evidence for the mental health demonstration project: a ......the outcomes evaluation of the mental...

Evidence for the Mental Health Demonstration Project: A Mixed Methods Study PREPARED FOR

DEPARTMENT OF HOUSING AND PUBLIC WORKS (NOVEMBER, 2017)

Authors Zoe Walter

Cameron Parsell

Lynda Cheshire

Acknowledgements We acknowledge the Department of Housing and Public Works and Queensland Health

for funding the evaluation

Prepared for Department of Housing and Public Works

Prepared by Institute for Social Science Research

The University of Queensland

Long Pocket Precinct

Level 2, Cycad Building (1018)

80 Meiers Rd

Indooroopilly Queensland 4068

Australia

Phone +61 7 3346 7471

Email [email protected]

Date prepared December 2017

ISSR Project number ISSR021344

mailto:[email protected]

Prepared for: Department of Housing and Public Works Page iii

CONTENTS

Contents .................................................................................................................................. iii

Tables ....................................................................................................................................... v

Figures..................................................................................................................................... vi

Acronyms and abbreviations ............................................................................................... vii

Executive Summary ................................................................................................................ 1

1 Introduction ..................................................................................................................... 6

1.1 Background ............................................................................................................... 7

1.2 Summary of Interim Report Findings ........................................................................ 8

1.3 Outcome Evaluation ............................................................................................... 10

1.4 Evaluation Research Design .................................................................................. 10

1.5 Ethics ...................................................................................................................... 15

2 process evaluation and interim report findings ......................................................... 16

2.1 Participant Referral, Assessment, and Intake Processes ....................................... 16

2.2 The Practice Elements of the Mental Health Demonstration Project ...................... 24

2.3 Evaluation of the Model .......................................................................................... 31

2.4 Modifications Since Interim Report ......................................................................... 35

3 Tenancy Data ................................................................................................................. 37

3.1 Participant Characteristics ...................................................................................... 37

3.2 Participant Housing outcomes ................................................................................ 44

3.4 Summary ................................................................................................................ 50

4 Health Data .................................................................................................................... 51

4.1 Consumer Integrated Mental Health Application Data ............................................ 51

4.2 Diagnoses ............................................................................................................... 55

4.3 Alcohol tobacco and other drugs ............................................................................ 56

4.4 Emergency Department Data ................................................................................. 57

4.5 Summary ................................................................................................................ 58

5 Tenant Interviews .......................................................................................................... 60

5.1 The MHDP Tenant Interviewees ............................................................................. 60

5.2 Signing Up to the Project ........................................................................................ 62

5.3 The Provision of Support: A Tenant Perspective .................................................... 64

5.4 Tenant Experiences of the MHDP .......................................................................... 65

5.5 Client Outcomes Resulting from Participation in the MHDP ................................... 69

5.6 Exiting the Project: Tenant Experience ................................................................... 75

5.7 Conclusion .............................................................................................................. 79

6 Tenant Surveys ............................................................................................................. 81

6.1 Participant Self-reported Perceptions ..................................................................... 81

Institute for Social Science Research Final Report

Prepared for: Department of Housing and Public Works Page iv

6.2 Outcome Star Data ................................................................................................. 83

6.3 Outcome Summary of Findings .............................................................................. 84

7 E-Modules ...................................................................................................................... 85

7.1 Introduction ............................................................................................................. 85

7.2 Mental Health Modules ........................................................................................... 86

7.3 Housing Modules: Introduction to the Housing and Homelessness System .......... 92

7.4 Summary .............................................................................................................. 101

8 Overall Conclusion ..................................................................................................... 102

8.1 Reflection of Key Areas of MHDP ......................................................................... 102

8.2 Conclusions .......................................................................................................... 108

References ........................................................................................................................... 114

Appendix .............................................................................................................................. 115

Measure – MHDP Autonomy Support Climate Questionnaire .......................................... 115

Measure for Perceived Competency for Maintaining Housing Tenancy ........................... 115


Prepared for: Department of Housing and Public Works Page v

TABLES

Table 1. Participant demographics table for tenants who were interviewed ........................... 12

Table 2. Participant demographics table ................................................................................. 39

Table 3. Participant Project Information .................................................................................. 40

Table 4. Number of males and females by tenancy stage ...................................................... 41

Table 5. Stage by Status ......................................................................................................... 41

Table 6. Housing Service by Engagement Status ................................................................... 42

Table 7. Duration of time in project by engagement status ..................................................... 42

Table 8. Duration of time in project by demographic factors, housing factors, and referral

reason for people who completed ........................................................................................... 43

Table 9. Housing Codes – Summary of Total 52 Participants (N = 52) ................................... 47

Table 10. Comparison of Housing Codes received in the 6 months before entering the MHDP

and 6 months after exiting the MHDP...................................................................................... 48

Table 11. Mental health service usage before, during, and after participating in the MHDP. . 51

Table 12. Differences in the Total service usage (intervention duration and services received)

in the 6 months before entering the MHDP and 6 months after exiting the MHDP ................. 52

Table 13. Instances of services utilised by project participants in the 6 months before, during,

and 6 months after the MHDP ................................................................................................. 53

Table 14. Average score on the HoNOS across domains for 6 months before entering the

MHDP, during the MHDP, and 6 months following MHDP ...................................................... 54

Table 15. HoNOS score changes from Start to End of MHDP ................................................ 55

Table 16. Primary diagnosis given during 6 months before entering the MHDP, during the

MHDP, and 6 months after exiting the MHDP ......................................................................... 56

Table 17. Emergency Department Presentations Information................................................. 57

Table 18. Changes Pre to Post in Emergency Department Presentations.............................. 58

Table 19. Recovery Outcome Star Measure means for initial and final review (n = 29). ........ 83

Table 20. Characteristics of respondents across the Mental Health Modules ........................ 86

Table 21. Characteristics of respondents across the Housing modules.................................. 93


Prepared for: Department of Housing and Public Works Page vi

FIGURES

Figure 1. Time Frame of Footprints SHouT Assessment Measures ............................................................................... 14

Figure 2. Governance and Operation Framework .......................................................................................................... 30

Figure 3. Changes in number of housing codes from pre to post project participation. .................................................. 45

Figure 4. Autonomy Perceptions ..................................................................................................................................... 81

Figure 5. Mean level of perceived competency across time ........................................................................................... 82

Figure 6. Change in perceived competency over time .................................................................................................... 82

Figure 7. Change in outcomes (from initial review to final review) on Outcome Star measure. ..................................... 84

Figure 8. Level of understanding the mental health system pre and post module 1 completion .................................... 87

Figure 9. Factors affecting understanding the mental health system pre and post module completion ......................... 88

Figure 10. Level of suicide awareness pre and post module 2 completion .................................................................... 88

Figure 11. Factors impacting confidence in suicide awareness pre and post module 2 completion .............................. 89

Figure 12. Factors impacting confidence and commitment in applying knowledge learnt in module 2 .......................... 89

Figure 13. Changes in level of understanding factors associated with alcohol and other drugs .................................... 90

Figure 14. Factors affecting level of confidence in understanding .................................................................................. 91

Figure 15. Factors impacting confidence and commitment in applying knowledge learnt in module 3 .......................... 91

Figure 16. Changes in level of understanding for factors related to navigating DHPW .................................................. 94

Figure 17. Level of confidence in navigating the DHPW pre and post module 1 completion ......................................... 95

Figure 18. Factors affecting confidence in navigating the DHPW pre and post module 1 completion ........................... 95

Figure 19. Commitment and confidence in applying course knowledge for Module 1 .................................................... 96

Figure 20. Factors affecting commitment and confidence in applying course knowledge for Module 1 ......................... 96

Figure 21. Mean level of understanding of applicant processes pre and post module completion. ................................ 97

Figure 22. Level of confidence in understanding applicant processes ........................................................................... 98

Figure 23. Factors impacting confidence in understanding pre and post module completion ........................................ 98

Figure 24. Factors affecting confidence and commitment in applying course knowledge, post module 2 completion ... 99

Figure 25. Mean level of confidence in understanding processes and procedures pre and post module 3 completion. 99

Figure 26. Level of confidence in understanding tenant procedures and processes .................................................... 100

Figure 27. Confidence and commitment in applying Module 3 knowledge ................................................................... 100

Figure 28. Factors affecting commitment and confidence in applying Module 3 knowledge ........................................ 101


