients would<br />
continue to improve suggested that clients had<br />
someone to talk to, they received positive feedback<br />
<strong>and</strong> encouragement from staff, <strong>and</strong> clients had their<br />
own homes in the community. Receiving a <strong>HASP</strong><br />
package <strong>and</strong> the dedication of all staff/agencies<br />
were also seen as likely to contribute to ongoing<br />
improvement in <strong>HASP</strong> clients. Case Managers felt<br />
that while the NGO sector would continue to contribute<br />
to client functioning, gains in functioning would be<br />
limited by the severity of disability in some clients.<br />
6.6 Changes in Mental Health Act<br />
(MHA) status<br />
The status of clients under the Mental Health Act on<br />
entry into <strong>HASP</strong> was accessed using data contained<br />
in the CIMHA database. This information was then<br />
compared with the status of clients at the point of<br />
data collection (Mar–June 2010). Data for 76 clients<br />
was available for both time-points. Over the study<br />
period, restrictions placed on clients had been<br />
signifi cantly relaxed (Chi sq. = 12.59, p = 0.002).<br />
The proportion of clients on Involuntary Treatment<br />
Orders (ITOs) decreased from 46% to 22%, while the<br />
proportion of clients with voluntary status increased<br />
from 43% to 70% (Table 6.2).<br />
Table 6.2 Changes in mental health status<br />
of <strong>HASP</strong> clients<br />
MHA status on<br />
Admission to <strong>HASP</strong><br />
(n=76)<br />
Voluntary 33 (43.4%)<br />
ITO 35 (46.1%)<br />
Forensic 8 (10.5%)<br />
MHA status<br />
at end of June 2010<br />
(n=76)<br />
Voluntary 53 (69.7%)<br />
ITO 17 (22.4%)<br />
Forensic 6 (7.8%)
6.7 Physical <strong>and</strong> mental health<br />
Links between mental illness <strong>and</strong> premature death<br />
have brought the physical health of individuals with<br />
mental health conditions into focus in recent times.<br />
We invited clients to provide a rating of their physical<br />
health. While 35% of clients rated their physical health<br />
as very good/excellent, 25% rated their physical<br />
health as being poor/fair (see graph below). Almost<br />
half of the clients (49.3%) indicated that they had a<br />
physical health problem <strong>and</strong> 33% claimed to be taking<br />
medications for physical health problems.<br />
Fig. 6.4 Rating of physical <strong>and</strong> mental health<br />
Percent<br />
45<br />
40<br />
35<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
Poor<br />
Legend Physical<br />
health<br />
Fair<br />
Good<br />
Mental<br />
health<br />
Very<br />
good<br />
Excellent<br />
Three-quarters of the clients (n=60) smoked cigarettes<br />
with a daily intake of between fi ve <strong>and</strong> 50 cigarettes<br />
(average daily use was 20.5 cigarettes, sd= 8.2). In the<br />
month prior to interview, 41 clients (53.9%) had drunk<br />
alcohol, with two clients claiming to have had alcohol<br />
on every day in the past month. One-third of those who<br />
had alcohol had only two drinks on the days that they<br />
consumed alcohol. Four of the clients claimed to have<br />
had cannabis in the month prior to interview.<br />
6.8 Overall quality of life<br />
An overall rating of quality of life was obtained by<br />
asking clients to rate their quality of life on a 10-point<br />
scale where ‘1’ was the worst quality of life possible<br />
<strong>and</strong> ‘10’ was the best quality of life possible. <strong>HASP</strong><br />
clients provided a mean rating of 6.87 out of a possible<br />
total score of 10.<br />
Fig. 6.5 Rating of overall quality of life<br />
Percent<br />
25<br />
20<br />
15<br />
10<br />
5<br />
0<br />
One<br />
Two Three Four<br />
Five<br />
<strong>HASP</strong><br />
Six<br />
Seven Eight<br />
Nine<br />
Ten<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
59
60<br />
Section 6 The ability of the program to maintain clinical functioning <strong>and</strong> provide<br />
an acceptable quality of life for those supported by the program<br />
6.9 Emotional responses experienced<br />
External observers frequently comment that clients<br />
living in supported housing models are lonely,<br />
bored, depressed, etc. To assess this, we asked<br />
<strong>HASP</strong> clients to outline how they felt about a number<br />
of psychological emotions that one experiences in<br />
everyday life. Clients were asked to think about the<br />
past month <strong>and</strong> indicate if they had experienced the<br />
emotions indicated in the past month. The responses<br />
are provided in the table below.<br />
Table 6.3 Emotional responses experienced<br />
in past month<br />
In the past month have you been… Yes%<br />
a. pleased about having accomplished<br />
something?<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
85.7<br />
b. lonely? 40.3<br />
c. bored? 50.6<br />
d. happy that things went your way? 79.2<br />
e. so restless that you couldn’t sit long<br />
in a chair?<br />
f. proud because someone complimented<br />
you on something you had done?<br />
31.2<br />
77.6<br />
g. upset because someone criticised you? 27.3<br />
h. particularly excited or interested<br />
in something?<br />
67.5<br />
i. depressed or very unhappy? 31.2<br />
j. on top of the world? 60.5<br />
Over 85% of clients were pleased about having<br />
accomplished something in the past month. While we<br />
did not ask what had been accomplished, some clients<br />
did volunteer answers which included staying well,<br />
being able to stay out of hospital, making a new friend<br />
or getting a job or volunteer work. A further 80% were<br />
happy that ‘things had gone their way’ <strong>and</strong> were proud<br />
that someone had complimented them on something<br />
they had done (77%).<br />
On a negative note, just over 40% claimed to have<br />
felt lonely <strong>and</strong> over 30% indicated that they had felt<br />
depressed in the past month. In addition, just over<br />
50% felt bored. Additional analysis of these responses<br />
found that most of the clients who indicated that they<br />
were lonely, bored or depressed were actually the<br />
same clients. Thus individuals who indicated that they<br />
were lonely were also likely to indicate that they were<br />
bored <strong>and</strong> or depressed.