Prepared for: Department of Housing and Public Works Page vii

ACRONYMS AND ABBREVIATIONS

ACT Acute Care Team

ASB Anti-Social Behaviour

ATOD Alcohol, tobacco, and other drugs

CAIRT Cross-Agency Intake and Review Team

CCT Community Care Team

CIMHA Consumer Integrated Mental Health Application

DHPW Department of Housing and Public Works

ED Emergency Department

HoNOS Health of a Nation Outcome Scale

HSC Housing Service Centres

HSIC Housing Service Integration Coordinator

HSP Housing Support Plan

QH Queensland Health

QMHC Queensland Mental Health Commission

MHDP Mental Health Demonstration Project


Prepared for: Department of Housing and Public Works Page 1

EXECUTIVE SUMMARY

A two year Mental Health Demonstration Project (MHDP) commenced on the 1st of January 2016 in the

Chermside and Fortitude Valley Housing Service Centre (HSC) catchment areas. The MHDP trialled a new

integrated housing, mental health, and welfare initiative to assist people in social housing to sustain their

tenancies whilst managing mental illness or related complex needs. This Final Report presents the findings for

the Outcomes Evaluation of the Mental Health Demonstration Project (MHDP) as implemented and delivered

between 1st January 2016 and 31st of July 2017. The evaluation draws on qualitative interviews with MHDP

tenants (n = 21 tenants), a survey with MHDP tenants on perceptions of autonomy (n = 14) and competency (n =

44), Footprints Outcome data (n = 29), DHPW administrative data (n = 115), Queensland Health administrative

data (n = 75), and pre and post data from the Learning Management System E-modules on housing and mental

health (for post data, understanding mental health module n = 214, suicide awareness module n = 192, alcohol

and other drugs module n = 157, navigating housing services module n = 74, applicant processes module n =

44, and tenant processes module n = 37). Additionally, key stakeholders were consulted to discuss and refine

the final analysis of the outcomes evaluation.

1.1.1 What were main processes of the MHDP and how was this delivered in practice?

The process evaluation concluded that the MHDP was delivered in accordance with the Service Delivery

Model in the first six months of operation.

The MHDP Service Delivery Model took a case coordination and case management approach, which

was facilitated by the Housing Service Integration Coordinator situated within the Department of Housing

and Public Works. The Model included broad-based non-clinical psycho-social and tenancy support

services to meet the specific needs of participants, which was provided by Footprints Inc., clinical mental

health support service capacity provided by two Queensland Health mental health clinicians (situated in

Metro North Acute Care Teams), and brokerage funding to purchase specialised or top up psycho-social

and/or tenancy support services.

Additionally, learning management system e-modules were developed to enhance the capability of HSC

staff and local network partners, in the areas of mental health, and housing and homelessness.

1.1.2 Who was referred in the project?

As of the 31st of July 2017, 115 tenants had been referred and accepted into the MHDP project.

There were more females than males referred in the project. The most commonly occurring family type was

single person, followed by single person with children. The Chermside Housing Service Centre (HSC) had

more tenants referred into the project compared to the Fortitude Valley HSC.

Relatively equal numbers of people were referred in at the three different tenancy risk stages (crisis, early

intervention, and prevention). The most commonly occurring reason for referral was for “neighbourhood



issues”, with 42% of the sample having this listed as a presenting concern. The second most common reason

was “personal issues” (30%), followed by mental health issues (24%).

Hoarding and squalor was a significant issue affecting people’s tenancies that was chronic and enduring in

nature. The majority of hoarding and squalor referrals were in the crisis risk stage of their tenancy and people

who had hoarding and squalor often had multiple referral reasons.

1.1.3 What were the tenancy outcomes of participants referred into the project?

As described in detail in Section 3.4, the majority of participants in the project received fewer recorded

incidences that indicate tenancy problems in the 6 months after exiting the project, compared to the 6 months

prior to the project (79% received fewer total codes, 58% received fewer complaints, 52% received fewer

arrears or breaches, and 65% received fewer warnings). Tenants in the project who completed had a

significantly greater reduction in housing codes pre to post, compared to tenants who did not complete

(withdrew, disengaged, or never participated).

The data shows that the improved tenancy outcomes were achieved equally among Indigenous and

non-Indigenous participants.

Participants in the Fortitude Valley HSC had significantly more total housing codes entered in the period

before the project compared to the Chermside HSC. However, in the 6 months following the end of the

project, there were no differences between the two services on number of housing codes.

Qualitatively, the majority of tenants interviewed reported that their housing situations have improved,

including feeling more stable in their housing, either as a result of simply having a tenancy which had

previously felt precarious, or of being in an improved housing situation as the result of a transfer or clean-up.

There are signs of a changed, and improved relationship, between tenants and their housing office

which can be attributed to the MHDP (e.g. Section 5.5.4).

1.1.4 Who engaged and did not engage with the project?

Demographic factors, number of housing codes, and tenancy risk stage did not predict who withdrew from or

did not participate in the project.

Housing Service Centre was a predictor of who engaged and who withdrew; a greater proportion of

participants who were referred from the Fortitude Valley HSC withdrew or did not participate compared to the

Chermside HSC.

Stakeholders reflected that having adequate informed consent and an insight into their tenancy problems

were key factors in engagement.

1.1.5 What were tenant’s perspective of their support teams?

Tenants who completed the survey measures overwhelmingly felt their support team provided an autonomous

and supportive environment. This is similar to the interview responses, where the majority of tenants spoke in

positive terms about the support staff involved – especially the clinicians from Queensland Health and the

support workers from Footprints.



Tenants who were interviewed who did not feel they have benefitted from the project felt their voices had not

been heard and their requests have gone unmet. Primarily, these are tenants who are unhappy with their

housing arrangements, either because they are living among neighbours with whom they frequently come into

conflict, or because they are in homes that they believe are unsuited to their needs.

1.1.6 What was the impact of the project on tenant’s health and use of the health-care system?

There was an increase in Queensland Health mental health service usage while participants where

involved with the MHDP. This suggests that for the duration of the project, participants accessed and

engaged with clinical services. We are unable to determine, however, if the service use was necessary

or required services, or if the way the clinical support was designed to be provided necessitated the high

service use.

Relatively few participants accessed Queensland Health mental-health services (as recorded on

CIMHA) in the 6 month period before they entered the MHDP, or in the 6 month period following their

exit from the MHDP. Similarly, only 10 individuals had information recorded in the Alcohol, Tobacco and

Other Drugs (ATOD) database for the period of time examined (6 months pre MHDP to 6 months post

MHDP).

Participants observed health and social functioning (as measured by the HoNOS) improved significantly

from the when they first started the MHDP, to when they exited the MHDP. It is unknown whether these

improvements were sustained over time.

The number of people accessing the emergency department decreased from pre to post participation in

MHDP. The total length of stay and total number of admissions also decreased. This suggests there was

a reduction in unplanned and acute care needs for the majority of participants. There were a minority of

participants who were accessing the services at a high frequency, even after exiting the MHDP.

Interviews with participants are also congruent with the administrative data. Tenants reported improved

mental health outcomes as manifest in feeling happier, more confident, being less dependent on

medication, having goals in life that they are working towards, and feeling more competent in managing

their tenancies and relationship with DHPW. Tenants reported these outcomes partly because of the

reduced anxiety surrounding their tenancies and partly because of the clinical and non-clinical health

support they received through the project.

This is also congruent with the Recovery Outcome Star data, where participants who completed the

measure had, on average, improved outcomes in the area of mental health, and relationships.

1.1.7 Did the mental health, housing and homelessness learning management system e-modules

improve capabilities across housing, health, and other services?

Two sets of e-modules were developed to provide training for frontline service delivery staff who work

with social housing tenants with mental illness, mental health and wellbeing issues, or related complex



needs, with the aim of strengthening the capability of service delivery staff and networks partners to

improve the housing stability for those tenants.

The e-module component of the MHDP enhanced completers of the modules perceptions of their

competency and confidence in the areas targeted by the modules. That is, participating in the mental

health, suicide and alcohol and other drugs training was associated with reported improvements in

respondents’ awareness and understanding of mental health, suicide, and alcohol and other drugs.

Similarly, participating in the Housing modules was associated with reported improvements in

understanding the DHPW.

The biggest factor that impacted respondents’ confidence and commitment in applying what they

learned was having the necessary resources and time.

1.1.8 Key Conclusions and Recommendations

The MHDP meets an urgent need; the MHDP worked with a range of tenants who had factors in their life

that either had impacted their tenancy or could potentially impact their tenancy. The project provided

both a crisis approach to work with tenants at risk of eviction, as well as providing a preventative

approach to support individuals to maintain sustainable housing.

The overall findings suggest that the MHDP did address service provision and systems gaps evident in

meeting the needs of social housing tenants with mental illness or complex problems. In many cases,

participants of the project did not have this support before, or did not have an integrated support system

that was directed towards sustaining their housing tenancy.

The initiative helps establish the DHPW as a human service organisation, and the model moreover is a

useful mechanism to achieve inter-departmental and interdisciplinary collaboration.

Service integration and having resources to provide both clinical and non-clinical support in a

complementary fashion was a key contributor to success.

A barrier to providing integrated support identified by stakeholders was difficulties in coordinating

support with funded services and government agencies outside the three core agencies of the MHDP

that a tenant may have been involved with, such as child safety, disability services, and public

guardians. One of the central benefits of the project was the funding source and project design that

ensured the commitment and contribution from the three partners.

The project developed and evolved across the duration of the project, adapting to the needs and

practical considerations of delivery the program. The project embodies the features of a trial and

demonstration initiative.



Four months of support is insufficient. The average level of support that tenants received was

approximately 7 months, (described in more detail in Section 3.1). The duration of support should be

flexible and extended, to reflect the longer needs of more complex tenants or tenant with complex and

chronic mental health or other complex needs (such as hoarding and squalor).

Gaps still exist within the service system and this is reflective of the organisational and policy

frameworks.

1.1.9 Conclusion

The aim of the MHDP was to ensure fairness in social housing for tenants who experience mental illness, mental

health and wellbeing issues, or related complex needs whose behaviours as a result may jeopardise their ability

to maintain or sustain their tenancies. Specifically, the objective of the MHDP was to support social housing

tenants who were at risk of tenancy failure to address the issues putting their tenancies at risk; or to provide

early support and assistance to tenants to maintain a sustainable housing situation. Overall, integrating the

findings of the outcomes evaluation suggests that the MHDP did meet this aim and provided a needed service

that contributed to improving tenants’ lives. There is a need within the existing service system to provide support

for individuals with complex issues, and the types of issues faced by tenants are complex and multi-faceted.

The prospect of the MHDP generating longer-term change is contingent on signs of capability enhancement

across various areas; across agencies, within the DHPW itself, and among tenants themselves. While there are

signs of a) greater degree of collaboration between agencies and b) changed, and improved relationship,

between tenants and their housing office which can be attributed to the MHDP, it appears too soon to know

whether broader capability enhancement within and across DHPW to encompass all tenants, and not just those

known to be in the project, has been achieved to the level required.



1 INTRODUCTION

This Final Report presents the findings of the outcome evaluation of the Mental Health Demonstration Project

(MHDP; also referred to as “the project”). The Outcomes Evaluation focuses on tenant’s experiences with and

outcomes from the MHDP between 1st January 2016 and 31st July 2017. The MHDP draws on theories,

research, and practice evidence about service integration, sustaining tenancies, and meeting the housing,

health, and support requirements of social housing tenants with mental illnesses and other complex needs.

Queensland social housing providers, consistent with a national trend since the 1990s, have targeted the limited

stock available to applicants who are able to demonstrate the highest support needs and the lowest opportunity

to access housing outside of the social sector. As a direct consequence, social housing tenants work with and

have unmet needs from a range of social and health service providers. Although there are bespoke supportive

housing models for people with physical disabilities, psychiatric disabilities, and people exiting chronic

homelessness (Bruce et al. 2012; Parsell et al. 2016a), in Queensland there is routinely disconnect between the

support needs that make people eligible for social housing, on the one hand, and providing the resources and

support that those individuals require to sustain social housing, on the other (Jones et al. 2014).

Moreover, the Department of Housing and Public Works (DHPW) does not have the internal capacities to identify

or to respond to the health and social needs of tenants. Housing Officers at the Fortitude Valley and Chermside

Housing Service Centres manage approximately 500 tenancies at a time. Housing Officers work with tenants

experiencing health and social problems on a day-to-day basis but they have not been employed nor have they

been resourced to address complex social and health needs. Indeed, a primary impetus for the MHDP was a

report that found social housing tenants with mental illnesses and complex needs were issued antisocial

behaviour strikes that placed them at risk of eviction (Jones et al. 2014). As will be demonstrated throughout this

report, the MHDP aims to provide and facilitate health and psychosocial support integrated with social housing to

prevent eviction and to promote the conditions for positive and sustainable tenancies for people with mental

illnesses and complex needs.

Drawing on data from a range of sources, the Outcomes Evaluation examines the characteristics of participants

in the MHDP, tenancy issues pre and post MHDP participation, mental health service usage, changes in health

outcomes, the tenant’s perspectives on the MHDP, and their perceptions of autonomy, competency, and

outcomes. This Final Report presents the third evaluation output and is the second piece of empirical evidence

about the MHDP. The Interim Report was the second evaluation output, produced October 2016 and the

evaluation framework and program logic was the first output, produced in March 2016.



1.1 BACKGROUND

1.1.1 Mental Health Demonstration Project

The MHDP is a joint initiative of the DHPW and Queensland Health with the involvement of a range of other

government and nongovernment agencies. Footprints in Brisbane Inc. have been funded to deliver non-clinical

support services to MHDP participants.

The MHDP piloted an early intervention and prevention approach to assist social housing tenants with mental

illness or related complex needs to sustain their tenancies. At the centre of the model is the integration of

housing, mental health, and social welfare services.

The MHDP has been established in the Chermside and Fortitude Valley Housing Service Centre areas, which

also encompasses part of the Metro North Queensland Health catchment area. The MHDP is defined as:

Taking a holistic approach to understanding the factors impacting negatively on a person’s tenancy and to providing

appropriate clinical and non-clinical support to meet the tenant’s specific needs (Department of Housing and Public

Works n.d.)

The MHDP has been established to address service provision and systems gaps evident in meeting the needs

of social housing tenants with mental illness or complex problems. The service and system gaps were identified

in a report funded by the Queensland Mental Health Commission (QMHC) which examined the impact of the

former Anti-Social Behaviour (ASB) Management Policy on social housing tenants living with mental illness,

mental health difficulties and problems with substance use (collectively referred to as ‘complex needs’). The

QMHC funded research demonstrated that the effectiveness of the ASB Management Policy could be improved

by adopting a more comprehensive and strategic approach to meeting tenants’ needs that includes an emphasis

on support. The most effective approach to reducing ASB is one that combines sanctions with preventative,

supportive, and rehabilitative strategies. Sanctions and support, the research concluded, should be viewed as

complementary rather than contradictory strategies. This research underpinned the QMHC’s Ordinary Report,

Social Housing: Systemic Issues for Tenants with Complex Needs that proposed systemic changes to address

unintended consequences for tenants living with mental illness and complex needs. The DHPW accepted or

supported all of the Ordinary Report’s recommendations. Subsequently, in 2016, the DHPW abolished the

former Anti-Social Behaviour Management Policy and introduced the Fair Expectations of Behaviour Policy.

Together with the Fairness Charter, the MHDP is a mechanism to meet the needs of tenants with mental

illnesses and complex needs. The MHDP is an innovative approach that draws on the evidence base and

focuses on the role of support and rehabilitative services. Moreover, the MHDP recognises that the DHPW,

Queensland Health, and community organisations have a significant role to play in working with and supporting

tenants with mental illness or related complex needs.

The DHPW identifies key elements of the MHDP as follows:

Training and development, and protocols to strengthen local collaborative networks;



Strengthening the capability of HSC staff and local network partners to engage and support people with

mental illness, mental health and wellbeing issues, or related complex needs;

Additional clinical mental health support service capacity through Queensland Health’s local Hospital

and Health Service Community Care Team (CCT);

Additional mobile/in-home broad-based non-clinical psycho-social and tenancy support services to meet

the specific needs of participants;

A case coordination and case management approach centred around integrated individual Housing

Support Plans;

A brokerage fund to enable the ready purchase of specialist supports/services required for individual

Housing Support Plans (for example: specialist drug and alcohol counselling, Indigenous and other

cultural support), or to resolve service system capacity issues if necessary.

Based on these elements, the primary aim of the MHDP is to assist tenants with mental illness or related

complex needs sustain their social housing tenancy. The aim of the project was to ensure fairness in social

housing for tenants who experience mental illness, mental health and wellbeing issues, or related complex

needs whose resultant behaviours may jeopardise their ability to sustain their tenancies. As such, the MHDP

was established to work with tenants at risk of eviction, as well as providing an early intervention approach to

support individuals to maintain sustainable housing. It aimed to address service provision and systems gaps

evident in meeting the needs of social housing tenants with mental illness or complex problems.

1.1.2 Mental Health Demonstration Project Evaluation

The purpose of the overall evaluation is to:

Generate valid and reliable findings regarding the development, implementation, operation, and outcomes of the

Project [MHDP] that can be drawn upon as the basis of practical recommendations to government about how to

ensure the Project achieves its short, medium and long term goals (Department of Housing and Public Works 2016)

The evaluation was conducted in two phases – the process evaluation and the outcomes evaluation, detailed

below.