6.10 Section summary<br />
The average time spent in inpatient care for each<br />
individual decreased signifi cantly from an average of<br />
227 days in the 12 months prior to <strong>HASP</strong>, to an average<br />
of 18.9 days in the 12 months post-<strong>HASP</strong>. Moreover,<br />
the number of admissions also decreased signifi cantly<br />
from an average of 1.22 admissions in the 12 months<br />
prior to <strong>HASP</strong>, to an average of 0.66 admissions per<br />
individual in the 12 months post-<strong>HASP</strong>.<br />
In terms of functioning, there was a trend towards<br />
improved clinical <strong>and</strong> general functioning. While<br />
improvements were not statistically signifi cant, the<br />
clients as a group did not deteriorate following entry<br />
into <strong>HASP</strong>. Indeed, the fi ndings indicate that over half<br />
of the clients improved in general functioning <strong>and</strong> over<br />
40% in their clinical functioning in the 12 months since<br />
joining <strong>HASP</strong>.<br />
It would appear that support workers are more<br />
positive than Case Managers about the potential<br />
for the functioning of clients to change in the future.<br />
However, it should be noted that ‘functioning’ can<br />
have different meaning among different groups. For<br />
example, functioning for a Case Manager could imply<br />
clinical functioning, while functioning for a support<br />
worker could mean general/life skills functioning.<br />
The literature suggests that while life skills are likely<br />
to improve over time, improvement in clinical<br />
functioning, particularly in the area of symptoms,<br />
is much more diffi cult to achieve.<br />
Restrictions placed on clients through the Mental<br />
Health Act had been signifi cantly relaxed since clients<br />
joined <strong>HASP</strong>. The proportion of clients on Involuntary<br />
Treatment Orders (ITOs) decreased from 46% to<br />
22%, while the proportion of clients with voluntary<br />
status increased from 43% to 70%.<br />
Almost half of the clients (49.3%) indicated that they<br />
had a physical health problem, while 33% claimed<br />
to be taking medications for physical health problems.<br />
Three-quarters of the clients (n=60) smoked with a<br />
daily intake of around 20 cigarettes. In the month prior<br />
to interview 41 clients (53.9%) had consumed alcohol,<br />
with two clients claiming to have had alcohol on every<br />
day in the past month. One-third of those who had<br />
alcohol had consumed only two drinks on the days that<br />
they had alcohol. Four of the clients claimed to have<br />
had cannabis in the month prior to interview.<br />
Clients rated their overall quality of life with a mean<br />
rating of 6.87 out of a possible total score of 10.<br />
Notwithst<strong>and</strong>ing these positive views, just over<br />
40% claimed to have felt lonely <strong>and</strong> over 30% indicated<br />
that they had felt depressed in the past month.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
61
62<br />
Section 7<br />
How do costs of providing care under <strong>HASP</strong><br />
compare with alternative care options?<br />
A comprehensive economic evaluation of <strong>HASP</strong> would require considerable time <strong>and</strong><br />
expertise (Lapsley et al., 2000) <strong>and</strong>, as such, is beyond the scope of this broader evaluation.<br />
In the absence of an in-depth economic evaluation, we have provided ‘estimates’ of the<br />
costs associated with both community <strong>and</strong> inpatient options. As such, a degree of caution<br />
is required when quoting or using the data from this section of the report.<br />
The costs associated with sourcing accommodation,<br />
locating support services <strong>and</strong> transitioning individuals<br />
into the community are diffi cult to quantify. Recurrent<br />
costs are much easier to identify since they are likely<br />
to be tied to each individual. An estimate of the<br />
recurrent costs associated with inpatient <strong>and</strong><br />
community care are provided below.<br />
7.1 Costs associated with<br />
community care<br />
There are three major contributors to the recurrent<br />
cost of community care — (i) costs associated with<br />
non-clinical support services (support agency, support<br />
workers), (ii) costs associated with the provision of<br />
mental health services (Case Manager, GP, etc) <strong>and</strong><br />
(iii) inpatient care costs for those requiring admission<br />
to hospital. These different cost drivers are discussed<br />
below.<br />
(i) Disability support costs<br />
The average cost of providing disability support was<br />
estimated to be $47.50 per hour. This includes the cost<br />
of providing ‘in-home’ support services to clients <strong>and</strong><br />
the administration costs associated with supervision<br />
<strong>and</strong> service coordination. Given that the average client<br />
was receiving 20 hours of support per week at followup,<br />
this would equate to a cost of $950 per week or<br />
$49,500 per annum.<br />
(ii) Case management costs<br />
The major costs in this category include those incurred<br />
in the provision of mental health services (e.g. case<br />
management <strong>and</strong> GP services). Given that the majority<br />
of clients receive a visit from their Case Manager<br />
every two weeks, or visit to a GP every two weeks,<br />
the estimated average cost is $4,500 pa (i.e. 30 visits<br />
per year at $150 per visit).<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
(iii) Inpatient care costs<br />
Despite the best efforts of all involved, a subgroup<br />
of clients will require admission to inpatient care.<br />
The average daily cost of an acute inpatient care<br />
in Queensl<strong>and</strong> is estimated to be $670 per day<br />
(K Fjeldsoe, personal communication, Oct 2010).<br />
The average length of stay for those admitted to acute<br />
inpatient care in the 12 months post-<strong>HASP</strong> was 18.9<br />
days. We have allocated one admission per client, per<br />
year, however, this is likely to be an overestimate given<br />
that the majority of clients did not require hospital<br />
admission (only 36.6% of clients required admission<br />
to acute inpatient care since joining <strong>HASP</strong>). Thus<br />
the cost of keeping a client in hospital post-<strong>HASP</strong><br />
is approximately $12,663 (based on an average stay<br />
of 18.9 days at a cost of $670 per day).<br />
Table 7.1 Estimated costs of keeping client in <strong>HASP</strong><br />
for 12 months<br />
Disability support costs<br />
Case management costs<br />
Acute inpatient care costs<br />
(per admission)<br />
TOTAL $66,663<br />
$49,500<br />
$ 4,500<br />
$12,663<br />
In summary, the approximate recurrent cost for the<br />
‘average’ client in <strong>HASP</strong> (who has one admission to<br />
acute inpatient care in a given year) is $66,663 per<br />
year or $183 per day. Should the patient not require<br />
admission to acute care, the cost decreases to<br />
$54,000 or $148 per patient day.