1.2 SUMMARY OF INTERIM REPORT FINDINGS

The Interim Report presented the findings for the process evaluation of the MHDP, as implemented and delivered

between 1st of January and 1st of July 2016 (Parsell et al. 2016b). The process evaluation drew on qualitative

interviews with MHDP stakeholders, analysis of published literature and project documents, a survey with MHDP

stakeholders, and analysis of pre and post data from the Mental Health e-modules.

The process evaluation concluded that the MHDP was delivered in accordance with the Service Delivery Mode in the

first six months of operation. Further, the MHDP was implemented and delivered on a basis of a continuous

improvement model. Key project stakeholders observed and reflected upon initial implementation and delivery as a



means to overcome emerging problems and to develop the systems and service delivery model. The MHDP has been

implemented, and for the first six months operated, in a productive, professional, and efficacious way. As a result of

the MHDP, the DHPW had better inter-department and interdisciplinary access. The project provided the DHPW

additional resources from external clinical and non-clinical professionals to meet tenant needs. A majority of

stakeholders surveyed perceived the MHDP as having positive impacts upon practice systems integration. Further,

respondents widely reported that they had high levels of understanding of their roles and the roles of others in the

project. Stakeholders experienced the MHDP as an opportunity for the DHPW to develop greater clinical and non-

clinical knowledge about the needs of, and best responses to, social housing tenants. Representatives from the

DHPW, Queensland Health, and Footprints expressed the view that they had long understood that their tenants,

patients, and clients experienced problems and required solutions that crossed departmental and disciplinary

boundaries. It was the MHDP, however, that represented a practical resource to realise the inter-department and

interdisciplinary access.

However, the report found that there was not a unified understanding of what problems tenants experienced or how

the MHDP represented a solution. There were likewise different ideas about problems and project solutions expressed

by stakeholders across the three lead organisations.

The process evaluation suggested that the MHDP was appropriate to meet tenant needs, and demonstrated that

tenants were eligible and referred into the MHDP because of experienced or predicted tenancy problems. Both tenants

with identifiable mental illnesses and without known mental illnesses were eligible and targeted for the project. In

practice, the referral process was established in broad ways to encompass the variety of issues that can impact

housing tenancies, rather than a project specific to people with mental health or what are generally considered

complex needs. Stakeholders perceived that the MHDP positively impacted tenants.

The evaluation also highlighted that four months of support will be insufficient for some tenants with mental illnesses

and complex needs. The limits to what four months of support can provide, without discounting the significant positive

impacts, raises broader questions about the long term integration of social housing with clinical and non-clinical

support services. In the Interim report, it was suggested that embedding professionals with social work, psychological,

and case coordination expertise within Housing Service Centres may represent an efficient means of reducing tenancy

problems by improving the practice systems, capability, and capacity of the DHPW.

The process evaluation had mixed evidence that the MHDP had achieved capability enhancements. Qualitative data

showed that some individual practices and relationships among stakeholders may be effective as an immediate

response to a tenant, but they may indicate that broader capability development had not yet been realised (consistent

with survey data). Stakeholders speak about responding differently to tenants, but the different approach is identified

only when the tenant is an active MHDP participant. They did not articulate how the MHDP has been a mechanism for

the broader DHPW staff to deliver housing services differently to tenants who are not actively working with the project.

The process evaluation also outlined that some stakeholders experienced the MHDP’s focus on governance and

management as disproportionate. In turn, they argued that the work directed toward governance and management

detracted from the direct work with tenants and indeed the work required to achieve systems integration.

Relevant aspects of the process evaluation are included below to give a more thorough understanding of the MHDP

processes, and detailed key information of the findings of the Interim Report.



1.3 OUTCOME EVALUATION

The Outcomes Evaluation will examine whether the MHDP has achieved a range of tenant and service system

outcomes; specifically, the Outcomes Evaluation aimed to address the following questions:

Have project participants sustained housing?

Have project participants accessed and engaged with required clinical services?

Have project participants accessed and engaged with non-clinical support services?

Has the MHDP identified tenants at risk of not being able to sustain their housing?

Is the MHDP unable to engage and successfully work with some tenants in the target group?

Is the MHDP a successful approach to achieving collaboration across government and community

organisations for the purposes of supporting tenants to sustain housing?

Has the MHDP demonstrably enhanced the capability of the housing, health and community organisations to

support tenants to sustain housing?

Do the housing, health and community organisations have a shared understanding of the MHDP approach

and objectives?

Is the MHDP successful in delivering a planned preventative approach, rather than a crisis reactive approach?

Have MHDP participants successfully engaged with the Learning Management System e-modules on

housing and mental health?

To what extent is participating in the mental health, suicide and alcohol and other drugs training associated

with reported improvements in participant’s awareness and understanding of mental health, suicide and

alcohol and other drugs?

To what extent is participating in the housing training associated with reported improvements in participant’s

awareness and understanding of the housing system?

How could the MHDP be improved?

How does the MHDP sit within the existing service system (complementary, crowding, filling a vital gap)?

What lesson does the MHDP provide for housing, health, and community service delivery and tenancy

sustainment outside of the trial area?

1.4 EVALUATION RESEARCH DESIGN

A multi-method research design was utilised to address the diverse and comprehensive research questions. The

methods used included: analysis of participating tenants’ pertinent tenancy data recorded and stored by DHPW;

analysis of participating tenants’ pertinent health data recorded and stored by Queensland Health; semi-

structured qualitative interviews with participating tenants; analysis of Footprints survey data; and an analysis of

e-module data.

1.4.1 Tenancy Data

The analysis of participating tenants’ (n = 115) pertinent tenancy data recorded and stored by DHPW was

conducted in close partnership with the DHPW. Additionally, data from Tenancy Support Project Portal was also

obtained. The DHPW provided the research team with access to the data and assisted the research team to



understand the internal frameworks and language used to construct the data. The DHPW data was

systematically analysed to identify and measure the participants’ housing outcomes and experiences both pre

and post the MHDP.

The analysis involved accessing data from 3rd August 2015 to 31st of July 2017 and examining tenancy codes for

the 6 months prior to a participant entering the project (Before), the codes entered for a participant during the

project duration (During), and the codes entered for a participant for the 6 months after exiting the project (After).

Thirty-one of the participants with insufficient housing history in the 6 months prior to entering were in the

prevention tenancy risk stage. As such, we are not properly able to understand the effectiveness of the project,

as operationalised as examining changes in their recorded tenancy incidences from pre to post project

participation, for participants who were referred into the project as preventative. To statistically test for significant

differences in tenancy codes (complaints, warnings, arrears and breaches, referrals) pre and post participation in

the MHDP, a series of Wilcoxon’s Signed Rank Tests were conducted. Non-parametric analyses were used due

to the small sample size and skewed nature of the data.

1.4.2 Health Data

The analysis of participating tenants’ pertinent health data recorded and stored by Queensland Health (n

= 75) was conducted in close partnership with Queensland Health. Queensland Health staff provided the

research team with access to the data, and assisted the research team to understand the internal frameworks,

measures and language used to construct the data. The Queensland Health data analysis included data

obtained from the Consumer Integrated Mental Health Application (CIMHA), which included mental health

service usage and Health of a Nation Outcomes Scales, and diagnoses. We also accessed alcohol, tobacco and

other drugs (ATOD) data, as well as data indicating participants’ hospital admission and emergency department

admission data. The aim of the analysis was to identify and measure whether, or not, participants have achieved

health outcomes consistent with the MHDP objectives. Due to requirements of informed consent to access their

de-identified Queensland Health data, the final 75 participants used in these analyses represents a sub-sample

of the 115 participants of the MHDP. That is, a portion of the MHDP participants who withdrew from the project

was assumed to withdraw consent for their data to be used, and thus were not included in this component of the

analysis (n = 34). Additionally, a subset of the MHDP participants did not sign the appropriate consent form, and

were also not included in the data sent to the researchers (exact number unknown). As before, to statistically

test for significant differences in health service usage (including CIMHA data and emergency department data)

pre and post participation in the MHDP, a series of Wilcoxon’s Signed Rank Tests were conducted. Non-

parametric analyses were used due to the small sample size and skewed nature of the data.

1.4.3 Qualitative Interviews

Semi-structured qualitative interviews with 21 participating tenants was conducted to ascertain their

perspectives of and experiences with the MHDP. Tenants are seen as critical participants in the research, as

their position as consumers provides valuable information about receipt of and engagement with the MHDP.

The approach was designed to yield a nuanced understanding of outcomes to serve three main purposes:



To assess tenants’ perceptions on managing their mental illness and the impact of the MHDP, for example, to

what extent, and how, has participation in the MHDP impacted the management of their mental health?

To build on and provide richer insight into the data obtained from secondary analysis of tenants housing

records, for example, interviews with tenants will give them the opportunity to articulate their firsthand

perspectives of the impact of the MHDP on their housing outcomes.