7.2 Comparing <strong>HASP</strong> with inpatient/residential alternatives<br />
It should be noted that <strong>HASP</strong> clients could enter the program from a range of facilities, including acute inpatient<br />
units, community care units (CCUs) <strong>and</strong> extended treatment <strong>and</strong> rehabilitation units. It is reasonable to conclude<br />
that if clients could not access <strong>HASP</strong>, they would remain in one of these residential facilities. Thus it is useful to<br />
compare <strong>HASP</strong> costs with those associated with these ‘alternate’ facilities. The estimated costs of care in these<br />
facilities are provided in the table below. As a consequence of the additional costs associated with the provision<br />
of infrastructure, such as libraries <strong>and</strong> education departments at psychiatric hospitals (where two of the largest<br />
extended treatment units are located), the bed day cost at extended treatment <strong>and</strong> rehabilitation units is<br />
signifi cantly higher than at CCUs.<br />
Table 7.2 Cost of care — <strong>HASP</strong> versus alternative options.<br />
Service Type Annual/Daily Cost<br />
Acute Inpatient Unit<br />
Community Care Unit<br />
Extended Treatment & Rehabilitation<br />
Project 300<br />
<strong>HASP</strong> (with one acute admission)<br />
<strong>HASP</strong> (no admission)<br />
7.3 Cost of care pre <strong>and</strong> post-<strong>HASP</strong><br />
Of the 80 clients in our sample, we have admission<br />
data (number of admissions <strong>and</strong> length of stay) for<br />
70 clients at 12 months prior to entering <strong>HASP</strong> <strong>and</strong><br />
12 months post entry into <strong>HASP</strong>. The average time<br />
in inpatient care prior to <strong>HASP</strong> was 227 days <strong>and</strong><br />
the average time post-<strong>HASP</strong> was 18.9 days. Most of<br />
the clients entered the program from an extended<br />
treatment <strong>and</strong> rehabilitation unit or from a community<br />
care unit. Given the cost estimates outlined in the<br />
table above, the average cost of care in an extended<br />
treatment unit for the 70 clients in the 12 months prior<br />
to <strong>HASP</strong> would be $147,550 per client (for a stay of<br />
227 days), while the average cost post-<strong>HASP</strong> was<br />
$12,663 per client (for a stay of 18.9 days).<br />
$244,550 pa. ($670 per day)<br />
$140,525 pa. ($385 per day)<br />
$200,750 pa. ($650 per day)<br />
$ 60,626 pa. ($166 per day – in 2007)<br />
$66,663 pa. ($183 per day)<br />
$54,000 pa. ($148 per day)<br />
7.4 Section summary<br />
It should be noted that there are considerable ‘upfront’<br />
costs involved in sourcing accommodation for programs<br />
such as <strong>HASP</strong>. Most housing providers do not have a<br />
supply of surplus housing, therefore, housing options<br />
have to be purchased or constructed to meet the<br />
additional dem<strong>and</strong> generated by these programs. These<br />
costs have not been considered in our estimate as they<br />
are diffi cult to estimate with any degree of accuracy.<br />
The recurrent costs for a client with an average of<br />
20 hours of support per week ($66,663) are signifi cantly<br />
less expensive than keeping the same client in acute<br />
inpatient care or in a CCU. Indeed, our fi ndings suggest<br />
that it would be possible to keep two clients in <strong>HASP</strong> for<br />
the cost of keeping one client in a CCU, or four clients<br />
in <strong>HASP</strong>, for the cost of keeping one client in an acute<br />
inpatient unit.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
63
64<br />
Section 8<br />
Discussion<br />
The purpose of this study was to ‘undertake an evaluation of the <strong>Housing</strong> <strong>and</strong> <strong>Support</strong><br />
<strong>Program</strong> (<strong>HASP</strong>) to determine delivery <strong>and</strong> outcome effectiveness <strong>and</strong> effi ciencies, as well<br />
as to identify <strong>and</strong> recommend opportunities for the future management of the program.’<br />
The evaluation team was asked to focus on:<br />
the effectiveness of the collaborative process<br />
established across agencies<br />
the process of providing clinical, non-clinical<br />
<strong>and</strong> housing services to clients<br />
the opportunities available through the program<br />
for clients to maximise their recovery <strong>and</strong> participate<br />
in community life — the focus here will be on social,<br />
recreational, educational, <strong>and</strong> vocational activities<br />
in the community<br />
the ability of the program to maintain clinical<br />
functioning <strong>and</strong> provide an acceptable quality<br />
of life for those supported by the program.<br />
A degree of caution is required in attempting to<br />
generalise the results of this study to other settings<br />
or populations. The clients in our sample volunteered<br />
to participate when invited to do so. As such, they may<br />
be different from those who declined to participate<br />
in important ways that may have an impact on the<br />
fi ndings. Notwithst<strong>and</strong>ing this, the 80 <strong>HASP</strong> clients<br />
who contributed to the evaluation from across<br />
Queensl<strong>and</strong> are likely to represent the broader<br />
population of clients in the program.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
8.1 The effectiveness of the collaborative<br />
process established across agencies<br />
It was apparent from discussions with staff at the<br />
coalface that many were concerned about interagency<br />
collaboration <strong>and</strong> communication within the program.<br />
It was felt that a single point of contact for <strong>HASP</strong> was<br />
required within each district. Some aspects of this<br />
role have been provided by <strong>Support</strong>s Facilitators<br />
across the state. However, the reforms outlined in the<br />
Growing Stronger reforms indicate that the <strong>Support</strong>s<br />
Facilitator role is likely to change. <strong>Support</strong>s Facilitators<br />
will have less input into programs such as <strong>HASP</strong>.<br />
It has been suggested that the role of the current<br />
Service Integration Coordinator (SIC) position could<br />
be broadened to provide these functions. Indeed,<br />
many of the Service Integration Coordinators have<br />
been invaluable in improving coordination between the<br />
agencies involved in <strong>HASP</strong>. However, there is variation<br />
in the way in which the role has been interpreted <strong>and</strong><br />
implemented. It is clear that some clarity is required<br />
around the role to be provided by Service Integration<br />
Coordinators <strong>and</strong> their involvement, if any, in programs<br />
such as <strong>HASP</strong>.<br />
Many people noted the arduous nature of completing<br />
the paperwork to nominate clients for <strong>HASP</strong>. The<br />
paperwork required <strong>and</strong> the quantity of supporting<br />
documentation made the application process<br />
cumbersome <strong>and</strong> time-consuming. It was noted that<br />
in smaller teams it can be extremely diffi cult to fi nd an<br />
occupational therapist to provide an assessment, or to<br />
obtain a report from a psychiatrist. As a consequence,<br />
many of the clinical staff interviewed suggested<br />
changes to the selection process at the district level.<br />
It was proposed that the Case Manager could complete<br />
a one/two-page summary for their nominated client/s<br />
<strong>and</strong> then present this to their District Review Team.<br />
The District Review Team could ask questions of the<br />
Case Manager <strong>and</strong> prioritise nominations. Once a client<br />
had been shortlisted to advance to the next level, the<br />
Case Manager would provide a more detailed written<br />
application, which could then be submitted formally<br />
to the statewide panel. This would increase the quality
of applications, increase Case Manager involvement<br />
with the process, improve the estimation of support<br />
needs, <strong>and</strong> may decrease the risk of inappropriate<br />
clients being nominated.<br />
Notwithst<strong>and</strong>ing the above concerns, there was a<br />
general impression that the appropriateness of <strong>HASP</strong><br />
referrals had improved in recent years. The information<br />
sessions provided across the state by members of<br />
the <strong>HASP</strong> Operational Partnership were seen as being<br />
useful for clinical staff in decision-making around<br />
client selection for <strong>HASP</strong>. Nonetheless, there was<br />
a perception among some support agencies that<br />
mental health staff were using the program to<br />
discharge their most diffi cult clients. Many of these<br />
clients were considered inappropriate for <strong>HASP</strong> as<br />
they required more support hours than could be<br />
provided through <strong>HASP</strong>. This is similar to fi ndings<br />
from earlier work carried out in New South Wales,<br />
which suggests that mental health services nominated<br />
their most disabled clients, many of which were<br />
inappropriate, for the housing <strong>and</strong> support program<br />
(Muir et al., 2006).<br />
A number of stakeholders noted that some clients have<br />
three care plans — a transition plan, a plan developed<br />
by clinical services <strong>and</strong> a plan developed by the<br />
support agency. It is diffi cult to see how a coordinated<br />
approach to service provision can be maintained when<br />
individual clients have up to three care plans. Each<br />
client should have a single care plan which has input<br />
from all stakeholders, including the client. This care<br />
plan should be used to guide interventions with the<br />
client <strong>and</strong> be reviewed <strong>and</strong> updated on a regular basis<br />
— at least every three months.<br />
<strong>Final</strong>ly, communication at the local level can also be<br />
problematic when a range of staff is involved with the<br />
same client. We found that one agency was using a<br />
diary (kept in the homes of clients) to keep a record<br />
of appointments <strong>and</strong> other activities carried out for<br />
clients. All persons entering the home of the client<br />
were encouraged to make an entry in the diary so as a<br />
record of the visit was documented. The diary provides<br />
a record of visitors to the home (including staff), an<br />
audit trail of interventions carried out <strong>and</strong> the date<br />
the interventions were provided. It is suggested that<br />
all support agencies consider using a diary to improve<br />
communication between staff <strong>and</strong> staff, <strong>and</strong> staff<br />
<strong>and</strong> clients.<br />
8.2 The process of providing clinical,<br />
non-clinical <strong>and</strong> housing services<br />
to clients<br />
Clinical Service Provision<br />
Clinical service provision within <strong>HASP</strong> is usually<br />
provided by Case Managers employed by Queensl<strong>and</strong><br />
Health. The primary role of Case Managers is to provide<br />
clinical interventions such as assessment, illness<br />
monitoring <strong>and</strong> treatment. Case Managers were held<br />
in high regard by clients. Many clients attributed<br />
improvements in their health to their Case Managers.<br />
Indeed, over 60% of clients believed that their Case<br />
Manager helped them with their symptoms. Most<br />
clients (89%) indicated that they could get in contact<br />
with their Case Manager if they had a problem.<br />
Both Case Managers <strong>and</strong> support workers expressed<br />
satisfaction with the collaborative working<br />
relationships they have developed. Ninety-fi ve percent<br />
of Case Managers outlined that they valued the<br />
support worker role <strong>and</strong> 92% felt that support workers<br />
had a valuable role to play in the treatment planning<br />
process. Despite this, some support workers felt that<br />
they could have greater involvement in decisions <strong>and</strong><br />
planning around patient care.<br />
<strong>Support</strong> workers also raised concerns about<br />
Case Manager involvement in <strong>HASP</strong> <strong>and</strong> felt that<br />
Case Managers could play a greater role in the overall<br />
program. Reasons highlighted for the perceived<br />
lack of involvement included the high caseloads that<br />
some Case Managers were expected to carry <strong>and</strong> the<br />
presence of support workers in the lives of the clients.<br />
Case mangers were aware that support workers<br />
would contact them if they observed changes in client<br />
symptoms/behaviour. Muir <strong>and</strong> colleagues (2007),<br />
in a NSW study, found that Case Managers had less<br />
involvement with clients supported by NGOs due<br />
to the auxiliary services provided by support workers<br />
(Muir et al., 2006).<br />
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Non-clinical Service Provision<br />
<strong>Support</strong> services are often essential in compensating<br />
for the lack of a family network <strong>and</strong>/or reducing the<br />
burden of care placed on carers (Oliver et al., 1996).<br />
They assist people to navigate the fragmented maze<br />
of mainstream social <strong>and</strong> disability services by<br />
linking people to community-based recreational <strong>and</strong><br />
vocational services. Non-government organisations<br />
have been able to develop models of care that allow<br />
for the episodic <strong>and</strong> fl uctuating nature of chronic<br />
illness. Moreover, the community focus of the disability<br />
sector, which is not treatment or illness-orientated,<br />
offers an alternative to existing medical models.<br />
Many of the clients spoke about their relationship<br />
with their support workers <strong>and</strong> described them<br />
as friends, mates <strong>and</strong> companions. The issues of<br />
friendship between support workers <strong>and</strong> clients can<br />
be viewed in different ways. On one h<strong>and</strong>, support<br />
workers who are too successful at becoming friends<br />
for clients may defeat the long-term goal of reducing<br />
contact with clients (i.e. as independence increases).<br />
On the other h<strong>and</strong>, clients making friends with those<br />
people with whom they have most contact is not only<br />
a good survival strategy, but also exercises a capacity<br />
for friendship which can be used outside the home<br />
environment to widen support networks.<br />
<strong>Support</strong> workers felt, as a result of their interactions<br />
with Case Managers, that they had an important role<br />
to play in the treatment process. However, just over<br />
half (54%) agreed that Case Managers had provided<br />
them with as much information as they needed. Six in<br />
every 10 support workers expressed a desire to have<br />
a greater say in the services provided to <strong>HASP</strong> clients.<br />
Only one-third of support workers indicated that they<br />
were involved in developing care plans for clients.<br />
However, in most support agencies this task is left to<br />
the <strong>Support</strong>s Coordinator who disseminates relevant<br />
information to the support workers.<br />
Training for support workers was raised by Case<br />
Managers <strong>and</strong> support workers themselves. Both<br />
groups felt that support workers require more training<br />
in a range of areas to enable them to work with clients<br />
who have complex needs. Indeed, almost half of the<br />
support workers involved in the study (45%) felt they<br />
required more training to be able to work effectively<br />
with their <strong>HASP</strong> clients. Training in the use of recovery<br />
principles was identifi ed as a key area for additional<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
training. While 85% outlined that they were familiar<br />
with the principles of recovery, 37% felt that they<br />
needed more training in the use of recovery<br />
principles in practice.<br />
<strong>Support</strong> workers highlighted issues with transport,<br />
lack of money <strong>and</strong> lack of motivation in their clients<br />
as key areas of concern. Lack of motivation in clients<br />
was mentioned by most of the support workers who<br />
participated in the study. <strong>Support</strong> workers found it<br />
diffi cult to engage clients in exercise or activities<br />
outside the home. One support worker described<br />
her client as being a ‘bit lazy… it’s so diffi cult to get<br />
him to do anything’. The issue here is unlikely to be<br />
laziness, rather a lack of motivation that is frequently<br />
found in conditions such as schizophrenia. Acquiring<br />
a better underst<strong>and</strong>ing of this issue (through training)<br />
may help support workers to appreciate consumer<br />
behaviours <strong>and</strong> how best to work with these.<br />
The disability support sector has demonstrated its<br />
ability to manage people with severe <strong>and</strong> persistent<br />
psychiatric disability in community settings. However,<br />
there is a danger that the disability sector will exp<strong>and</strong><br />
to meet needs that should be met by other services —<br />
a problem that has plagued the mental health sector<br />
for years. This could further marginalise <strong>and</strong> isolate<br />
people with mental illness. Onyett & Smith (2001)<br />
noted that the correct mix of clinical <strong>and</strong> non-clinical<br />
staff on mental health teams continues to be widely<br />
debated. Both groups of staff seem to be dependent<br />
on each other. Non-clinical support staff depend<br />
on clinical staff to ensure that adequate treatment<br />
<strong>and</strong> symptom control is provided to maximise the<br />
outcomes of support. Clinical staff, on the other<br />
h<strong>and</strong>, depend on non-clinical staff to provide lifestyle<br />
support to maximise the outcomes of treatment.<br />
The fi ndings suggest that support agencies were able<br />
to reduce the levels of support provided to clients over<br />
the study period. <strong>Support</strong> hours provided each week<br />
decreased by an average of 7.13 hours, from a mean<br />
of 27.6 hours on entry into <strong>HASP</strong> to a mean of 20.4<br />
hours at the follow-up time-point. However, fl exibility<br />