To explore tenants’ perceptions of changes in housing, health and social service systems prior to and

during the MHDP and thereby producing evidence of improvements in inter-agency and service

integration.

We purposefully sampled tenants who experienced both positive and negative outcomes within the MHDP. Our

recruitment process included proportional representation in genders, age range, Indigenous status, household

composition, dwelling type, tenancy risk status, housing provider, and levels and type of engagement with

MHDP. Thirty-nine people were identified as potential qualitative interview participants: 11 were unable to be

contacted; 3 declined to participate, and 3 agreed to participate but were unable to complete the interviews (for

example due to hospitalisation or cancelled for unknown reasons), and the remaining 21 people initially identified

participated in a one-off face-to-face interview. The demographic and project information for the 21 tenants who

were interviewed are summarised in Table 1.

Table 1. Participant demographics table for tenants who were interviewed

N %

Gender

Male 8 38%

Female 13 62%

Age

21 - 25 5 24%

35 - 55 8 38%

55+ 8 38%

Family Type

Couple 3 14%

Single Parent 5 24%

Single Person 12 57%

Other 1 5%

Income

Age Pension 2 10%

Disability Support Pension 14 67%

Parenting Payment 4 19%

Youth Allowance 1 5%

Indigenous Status

Aboriginal or Torres Strait Islander 3 14%

Not Aboriginal or Torres Strait Islander 16 76%

Not disclosed or Unknown 2 10%

Housing Service (at project entry)

Churches of Christ 1 5%



Chermside 12 57%

Fortitude Valley 8 38%

Tenancy Risk Stage

Crisis 9 43%

Early Intervention 7 33%

Prevention 5 24%

Referral Reasons

Hoarding and/or Squalor 4 19%

Poor property Conditions 3 14%

Mental Health Issues 4 19%

Personal issues 6 29%

Neighbourhood Issues 9 43%

Rent Arrears 1 5%



Participants were assured that participation was voluntary and they were able to discontinue or withdraw

consent at any time; they were assured that their decision to participate, or not, would have no bearing on the

support they receive from or their relationships with government and non-government organisations. Participants

were also made aware that the interview would be confidential, and the reporting of their interview would be

anonymous. Separate informed consent was obtained, and participants were reimbursed for their time.

Consistent with our approach to social science research, we will employ active methods to ensure that tenant

participants are provided with accessible information about the results of the evaluation.

Additionally, key stakeholders of the project were contacted to provide a perspective of the operation and

outcomes of the MHDP, including how the project had changed since the process evaluation, and stakeholder

perspectives of tenant outcomes. Perspectives of five stakeholders were obtained.

1.4.4 Footprints Survey and Outcome Data

The research team also analysed data of surveys that assessed participants’ perceptions of their outcomes, for

29 tenants who had data recorded at the initial and final review point (see Figure 1 for timeline of assessment

measures). The analyses used data collected by Footprints routinely as part of their case management

(Recovery Outcomes Star). Additionally, the research team developed two measures that were administered by

Footprints: one examined perceived autonomy climate in Tenancy Support Project (the name that the MHDP

was known as to tenants), and the second measured perceived competency for maintaining housing. Fourteen

MHDP tenants completed the measure of perception of autonomy and 44 tenants completed the competency

measure on at least one occasion. Participants completed the measures at the start of their support period, and

completed Outcome Star and competency measure on exiting the project and at three-monthly check in points.

The timeframe of assessments is summarised in the figure below.

Figure 1. Time Frame of Footprints SHouT Assessment Measures

The data obtained from Footprints was from the period of March 2016 to May 2017 for the Outcome Star data, and

September 2016 to May 2017 for the autonomy climate questionnaire and competency questionnaire. Fourteen

participants of the project completed the autonomy climate questionnaire, and 44 completed at least one time-point of

the competency questionnaire.



1.4.5 E-module Analysis

An analysis of the Mental Health, Housing and Homelessness Learning Management System’s three mental health

and three housing e-modules was conducted to assess the impact and effectiveness of the training modules on

government and non-government representatives’ awareness and knowledge of (a) mental illness, suicide ideation

and risk, and addiction to alcohol and other drugs and (b) the housing system. The analysis was based on responses

to the pre and post training module testing that MHDP stakeholders and partners completed. The DHPW provided the

research team with the survey data from the e-modules. The data is from the period of February 2016 to June 2017 for

the mental health modules and July 2016 to June 2017 for the housing modules.

1.5 ETHICS

The evaluative research was granted ethics approval from the University of Queensland Behavioural & Social

Sciences Ethical Review Committee (Approval Number 2016000386) and from the University of Queensland Human

Research and Ethics Committee (HREC Reference 2017000080). To comply with ethics approval, we ensured that

participation in the research was on the basis of informed and voluntary consent. Ethics approval also required us to

ensure that all personal information was kept confidential. As explained above, in reporting on the research we have

protected people’s anonymity by not presenting names or information that would lead to inferred identification.



2 PROCESS EVALUATION AND INTERIM REPORT

FINDINGS

In this chapter we present the Interim Report findings to provide the context of how the MHDP was implemented and

operationalised in practice. We describe the central elements, features and practices of the MHDP during its

implementation phase and describe the extent to which the MHDP is delivered in accordance with Service Delivery

Model. The findings in this chapter are drawn from qualitative data from interviews with key stakeholders and

observational data. As evidenced through the day-to-day practices and operation, in this chapter we demonstrate that

the MHDP has been delivered in accordance with the Service Delivery Model.

2.1 PARTICIPANT REFERRAL, ASSESSMENT, AND INTAKE PROCESSES

The section begins by examining the referral processes, the three categories of housing risk, and community housing

referrals. We then discuss the intake process, including which tenants are prioritised into the project. We conclude the

section by identifying the processes, challenges, and strategies used to achieve informed and voluntary consent.

2.1.1 Who is Being Referred?

The following section outlines the referral process for tenants into the project. We begin by outlining the target group

as defined in the Service Delivery Model, analyse who is being referred in practice, and end with a discussion on the

overall suitability of this process.

The service delivery model defines the MHDP target group as “social housing tenants who are experiencing difficulty

in sustaining their tenancies due to mental illness or associated complex issues, or who feel that supports would help

them to establish and maintain a more sustainable housing situation.” The Service Delivery Model defines social

housing tenants as “tenants whose tenancies are managed by DHPW or community housing providers.” As discussed

below, only tenants with long term leases, and not transitional leases, are eligible. Tenants currently receiving services

from other programs, such as Housing and Support Program, were generally not eligible or prioritised for participation.

To be eligible for the MHDP a tenant must be:

• Over 18 years of age;

• A current social housing tenant/household member;

• Residing within the catchment area of either the Chermside or Fortitude Valley HSC;

• Experiencing difficulty maintaining or sustaining their tenancy, or have the potential to experience

difficulty maintaining or sustaining their tenancy, due to behaviours related to mental illness or related

complex needs; and

• Willing to consent to participate in the Project, including the sharing of their relevant personal information

with other support agencies in the local network for the purposes of case co-ordination and case-

management and related project needs.

The Service Delivery Model provides no definition of what constitutes “mental illness” or “associated complex issues.”

Further, having the clause “or who feel supports would help them establish and maintain a more sustainable housing

situation” provides an opening to refer any tenant who is experiencing tenancy issues onto the project. Additionally,



including “establish” as well as “maintain” in the eligibility criteria allows new tenants to be referred on the MHDP,

before experiencing any tenancy issues or having their tenancy at risk. Overall, the eligibility criteria is inclusive of any

long term tenant who is experiencing or may experience a tenancy issue. Processes and issues about willingness to

consent are described in more detail in Section 2.2.4.

In addition to the aforementioned target group, to identify risk factors of unstable tenancies, the Service Delivery Model

provides a list of indicators of tenancy risk:

Display of behaviours which may be associated with cognitive impairment, substance misuse, or a mental

health issue (including risk-taking behaviours);

A high level of interaction with mental health, human services (including child safety), law enforcement and/or

emergency services agencies;

Medical/disability issues impacting on the tenant’s ability to meet their tenancy obligations;

Difficulties with parenting and/or carer responsibilities (including noise complaints, truancy issues);

Drug and alcohol misuse issues impacting on the tenant’s ability to meet their tenancy obligations;

Self-identification of mental health issues;

Poor property condition, including hoarding and squalor issues;

Verbal and physical abuse causing neighbourhood nuisances;

Complaints from neighbours about unruly visitors or unapproved occupants;

Domestic and family violence in the household;

Relationship breakdown, especially young parents, or single parent households.