of funding within the model needs to be continuously<br />
monitored as there is potential for over-servicing.<br />
Strauss (1996) notes that fl exibility in support should<br />
form the cornerstone of any disability support program<br />
<strong>and</strong> stresses that disability services should be on<br />
tap, not on top. In other words, services should be
available when <strong>and</strong> where needed by clients. It is<br />
clear that the provision of support services should be<br />
based on some ongoing assessment of client need,<br />
<strong>and</strong> services should be provided to match this need.<br />
In relation to <strong>HASP</strong>, there needs to be greater clarity on<br />
how decisions are made regarding the level of support<br />
provided to individuals within the model.<br />
While support agencies have greater freedom to<br />
meet client support needs within the ‘block’ funding<br />
model, there appears to be less fl exibility for clients<br />
to move between service providers. Clients wishing to<br />
transfer to another agency have to fi nd an agency with<br />
suffi cient funding capacity to cater for their support<br />
needs (since the transferring agency retains the<br />
funding). This can be especially diffi cult for consumers<br />
with large support packages. Thus, there needs to<br />
be a review of the block funding model to ensure that<br />
there is suffi cient fl exibility to enable clients to move<br />
between agencies if they so desire.<br />
Accommodation Services<br />
The provision of appropriate <strong>and</strong> affordable<br />
accommodation was considered by the clients<br />
<strong>and</strong> staff interviewed to be one of the most important<br />
components in the success of <strong>HASP</strong>. While it is clear<br />
that housing has a physical component (i.e. an<br />
identifi ed building), it also provides people with a<br />
sense of identity <strong>and</strong> ‘asylum’ from the outside world.<br />
The quality of housing has been found in previous<br />
studies to impact on the rehabilitation, functioning,<br />
<strong>and</strong> quality of life of people with mental illness.<br />
Individuals living in appropriate housing that met their<br />
needs had better outcomes at follow-up (Nelson et al.,<br />
1995; Baker & Douglas, 1990; Rosenfi eld, 1990).<br />
Having enough space was an important factor in<br />
overall satisfaction with accommodation. Clients<br />
valued having a spare bedroom for visiting family<br />
members. Others, with a fl air for art <strong>and</strong> other hobbies<br />
valued having a second bedroom which they used as a<br />
studio. However, some clients experienced diffi culties<br />
when friends of family members moved in to a spare<br />
room. Having people staying became a source of<br />
stress when these people refused to leave or began to<br />
dem<strong>and</strong> food <strong>and</strong> money from the client. Thus, careful<br />
assessment of the client <strong>and</strong> their need for additional<br />
bedrooms needs to be carried out as part of the<br />
process of allocating accommodation.<br />
The majority of <strong>HASP</strong> clients (76%) lived on their own.<br />
However, 22% felt that they would like to live with<br />
a roommate or friend in the future. The evaluation<br />
team notes that while <strong>HASP</strong> clients are not prevented<br />
from sharing accommodation, they are unable to share<br />
the support services they receive. It may be worth<br />
exploring how the program can better facilitate share<br />
housing for a small sub-group of clients who may<br />
prefer this option.<br />
Fourteen of the 80 clients in our sample had moved<br />
accommodation since joining <strong>HASP</strong>. Eleven of these<br />
had moved once, one had moved twice <strong>and</strong> two had<br />
moved thrice. There were three main reasons cited<br />
for moving — noise from neighbours <strong>and</strong> or unable<br />
to get along with neighbours (n=8), dislike of the area<br />
in which they lived (n=3), <strong>and</strong> to be closer to family<br />
(n=3). While client requests to move accommodation<br />
could be viewed as a negative for the program, it is<br />
reassuring that clients can ask to be relocated to a<br />
new neighbourhood <strong>and</strong> this appears to be feasible<br />
within <strong>HASP</strong>.<br />
It is clear that having one’s own home in the<br />
community provides a connectedness to that<br />
community. Themes that emerged from the interviews<br />
with clients suggest that stable housing plays an<br />
important role in one’s recovery. Clients viewed their<br />
housing as being important in providing stability in<br />
their lives <strong>and</strong> a platform from which to participate<br />
in the recovery process. Two other themes to emerge<br />
included a ‘sense of freedom’ <strong>and</strong> a ‘sense of home’.<br />
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8.3 The opportunities available through the program for clients to maximise their<br />
recovery <strong>and</strong> participate in community life — the focus here will be on social,<br />
recreational, educational <strong>and</strong> vocational activities in the community<br />
During interviews with clients we heard several<br />
accounts of how <strong>HASP</strong> had helped them to move from<br />
a life fi lled with despair <strong>and</strong> isolation to one of hope.<br />
All of the clients interviewed felt that the housing <strong>and</strong><br />
support provided through <strong>HASP</strong> were essential in<br />
promoting recovery. While eight of the 80 <strong>HASP</strong> clients<br />
(10%) were in paid employment, the hours worked<br />
ranged from four to 60 per week, with a mean of<br />
18.06 hours worked per week. However, it should<br />
be noted that over 40% of clients indicated that they<br />
would like to have paid employment as their main<br />
activity. Thus, there is some scope to engage with<br />
these clients <strong>and</strong> link them into training or other<br />
activities, such as volunteer work, to improve their<br />
chances of securing paid employment in the future.<br />
While 39% of the sample outlined that they would<br />
be able to fi nd someone to ‘put them up’ if they<br />
needed somewhere to stay for a few days, 44% felt<br />
that they would have trouble fi nding someone to drive<br />
them to hospital if they were ill. Indeed, over one-fi fth<br />
of clients indicated that they did not have ‘one person<br />
they could trust’. It is clear that many of the clients who<br />
claimed to have friends, included family members as<br />
friends. Indeed, over one-third of the clients outlined<br />
that they felt lonely <strong>and</strong> bored in the month prior to<br />
data collection.<br />
Access to suffi cient money <strong>and</strong> control over money<br />
are important factors in being able to maintain life<br />
in the community. Overall, <strong>HASP</strong> clients were satisfi ed<br />
with the amount of money they had to spend. Moreover,<br />
they expressed high levels of satisfaction with the<br />
amount of control they had over their money. This was<br />
somewhat surprising given that 51 of the 80 clients<br />
in the study (63%) had their fi nances managed by the<br />
Public Trustee. However, having their fi nances managed<br />
by the Public Trustee enabled some clients to purchase<br />
goods <strong>and</strong> services that they could never previously<br />
afford. By way of example, one client was able to save<br />
enough money to have a holiday in Cairns, while another<br />
described how he was able to buy a racing bicycle<br />
(something he had wanted to do for a number of years,<br />
but never had enough money to do so).<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
Nonetheless, clients should be encouraged (where<br />
possible) to manage their own fi nances. This may<br />
require further education <strong>and</strong> close monitoring of<br />
spending behaviour until clients gain skills in money<br />
management.<br />
It is clear from the interviews with clients that access<br />
to transport is an import factor in their lives. While<br />
public transport is frequently available, many clients<br />
feel anxious or uncomfortable about using public<br />
transport. In recognition of this, some support<br />
agencies provide private transport for their <strong>HASP</strong><br />
clients. Indeed, 66% of the clients indicated that their<br />
support agency/support workers provided transport.<br />
However, the payment of support agencies/workers<br />
for this service does raise some concerns. In some<br />
situations, it was noted that the client pays the support<br />
worker directly for the transport provided. In others,<br />
support workers transport clients free of charge <strong>and</strong><br />
claim the cost in their annual tax return as a workrelated<br />
deduction. <strong>Final</strong>ly, some agencies take funding<br />
from the client’s <strong>HASP</strong> package to fund transport<br />
costs. It is clear that there needs to be some clarity<br />
provided around the provision of transport <strong>and</strong> how<br />
the costs for transport are to be reimbursed by clients.