The list of indicators of tenancy risk clearly extends beyond the understanding of mental illness and complex needs, as

defined in the literature. For example, in the context of provision of housing and support services, Bleasdale’s widely-

used term “complex needs” applies to three groups of people:

People with physical or sensory disability whose needs in relation to housing combines a requirement for

physically accessible accommodation and built environment; for assistive technology and mobility aids; and

for personal support to assist in personal and domestic tasks;

People with cognitive impairment as a result of intellectual disability or an acquired brain injury who need

housing accompanied by support that may extend beyond personal and domestic support to include complex

case management and advocacy;

People with mental illness who similarly need housing accompanied by support services of varying types and

levels of complexity.

A number of the aforementioned tenancy risk factors in the Service Delivery Model do not fall within this category, for

example domestic and family violence in the household, difficulties with parenting or carer responsibilities (including

noise complaints, truancy issues), relationship breakdowns, and verbal and physical abuse causing neighbourhood

nuisances. Although these factors may be related to mental health issue, it is unknown if it is the cause or



consequence of mental health issues. This referral process suggests the scope of the project has been established, in

practice, in broad ways to encompass the variety of issues that can impact housing tenancies, rather than a project

specific to mental health. This was also articulated by a non-DHPW stakeholder, who observed:

So from the planning phase to the operations phase something changed in the scope. It clearly states mental health or

complex need. That complex need might not necessarily be a mental health need (non-DHPW Stakeholder)

Responsibility for identification and referral of eligible participants rested with DHPW staff working directly with tenants.

This appears to be congruent with how they see their role – as practitioners to identify tenants who they deem could

benefit from support from the project:

I’m usually the first point of contact, and [the MHDP] something I suggest or offer to tenants where I think it might be

suitable or helpful (DHPW Stakeholder)

The application of eligibility criteria by frontline DHPW practitioners reflects the broad and inclusive target group set out

in the Service Delivery Model. Housing officers refer tenants for reasons that extend beyond mental health issues; one

DHPW stakeholders said people are being referred into the project for “a bit of everything really.” It should be

acknowledged that Queensland Health likewise have extended their normal practices for engaging people into their

service whereby this project enables Queensland Health to work with people who would not normally be prioritised for

mental health services.

We present the long extract below to illustrate how housing officers on the ground utilise the MHDP for myriad

problems that they assess place tenancies at risk. The extract similarly demonstrates how the MHDP is perceived as

an appropriate resource to address the varied problems that tenants experience:

So the majority of the referrals come from my team in regards to clients who are having issues in terms of maintaining

and sustaining their tenancy or fulfilling their obligations under the Act, or they’ve been at risk of losing their tenancy

because of not maintaining or sustaining it. So they might have issues around - We’ve done ones for non-payment of

rent, where there’s been, you know, not just they’ve had a slip up with their rent, but where there might be a chronic

pattern of non-payment of rent, or they’re at-risk, they’ve been to court before, they’ve slipped back into arrears, they’re

not engaging. So for that, we’ve also done referrals around hoarding and squalor. We’ve done referrals around complex

and challenging behaviours, where there might be breaches being issued because of disruptive behaviour. There may be

other issues happening amongst or for the family, which are impacting them in some way that’s placing their tenancy at

risk. It might be that we’ve got other competing priorities, I suppose, within the family and they’re trying to meet those and

it’s preventing them from paying their rent, or they’re kind of juggling or they’re not able to juggle, probably more so, and

need some help and guidance around how to prioritise, how to budget. Relationship stuff, where there’s families that have

issues, parents and children, and it’s the children’s behaviour, perhaps, might be at a little bit out of control. The parents

have identified that they’re finding it difficult to talk to Little Johnny, and have him realise the impact of the behaviour.

They might need some extra support to come in to help with parenting. The work that Footprints do around, or

Queensland Health do around giving them strategies around how do deal with those different types of situations (DHPW

Stakeholder)

2.1.2 Early Intervention, Prevention, and Crisis

Tenants who are eligible for participation in the project can be at any of the stage along a “housing sustainability

spectrum” (Service Delivery Model), or “tenancy risk status” (Referral Form). The reasons for referral into the project

are identified as relevant from a preventative, early intervention or crisis point of view in terms of their impact or



potential impact on a tenant’s housing stability situation. These reasons for referral are identified within policy

documents, e.g. in the Service Delivery Model, and also included in the Referral Form used by housing officers to refer

a tenant into the project.

The below definitions of early intervention, prevention, and crisis are outlined in the Service Delivery Model and

Guidelines (Version 1.5 5.8.16):

Early Intervention – New Tenants who have identified complex needs at tenancy commencement. No current

engagement with any support provider;

Prevention – Current tenants including tenants moved from a previous tenancy who have identified issues in

the tenant’s current or previous tenancy which still need resolution and require support to prevent further

tenancy issues;

Crisis – Current tenants who have identified complex needs and issues that placing the tenancy at risk.

However, the definitions in the Participant Referral Form differ from the definition presented in the Service Delivery

Model and Guidelines. Below is the definition of prevention, early intervention, and crisis in the Participant Referral

Form:

Prevention – mitigate risks identified at commencement of tenancy (no breaches or warnings issued);

Early intervention – prevent recurrence or exacerbation of tenancy issues (already has some breaches or

warnings);

Crisis – address significant issues to sustain tenancy (tenancy is at risk due to multiple or serious breaches).

2.1.2.1 Early Intervention/Prevention

Early intervention/ Prevention is reliant on workers being able to accurately identify individuals who may be at risk in

the future – before having breaches or warnings issued. Rather than relying on tenancy team or current complaints,

warning or breaches in a tenancy, referrals for early intervention/prevention seems to be based on information

supplied in the housing application. The allocations team were identified as critical in operationalising tenants through

the early intervention/prevention streams:

So our allocations team are madly pumping through the early intervention referrals for [service integration coordinator]

and then the tenancy teams are bringing in the other referrals around that prevention or the crisis or more complex end

(DHPW Stakeholder)

In practice several indicators are used to identify individuals for early intervention/prevention referrals. One DHPW

stakeholder with practice experiences described pre-existing medical or mental health issues as an indicator that

support may be needed or tenants may have problems in the future:

So ones who might have just moved into an area or not have any issues yet, but we can identify that they will be facing

issues down the track. When they’ve supplied evidence to us about medical conditions or mental health issues they might

have or issues they’re facing, we can identify, at that stage, this person was going to need support (DHPW Stakeholder)

The disclosed presence of existing support agencies is also used to inform a referral through the early

intervention/crisis stream. There is a perception that referring people on the basis of existing service use can be



successful in identifying need and creating the conditions for the integration of support services to be directed toward

housing sustainment:

Yeah, so our allocations team can identify it sometimes and say, “this person, just watch out because they’ve identified

with us that they’re going to be facing some issues.” Sometimes you can just tell. If someone’s come in with a bunch of

different support agencies helping them, you can see they obviously need support (DHPW Stakeholder)

Overall, from the housing officer’s perspective, the prevention and early intervention tenancy risk status seemed to be

seen as a useful referral category for the project to mitigate potential risks to the tenancy either at the commencement

of the tenancy or before emerging issues reach the point of requiring action. However, concerns were also raised that

this pre-emptive support may not work within a mental health recovery framework and some stakeholders raised

concerns with the process of identifying and engaging people on the basis of a predicted risk profile:

2.1.2.2 Crisis

DHPW stakeholders with direct tenant contact widely endorse crisis status as appropriate for tenants who are at risk of

eviction. As a DHPW stakeholder explained, the crisis pathways is seen as: “we offer this to help you and the way

you’re going you could potentially lose your tenancy.” Housing officers’ descriptions about crisis referrals demonstrate

that these tenants are perceived as the “complex” clients that have ongoing difficulties and potentially are the clients

that would have been targeted in the former ASB three strikes policy. For tenants referred for reasons of crisis, the

DHPW ordinarily would have identified them requiring support that is beyond what the DHPW is able to provide, or the

tenants require more support than what the DHPW is usually able to assist tenants access through external support

providers:

Yeah, at-risk. So that one’s more, maybe it’s an ongoing one that’s been going for a couple years and we haven’t really

found a solution. There is some where it’s been ongoing. Up until before this year we tried to offer supports, but there

wasn’t a key setup, which, I guess, is where [MHDP] comes into play. So this one, maybe, people know the tenant, they

know there’s issues, some of them are gunning for us to get rid of them, and it’s kind of like we need to help (DHPW

Stakeholder)

This comment also highlights that people in the crisis category were perceived to be in direct and immediate need of

help. In practice, crisis as a reason for referral is used as a “last resort – used assertively for people who the DHPW

previously “hadn’t found a solution” and as a way to attempt all avenues of support. A DHPW stakeholder explains:

We do get to the point where we go to court and people are exited. But that’s a last resort for us. So we’re trying to really

make sure, whether it’s through tenancy support - we’re really pushing [MHDP] at the moment. If we can see that it’s

going to benefit someone, we’ll do it and we’ll continue to do it as much as we can and if the tenancy still falls over or falls

down then at least if they reach this worst case scenario, which inevitably sometimes we do, we can go to court or we can

reach that point knowing full well we’ve tried everything, and we’ve not just tried it once (DHPW Stakeholder)

Referrals for people who are at crisis, as described above, is simultaneously used to assist in every way possible to

avoid eviction and as evidence, when eviction is deemed necessary, that the DHPW had made every effort to prevent

eviction. This view was highlighted by a non-DHPW stakeholder when discussing the Housing Support Plan (see

Section 3.2.3).