8.4 The ability of the program to maintain clinical functioning <strong>and</strong> provide<br />
an acceptable quality of life for those supported by the program<br />
Six of the 194 clients who entered <strong>HASP</strong> were<br />
deceased at the time of follow-up. The one-year<br />
mortality rate of around 0.75% is much lower than<br />
that reported in previous studies. Leff <strong>and</strong> colleagues<br />
(1997), reported that 24 of the 737 clients (3.25%)<br />
discharged from two large psychiatric hospitals in<br />
the UK died within the fi rst 12 months of resettlement.<br />
In one of the earliest follow-up studies of clients<br />
discharged from long-stay hospitals in New South<br />
Wales, Andrews <strong>and</strong> colleagues (1990) reported<br />
that 13 of the 280 (6.25%) clients discharged to group<br />
homes had died in the follow-up period (which ranged<br />
from between 3–40 months). In a recent New South<br />
Wales study (Hobbs et al., 2000), one of the<br />
40 clients discharged (2.5%) died in the two-year<br />
period following discharge.<br />
The average time spent in inpatient care decreased<br />
signifi cantly from an average of 227 days in the<br />
12 months prior to <strong>HASP</strong>, to an average of 18.9 days<br />
in the 12 months post-<strong>HASP</strong>. In addition, the number<br />
of admissions to acute inpatient care also decreased<br />
signifi cantly from an average of 1.22 admissions<br />
in the 12 months prior to <strong>HASP</strong>, to an average of<br />
.66 admissions per individual in the 12 months<br />
post-<strong>HASP</strong>. Similar reductions in the need for inpatient<br />
care have been reported in previous studies. In a<br />
seven-year follow-up of ‘Project 300’ clients, Meehan<br />
<strong>and</strong> colleagues (2011) found that 40% of clients in<br />
the program had not been admitted to hospital in<br />
the seven years since entering ‘Project 300’. This is<br />
despite the fact that most had spent the two years<br />
prior to ‘Project 300’ in hospital. In the NSW study,<br />
Muir <strong>and</strong> colleagues (2007) found a 77.6% decrease<br />
in the number of days spent in hospital following the<br />
implementation of the HASI <strong>Program</strong> in NSW.<br />
There was a trend towards improved clinical <strong>and</strong><br />
general functioning. While improvements were not<br />
statistically signifi cant, the clients (as a group) did<br />
not deteriorate following entry into <strong>HASP</strong>. Indeed, the<br />
fi ndings indicate that over half of the clients improved<br />
in general functioning <strong>and</strong> over 40% improved in<br />
their clinical functioning in the 12 months since<br />
joining <strong>HASP</strong>. These fi ndings challenge the belief that<br />
conditions such as schizophrenia follow a course of<br />
progressive deterioration. Thus, support workers <strong>and</strong><br />
others involved in the treatment of these clients must<br />
maintain their recovery focus <strong>and</strong> hope for the future.<br />
Restrictions placed on clients through the Mental Health<br />
Act had been signifi cantly relaxed since clients joined<br />
<strong>HASP</strong>. The proportion of clients on Involuntary Treatment<br />
Orders (ITOs) decreased from 46% to 22%, while the<br />
proportion of clients with voluntary status increased<br />
from 43% to 70%. In the absence of all other measures,<br />
this suggests that client functioning <strong>and</strong> compliance<br />
with treatment is improving. It also indicates that efforts<br />
are being made by clinical services to reduce restrictions<br />
on clients where possible.<br />
Physical health issues are likely to become a concern<br />
for this cohort of clients in the future. Almost half of the<br />
clients (49.3%) indicated that they had a physical health<br />
problem, while 33% claimed to be taking medications<br />
for physical health problems. Almost three-quarters<br />
smoked cigarettes, with an average daily intake of<br />
20 cigarettes per person. A number of clients stated<br />
that they would like to stop smoking <strong>and</strong> had tried to<br />
do so without success. Implementing strategies to<br />
reduce cigarette-smoking may need to be considered.<br />
In the month prior to interview, 41 clients (53.9%) had<br />
consumed alcohol, with two clients claiming to have<br />
had alcohol on every day in the past month. One-third<br />
of those who had alcohol had only two drinks on the<br />
days that they consumed alcohol. Four of the clients<br />
claimed to have cannabis in the month prior to interview.<br />
Over 85% of clients were pleased about having<br />
accomplished something in the past month. While<br />
we did not ask what had been accomplished, some<br />
clients did volunteer answers, which included staying<br />
well, being able to stay out of hospital, making a new<br />
friend or getting a job or volunteer work. A further<br />
80% were happy that ‘things had gone their way’ <strong>and</strong><br />
were proud that someone had complimented them on<br />
something they had done (77%). Clients rated their<br />
overall quality of life with a mean rating of 6.87 out<br />
of a possible total score of 10. Notwithst<strong>and</strong>ing these<br />
positive views, just over 40% claimed to have felt lonely<br />
<strong>and</strong> over 30% indicated that they had felt depressed in<br />
the past month.<br />
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Section 8 Discussion<br />
8.5 <strong>Program</strong> costs<br />
Overall, the cost of keeping the ‘average’ client in <strong>HASP</strong><br />
for 12 months is signifi cantly less expensive than<br />
keeping the same client in a CCU or in acute inpatient<br />
care. The fi nding suggests that one could maintain<br />
two clients in <strong>HASP</strong> for the cost of keeping one client<br />
in a CCU <strong>and</strong> four clients in <strong>HASP</strong> for the cost of<br />
keeping one client in an acute inpatient unit. It should<br />
be noted that the costs are based on recurrent costs<br />
only. There are considerable ‘upfront’ costs involved<br />
in sourcing accommodation for programs such as<br />
<strong>HASP</strong>. Most housing providers do not have a supply<br />
of surplus housing, therefore, housing options have<br />
to be purchased or constructed to meet the additional<br />
dem<strong>and</strong> generated by these programs. These costs<br />
have not been considered in our estimate.<br />
There is wide variation in the size of individual support<br />
packages — some packages cost signifi cantly less <strong>and</strong><br />
others signifi cantly more than the average package of<br />
around 20 hours of support per week. This variation<br />
is not unexpected. It highlights the importance of<br />
having individual programs of support that address the<br />
unique needs of each individual. This is undoubtedly<br />
a major contributor to the high levels of satisfaction<br />
<strong>and</strong> improvements in functioning observed in this<br />
evaluation. Indeed, our individual cost estimate<br />
of $66,600 is similar to that obtained in the New<br />
South Wales ‘<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> Initiative’ (HASI)<br />
study which reported a recurrent cost of $57,530 per<br />
individual in 2007 (Muir et al., 2007).<br />
The one major theme to emerge from all the studies,<br />
<strong>and</strong> from <strong>HASP</strong>, is that community care is generally less<br />
expensive than hospital care for the majority of clients.<br />
Leff <strong>and</strong> colleagues (1997) found that approximately<br />
10% of clients with high support needs are likely to<br />
cost more in the community than in hospital. Based on<br />
estimates for the <strong>HASP</strong> cohort, none of the packages<br />
exceeded $140,525 per year which is the estimated<br />
cost of maintaining a client in a Community Care Unit<br />
for 12 months.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
8.6 Conclusions<br />
Given the focus on community care in national<br />
policy, the fi ndings have implications for service<br />
provision. <strong>HASP</strong> is an excellent example of how<br />
government agencies can work together to improve<br />
the wellbeing of people with psychiatric disabilities.<br />
<strong>HASP</strong> demonstrates that given adequate support,<br />
stable housing <strong>and</strong> good case management, the<br />
accommodation needs of people with psychiatric<br />
disabilities can be met through ordinary/normal<br />
housing in the community. Indeed, those involved<br />
in the planning of future resettlement programs are<br />
encouraged to consider the <strong>HASP</strong> model.<br />
Assessed on any measure, our fi ndings indicate that<br />
<strong>HASP</strong> has been as successful, if not more successful,<br />
than the majority of supported housing programs<br />
reported in the literature. Community care within <strong>HASP</strong><br />
appears to have an overall economic advantage over<br />
hospital care <strong>and</strong> no clear disadvantage for clients.<br />
Those who participated in the interviews expressed<br />
high levels of satisfaction with the program <strong>and</strong> felt<br />
that <strong>HASP</strong> was instrumental to their recovery.<br />
All of the clients in the evaluation demonstrated<br />
a strong preference for community living. The freedom<br />
<strong>and</strong> choice that community living offers appears to<br />
compensate for the increased responsibility associated<br />
with such living. Overall, it is clear that while some<br />
clients have made considerable advances in securing<br />
a future in the community, others have been less<br />
successful in taking advantage of the opportunities<br />
available to them. While service models continue to<br />
provide support, they must also allow for what Deegan<br />
(1992) calls the ‘dignity of risk <strong>and</strong> the right of failure’.<br />
Thus, the challenge for service providers is to fi nd<br />
the right balance between the provision of planned<br />
interventions for clients <strong>and</strong> ensuring that clients have<br />
the freedom to be self-determining individuals.