I guess one theory is that Housing utilise the plan in case they have to take the case to QCAT. So the plan clearly

outlines what supports have been provided, how the client responded, and what their level of engagement was, how



many hours of support were delivered. So it can also be used to kind of show how much funding has gone towards a

client (non-DHPW stakeholder)

Although there is a perception that referring people because of their crisis’s may be used as substantiating evidence in

an eviction process, many stakeholders expressed the view that referring people who are at a crisis housing stability

situation is not appropriate and thus would not be used for tenants who are likely to be evicted. As one DPHW

stakeholder put it:

People that I knew whose tenancy was going to fail, there’s no point putting them in a project for four months if their

tenancy is still going to end because of disruptive behaviour or whatever else (DHPW stakeholder)

Indeed, another DHPW stakeholder rejected the proposition that the MHDP has or would be used to make a case for

QCAT. The understandings of the MHDP as not an intervention to support a case in QCAT is reflected in the Service

Delivery Model which states that the crisis as a reason for referral (as with early intervention/prevention) is only

appropriate when it is deemed to assist with sustaining the tenancy. The driving premise of the project is to promote

the conditions for tenants to build “their individual capability to resolve tenancy issues and sustain their tenancies.” The

project is thus premised on an assumption that the intervention will enact positive change to avoid eviction. Despite

these overarching ideas and formal guidelines, some stakeholders did express a view that the MHDP was sometimes

practiced in a way where tenant change was not expected, whereby tenants are referred into the project even when

the DHPW expects eviction. A DHPW stakeholder observed, “I think in [area office] end they were putting people in

who were in that crisis end and they were still going to take action regardless, even if they were in the project.”

The views of the DHPW representative were endorsed by project stakeholders outside of the DHPW. A non-DHPW

stakeholder advised that tenants referred through the crisis stream were still being pursued by the DHPW through the

QCAT process:

So right off the top of my head, nearly 10% of [the MHDP] current caseload are going to, very shortly, or are in a series of

QCAT hearings that are aimed at eviction (non-DHPW Stakeholder)

This was described in more detail in the Interim Report, and provides a specific example of an experience of

stakeholder working directly with participants who were in the MHDP that highlights how crisis as a reason for referral,

on some occasions at least, was practiced in a way contrary to the formal procedures, and indeed, contrary to how

many stakeholder believe the project ought to function. There was not a unanimous understanding of how the project

should operate.

2.1.3 Informed Consent and Voluntary Participation

Formal procedures dictate that participation in the MHDP requires tenants to be fully informed of the project so that

they can provide voluntary consent, or conversely, voluntarily refuse to participate. Stakeholders widely endorsed the

necessity of tenants being afforded the opportunity to give informed consent to enable voluntarily participation in the

MHDP. In this section we identify some of the challenges that engaging tenants in an informed and voluntary manner

represent. We also present strategies that MHDP stakeholders practiced to achieve informed and voluntary consent.

A DHPW representative described the challenges engaging the tenant cohort into the MHDP, and indeed how the

detailed consent process added further challenges to engaging tenants. The stakeholder argued that the challenges to

engage tenants voluntarily was symptomatic of the problems that made tenants a priority for the MHDP:



Once you’ve got the engagement you’re halfway to solving the problem, but many of our people are reluctant to engage.

So if we go out there with a really lengthy, convoluted, legal form and say, “We’d like you to sign this,” then they’re going

to back off and then we haven’t achieved what we wanted to (DHPW Stakeholder)

Another DHPW stakeholder who works on the ground with tenants expressed similar views about how difficult it was to

engage tenants:

Just from personal experience, some tenants just don’t want to sign the authority to disclose or the referral form because

they just don’t like Housing, don’t like the government, don’t like people knocking on their door with good reason (DHPW

Stakeholder)

Some stakeholders believed that there is a lack of engagement and participation among tenants who may be most in

need of the project. This was articulated by a DHPW stakeholder with frontline experiences working with tenants:

So the client says no initially and we’re like, “Okay, it’s voluntary to you.” If I use the example of behaviour, we’ll talk to

them about the consequences of the behaviour. We’ll try to educate them about if there’s further occurrences, what that

may mean, etcetera. It might go along good for a bit and then the same behaviour will start again. So we’ll revisit the

conversation of [the MHDP], this is what it can do, etcetera. They may be, second time, they may be inclined to give us

the consent there and then. So it’s not like we just try once and they’ve said no, so that’s it, it’s no for life, because

different things happen for different people. The timing we ask for consent at the first place might not be the right time for

them to agree to it. It might take a second attempt for them to go, “Oh, yeah, maybe I do,” or it might take for them to get

their first breach notice or a written warning or something before they go - and have that hard conversation with someone

about, “Your tenancy’s at risk.” “Oh, okay. Maybe I should engage with some support. I do need a bit of help.” (DHPW

Stakeholder)

This consent to the project, however, does not translate to participation. A DHPW stakeholder says “I think what’s

really difficult is that clients who are in most need, who’d really benefit, they don’t consent.” The stakeholder who

works closely with the project observed that it was tenants who would most benefit from the project “sadly, [are] the

ones who are going to miss out, or they consent and they just sign the form because they want us to go away and then

when Footprints or Health go to meet them they don’t want to participate.”

Because of tenant’s reluctance to engage with the DHPW, or more broadly a suspicion of legal and formal paperwork

that is the pathway into the project, a DHPW stakeholder described the approach of housing officers:

So we like to take, I guess, a softly-softly approach. So it’s about balancing those competing demands, competing

expectations, and still not alienating the tenant. So we’ve still got their involvement and got them involved because, from

our perspective, it’s clearly something that’s in their best interests. We just want to support them in their tenancy. But

people are suspicious, some of them are paranoid, some of them have got different ways of seeing the world, and that

can make it difficult. I guess that’s one of the disappointing things is when we’re trying to help them and they can’t see

that and their tenancy still goes on that downward path (DHPW Stakeholder)

Another DHPW stakeholder experienced tenants who initially provided consent to participate in the MHDP, but the

stakeholder believed that tenants agreed to participate only because they thought participation was required to prevent

eviction: “they’ll consent to it, because that’s kind of what they feel they have to do.” But because tenants are engaging

without truly consenting or truly feeling that they have a need for the MHDP, the stakeholder said that the tenants

routinely disengage and do not benefit from the MHDP. The stakeholder said that tenants who do not want to

participate will “shut down; won’t answer calls; won’t respond.”



Recognising the challenges to have tenants consent, or to have them actively engaged and keen to participate, even

when DHPW officers adopt a cautious and supportive approach, a non-DHPW stakeholder engaged in service delivery

believed that the problems with gaining tenants consent and full engagement with the project were a product of the

initial means of contact. The non-DHPW stakeholder said that when tenants had signed consent to participate, there

were examples where the tenant did not fully understand what they had signed up for. The non-DHPW stakeholder

described experiences with tenants thus:

I guess some clients were not really aware of what the project was about when they signed up for the project. So they

may have just signed off on the form because the Housing officer said to them, “Look, you have to sign the form,

otherwise we’ll take you to QCAT.” So they were forced into it or didn’t really understand what they signed up for. I guess

that manifested in them not wanting to engage, not wanting to meet us, delaying meetings, telling us after four or five

visits that, “Look, I’ve got no interest in wasting our time. I don’t actually care whether I’m going to be made homeless or

not (non-DHPW Stakeholder)

The non-DHPW stakeholder went on to argue that the consent problems could be overcome by initially engaging with

tenants in a more collaborative and informed manner:

I think this area could be resolved if [DHPW] and [support providers] would do a bit of a warm handover or warm referral.