Section 9<br />
Recommendations<br />
1. More information needs to be provided to the staff<br />
of all agencies concerning the selection criteria<br />
<strong>and</strong> the characteristics of clients most suitable<br />
for the program. It may be useful to develop<br />
an information package, such as a DVD, that<br />
outlines the criteria, the application process, the<br />
verifi cation process, <strong>and</strong> issues that need to be<br />
addressed as the client moves into <strong>HASP</strong>. Such<br />
a DVD could also be useful for clients who have<br />
been allocated a place in <strong>HASP</strong>. It would provide<br />
them with a better underst<strong>and</strong>ing of the process<br />
<strong>and</strong> the timelines to be expected.<br />
2. It is recommended that the application process<br />
be reviewed with the aim of reducing the burden<br />
placed on staff to nominate clients for <strong>HASP</strong>. It may<br />
be possible that a brief application (one or two<br />
pages) could be reviewed at the district level <strong>and</strong><br />
when a client or clients have been selected for that<br />
district, a more complete application could then be<br />
developed for review by the statewide <strong>HASP</strong> Panel.<br />
3. Notwithst<strong>and</strong>ing the previous recommendations,<br />
there was a general impression that the<br />
appropriateness of <strong>HASP</strong> referrals had improved<br />
in recent years. The information sessions provided<br />
across the state by members of the <strong>HASP</strong><br />
Operational Partnership were seen as being useful<br />
in keeping staff informed of developments in the<br />
program. It is recommended that these forums be<br />
continued.<br />
4. There is considerable variation in the contribution<br />
of Service Integration Coordinators to initiatives<br />
such as <strong>HASP</strong>. Clarity is required around the<br />
role <strong>and</strong> the level of involvement that Service<br />
Integration Coordinators should have in <strong>HASP</strong>.<br />
5. It was identifi ed that a regular review of support<br />
packages was required to ensure that the level<br />
of non-clinical support provided was in keeping<br />
with client needs <strong>and</strong> the promotion of recovery.<br />
<strong>Support</strong>s Facilitators (SFs) have traditionally<br />
provided some oversight of the program. However,<br />
it is unclear how this will be provided in the future<br />
given the changes to the SF role under the reforms<br />
outlined in ‘Growing Stronger’ (2007–2011).<br />
A system for reviewing support <strong>and</strong> related funding<br />
structures needs to be developed in light of the<br />
changes to the SF role.<br />
6. Communication at the local level can also be<br />
problematic when a range of staff is involved with<br />
the same client. We found that one agency was<br />
using a diary (kept in the homes of clients) to keep<br />
a record of appointments <strong>and</strong> other activities<br />
carried out for clients. All persons entering the<br />
home of the client were encouraged to make<br />
an entry in the diary so as a record of the visit<br />
was documented. The diary provides a record of<br />
visitors to the home (including staff), an audit<br />
trail of interventions carried out <strong>and</strong> the date the<br />
interventions were provided. It is suggested that<br />
all support agencies consider using a diary to<br />
improve communication between staff <strong>and</strong> staff,<br />
<strong>and</strong> staff <strong>and</strong> clients.<br />
7. While support agencies have greater freedom<br />
to manage client support needs within the ‘block’<br />
funding model, there appears to be less fl exibility<br />
for clients to move between service providers.<br />
Clients wishing to transfer to another agency<br />
have to fi nd an agency with suffi cient funding<br />
capacity to cater for their support needs (since<br />
the transferring agency retains the funding).<br />
This can be especially diffi cult for consumers with<br />
large support packages. Thus, the block funding<br />
model needs to be reviewed to ensure that there<br />
is suffi cient fl exibility within the model to enable<br />
clients to move more freely between agencies<br />
if they so desire.<br />
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
71
72<br />
Section 9 Recommendations<br />
8. The study found that many clients rely on support<br />
agencies/staff to provide them with transport.<br />
While this is a very worthwhile service, there is<br />
variation in the way in which clients are charged<br />
for this service. <strong>Support</strong> agencies need to clarify<br />
how this service can be provided so as to enable<br />
greater transparency in the way that clients<br />
reimburse agencies for the service.<br />
9. There is little consistency in the provision<br />
of ongoing training for support workers. Moreover,<br />
there is wide variation in the provision of clinical/<br />
practice supervision for support workers. It is<br />
recommended that a sub-group be established<br />
at the state level to provide direction for the<br />
future training <strong>and</strong> supervision needs of support<br />
workers.<br />
10. There are 52 different support agencies providing<br />
services to <strong>HASP</strong> clients <strong>and</strong> these tend to differ in<br />
respect to philosophy, models of service delivery<br />
<strong>and</strong> outcome expectations. To overcome this,<br />
the current model of service delivery needs to be<br />
more closely aligned to the principles of recovery.<br />
Indeed, almost half of the support workers who<br />
participated in the evaluation expressed a desire<br />
to know more about recovery <strong>and</strong> how this could<br />
be applied in practice.<br />
11. It was noted that clients can have a number<br />
of different care plans. It is recommended<br />
that service providers examine options for the<br />
development of a single care plan for each client.<br />
This care plan should be used by all stakeholders<br />
to guide client interventions <strong>and</strong> be reviewed <strong>and</strong><br />
updated on a regular basis – at least every three<br />
months. All stakeholders, including the client,<br />
should have input into the development <strong>and</strong><br />
review of the plan.<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
12. A number of clients stated that they would like to<br />
stop smoking. Implementing strategies to reduce<br />
cigarette-smoking should be considered. Reducing<br />
or ceasing cigarette-smoking would result in better<br />
health for clients <strong>and</strong> more spending money for<br />
other activities.<br />
13. While only 10% of clients were employed, over<br />
40% of clients indicated that they would like to<br />
have paid employment as their main activity. Thus,<br />
there is some scope to engage with these clients<br />
<strong>and</strong> link them into training or other activities such<br />
as volunteer work to improve their chances of<br />
securing paid employment in the future.<br />
14. A system of ongoing evaluation of the services<br />
provided <strong>and</strong> the outcome for clients needs<br />
to be established. Such a system should include<br />
a mechanism for obtaining feedback directly<br />
from the clients in the program. This could take<br />
the form of interviews with a sub-sample of clients<br />
or a satisfaction survey completed by clients on<br />
an annual basis.<br />
15. It is clear from this evaluation that <strong>HASP</strong> provides<br />
an effi cient <strong>and</strong> effective model for enabling those<br />
with severe psychiatric disability to maintain<br />
tenancies <strong>and</strong> establish a life in the community.<br />
It is also clear that dem<strong>and</strong> for <strong>HASP</strong> places far<br />
exceeds the number of packages available. It is<br />
recommended that the program be continued <strong>and</strong><br />
exp<strong>and</strong>ed to better meet the growing dem<strong>and</strong> for<br />
<strong>HASP</strong> places.
Section 10<br />
Reference list<br />
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Baker, F. & Douglas, C. (1990). <strong>Housing</strong> environments<br />
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Carling, P. (1995). Return to the Community:<br />
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Carling, P. & Ridgway, P. (1987). Overview of<br />
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Carter, M. (2008). From psychiatric hospital to<br />
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Institute for Social Research: Swinburne University<br />
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Caton, C., Wyatt, R., Felix, A., Grunberg, J. &<br />
Dominuquez, B. (1993). Follow-up of chronically<br />
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Clarkson, P., McCrone, P., Sutherby, K., Johnson, C.,<br />
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Commonwealth of Australia, (2006). A National<br />
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Cournos, F. (1987). The impact of environmental<br />
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Desl<strong>and</strong>es, M., & Kilner, D. (1997). Another Link in the<br />
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Farhall, J., Trauer, T., Newton, R. & Cheung, P. (2003).<br />
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Fry, A., O’Riordan, D. & Geanellos, R. (2002). Social<br />
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Harrington-Godley, S., Sabin, M., McClure, C.,<br />
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Hickie, I., Groom, L. (2005). Australian mental health<br />
reform: Time for real outcomes. Medical Journal of<br />
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Hobbs, C., Tennant, C., Rosen, A., Newton, L., Lapsley,<br />
H., Tribe, K. & Brown, J. (2000). Deinstitutionalisation<br />
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Leff, J. (1997). The outcome for long-stay non-demented<br />
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Leff, J. & Trieman, N. (2000). Long-stay patients<br />
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Lord, J. & Hutchison, P. (2003). Individualised support<br />
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<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)<br />
75
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Appendix 1<br />
<strong>HASP</strong> 2009–2010 Process fl owchart with timelines<br />
<strong>HASP</strong><br />
Information Sessions<br />
(Nov)<br />
<strong>HASP</strong> Cluster Coordinators<br />
forward the prioritised<br />
nominations to the QH Statewide<br />
<strong>HASP</strong> Coordinator (2 Feb)<br />
The <strong>HASP</strong> Interdepartmental Panel sits <strong>and</strong> considers all <strong>HASP</strong> prioritised<br />
nominations. The Panel approves 40 individuals to progress in <strong>HASP</strong>.<br />
Nomination info is forwarded to DCCS for support assessment <strong>and</strong><br />
verifi cation <strong>and</strong> to HHS for OT housing assessment<br />
DCCS <strong>HASP</strong> Coordinator forwards nomination info<br />
to the appropriate DCCS Regional Offi ce (23 Feb)<br />
DCCS SF:<br />
Assess <strong>and</strong> verifi es individual’s disability support<br />
needs <strong>and</strong> weekly support requirements<br />
Assists in identifying an NGO<br />
Forwards completed verifi cation to MHB<br />
Endorses the individual inclusion in <strong>HASP</strong> (4 May)<br />
DCCS MHB:<br />
notifi es QH, HHS <strong>and</strong><br />
individuals if not verifi ed<br />
for <strong>HASP</strong><br />
collates the verifi ed <strong>HASP</strong><br />
nominations<br />
negotiates with NGOs to<br />
deliver non-clinical support<br />
to <strong>HASP</strong> Individuals<br />
DCCS Minister approves funding<br />
to NGOs to provide non-clinical<br />
support<br />
DCCS recurrent <strong>HASP</strong> funding<br />
enables NGOs to deliver ongoing<br />
non-clinical support to the<br />
<strong>HASP</strong> individual<br />
<strong>Final</strong> <strong>Evaluation</strong> <strong>Report</strong><br />
QH District staff identify <strong>HASP</strong><br />
eligible individuals <strong>and</strong> progress<br />
their <strong>HASP</strong> nominations<br />
(Dec–Jan)<br />
Each QH District forwards their fi nal nominations<br />
(with support hours balanced to equate to their district quota)<br />
to the <strong>HASP</strong> Cluster Coordinators for consideration<br />
<strong>HASP</strong> Operational Group informs<br />
<strong>HASP</strong> Steering Group of the<br />
40 endorsed <strong>HASP</strong> individuals<br />
QH allocates a community Case<br />
Manager for all endorsed <strong>HASP</strong><br />
individuals to assist with their<br />
transition to the community<br />
DCCS Minister notifi es<br />
successful individuals<br />
<strong>and</strong> NGOs of approved funding<br />
<strong>and</strong> support provision (1 Aug)<br />
Individual living in the community (31 Dec)<br />
QH provides ongoing clinical<br />
support <strong>and</strong> treatment where<br />
required to the <strong>HASP</strong> individual<br />
Nominating staff communicate<br />
with district staff to determine<br />
the priority level of their clients<br />
QH letter informs individuals of<br />
<strong>HASP</strong> approval or withdrawal AND<br />
QH Statewide <strong>HASP</strong> Coordinator<br />
informs QH nominating offi cer<br />
of approval/withdrawal<br />
HHS <strong>HASP</strong> Coordinator forwards <strong>HASP</strong> nomination info<br />
to the appropriate <strong>Housing</strong> Service Centre (23 Feb)<br />
HHS OT completes a <strong>Housing</strong> Needs Assessment<br />
to inform <strong>Housing</strong> Service Centre of the individual’s<br />
housing requirements (4 May)<br />
HHS Area Manager forwards PEX<br />
request to HHS <strong>HASP</strong> Coordinator<br />
for replacement stock or to fi nd<br />
specifi c housing solution<br />
HHS progresses property<br />
searches <strong>and</strong> housing allocations<br />
for endorsed <strong>HASP</strong> individuals<br />
<strong>Housing</strong> allocation is made<br />
<strong>and</strong> tenancy commences<br />
HHS provides ongoing supportive<br />
tenancy management for the<br />
<strong>HASP</strong> individual
<strong>Housing</strong> <strong>and</strong> <strong>Support</strong> <strong>Program</strong> (<strong>HASP</strong>)
Disability <strong>and</strong> Community Care Services<br />
Department of Communities<br />
Phone: 3006 8702<br />
www.communities.qld.gov.au/disability