If the three parties sat around the table and Housing would explain their role in the project, [support providers] would

explain [their] role, that would create an opportunity for the client to say, “Yeah, I can actually picture myself working with

[support provider],” or “No, I’m not interested at all.” If they would voice their interest or disinterest honestly at the first

meeting, it would save us a lot of time in the long run (non-DHPW Stakeholder)

For tenants to provide voluntary consent they require the information about participation in the project to be sufficiently

informed. Voluntary consent requirements tenants to be informed. As described above, when tenants are not informed

they disengage and resources are wasted. Another non-DHPW stakeholder emphasised the significance of informed

and thus voluntary consent as philosophically important:

It was funny, the last time I knocked on the door and she was in there, clearly in there, and she just flicked her net curtain

and I just caught her and she flicked it back. She wouldn’t come to the door. We’ve got to be really careful. This is not

mandatory. We’re funded to do a job, yes, but we are not going to impose ourselves and we’re not going to turn checking

in into pestering. If somebody clearly doesn’t want to, whether it’s because they changed their mind, didn’t know what the

program was all about, or just plain had enough, then we’ll turn and we’ll walk away (non-DHPW Stakeholder)

MHDP stakeholders, both within the DHPW and those external, all acknowledged the importance of voluntary consent

and they likewise, through practical experiences, were conscious of the challenges engaging tenants voluntarily into

the project. The challenges should not be discounted. Tenants may have firsthand experiences to question the DHPW

interest in providing them voluntary support, and the problems that make them eligible for the MHDP may be

associated with a lack of trust in public institutions. Given the centrality of voluntary participation because of project

procedures, organisational philosophies, not to mention the efficacy of voluntary participation as a necessary

ingredient in the change process, the practice effort and skill to achieve voluntary participation cannot be over-

emphasised. The MHDP should see gaining informed and voluntary consent from tenants as a critical process of the

project. Gaining consent is not a one-off activity; the time spent gaining and renewing consent as a longer term

process will be rewarded through active participation that is required to achieve the tenancy sustainment and positive

life outcomes for tenants.



In addition to challenging gaining informed and voluntary consent and the necessity to see tenant consent as part of a

broader and long term collaborative process, the tenant consent form changed three times during the first months of

MHDP operation which exacerbated the aforementioned problems. The changes to the consent form meant that

consent forms that tenants had originally signed were null and void, in turn, DHPW stakeholders were required to ask

tenants to re-sign new consent forms. Two DHPW stakeholders with direct experience in obtaining tenant consent

reported the problems that changes to the consent form represented, detailed in the Interim Report.

Stakeholders involved in the management of the MHDP recognised that the process of having tenants sign consent

forms that were not agreed upon by all participate to the project was problematic for tenants and for staff involved in

obtaining consent. The legislative and cultural requirements for consent differed among MHDP partners, for example,

between the DHPW and Queensland Health. The issue was resolved and the stakeholders agreed on and now use a

participant consent form that satisfies the legislative requirements of all stakeholder organisations.

2.2 THE PRACTICE ELEMENTS OF THE MENTAL HEALTH DEMONSTRATION PROJECT

Building on and extending the analysis about referrals into the MHDP, the next section briefly outlines other key

elements of the MHDP in practice. Specifically, we examine the additional and broadened clinical and non-clinical

support services provided as part of the project and case-coordination and case-management practices (via CAIRT

and stakeholder meetings). The overall governance and operation structure is shown in Figure 2.

2.2.1 Case-coordination and Support

In practice, the MHDP operates through the collaboration between services via case coordination and the provision of

clinical and non-clinical supports. Case-coordination in the MHDP is occurring through several means, including

through inter-agency meetings, case-conferences, sharing of information between stakeholders, and developed

protocols and case-management tools, such as the Housing Support Plan.

We summarise the way housing, clinical, and non-clinical services are provided, by outlining the roles and function of

the DHPW, Footprints, and Queensland Health. Following this, we summarise how case-coordination is occurring via

CAIRT meetings and Stakeholder meetings. For clarity of discussion, we present some of this analysis distinguishing

between the clinical, non-clinical, and housing delivery of the MHDP. The discussion of the clinical, non-clinical, and

housing services separately, however, does not indicate that the three services are provided in isolation. Consistent

with the meta-findings of the MHDP constituting an integrated model (see evidence in Chapter Five), we emphasise

that the clinical, non-clinical, and housing services are delivered in an interdependent way. As discussed above, the

activities of the non-clinical provider, for example, rely upon identification and referral by the DHPW, and then case

coordination and joint decision making (see below) by all stakeholders. Each activities undertaken by the housing,

clinical, and non-clinical provider are reliant upon the activities, information sharing, and work among other

stakeholders in the project.

2.2.1.1 Non-Clinical Support

Consistent with the service delivery model, Footprints provide non-clinical support. The Service Delivery Model

describes the areas of non-clinical support as:

support and counselling on a one-on-one or group basis;

advocacy support and advice in accessing and using general community services;



guidance in how and where to shop for household goods and groceries;

programs relating to meal preparation and good nutrition;

programs relating to meal preparation and good nutrition;

assistance with obtaining membership at community clubs;

assistance in enrolling in social, recreational or physical activities and programs;

assistance with job search and job application processes;

coaching for interview preparation;

coordination of service delivery by multiple service providers who may be dealing with the same participant,

centred around the participants’ needs

The Footprints team comprises two recovery workers, two peer workers, one team leader, and one case manager.

The day-to-day activities of Footprints are driven by the Housing Support Plan.

A stakeholder said that “Footprints is focused on providing support on the recovery journey.” The ethical and

philosophical premise of Footprints’ work with tenants is “very focused on providing an environment where a

participant can explore their own recovery journey and to determine their own goals moving forward and then to create

an environment where those goals can actually be worked toward” (non-DHPW Stakeholder).

Through the activities of the MHDP, Footprints enacts work with tenants and provides support to assist them to

maintain their tenancies. Footprints achieves this by:

Providing psychosocial tenancy support, by creating realistic support plans that feature Housing goals (non-DHPW

Stakeholder)

In addition to the provision of direct non-clinical support, a primary focus of Footprints’ work is directed toward setting

up supports for tenants’ post-MHDP. Through the exit plan, Footprints practices in a way to establish referrals and to

ensure that the tenants is best placed to successfully manage their tenancy after they disengage with the project.

All MHDP stakeholders widely agreed that the psychosocial support, provided by Footprints, was a beneficial and

necessary component of the project. Indeed, it was recognised that Footprints would support nearly all tenants who

come into the project (whereas Queensland Health would support fewer tenants). Non-clinical psychosocial support is

deemed to be the primary need of tenants. This is congruent with the findings of the eligibility analysis, which

suggested that the target group of the project was extended beyond people with a mental illness (as discussed in

Section 3.1.1).

2.2.1.2 Health

The Service Delivery Agreement outlines the role of the Queensland Health Mental Health Clinicians as:

Responsible for delivering the clinical mental health services to participants required by their Tenancy Support Plans, for

the life of the Project.

Formally the roles of the mental health clinicians are vast, including the diverse activities involved in mental health

treatment, mental health assessment, and facilitating access to clinical supports. The mental health clinicians report

their role as commencing at the initial stages of tenants being identified, whereby mental health staff will assess what



the tenant need is and what role mental health clinicians are best placed to play. Depending on the initial referral,

which may include reviewing existing medical records, the mental health clinicians “will do a mental health assessment

and just take it from there.”

The clinical support occurs within the framework of the Metro North Hospital and Health Service. Two mental health

clinicians are employed full time on the project, and work as part of the acute care team. Congruent with the wider

philosophy of the current mental health system, the clinical support provided involves a focus on reconnecting

participants with primary health care and using strategies to redirect people from mental health system. The way this

operates in practice through the MHDP is described with reference to the broader public health system and the

synergies between the MHDP and Queensland Health:

It’s the growing population and the absence of mental health services, I think. The way that we’ve been heading is that

unless you’re in that top end of that triangle, in the top 1% or 2%, you don’t get to mental health services. You go back.

You’re pushed back to primary care. [Queensland Health is] now trained to look, when people come in, what are they

going to do for them to get them out? (DHPW Stakeholder)

There were a number of benefits and down-sides reported to being situated within an existing mainstream health

system. One of the benefits was access to broader range of resources provided.

Because it’s just not those two clinicians, those two clinicians have got to work with the acute care team and perhaps the

inpatient team and all of the other service providers in the Mental Health Metro North area. So it’s not just up to [the

clinicians] to meet all the mental health needs of the individuals. They need to be connecting them through. When

someone needs inpatient care that they are able to easily facilitate that as well (DHPW Stakeholder)

Further, access to mental health records, and ability to access greater amounts of information, was reported and

observed to be helpful to the integration and case-management of tenant’s support.

So despite the difficulties of having to work within the QLD health system, having two mental health clinicians employed

and working within the system also means that participants are more easily able to be connected within the health

system, and information is more readily available (e.g. prior records/ if known to the health system, access CIHMA),

further supports available beyond two health workers e.g. psychiatrist on team discussing case (non-DHPW Stakeholder)

However, stakeholders identified downsides to the mental health clinicians being located in a broader health system.

Although the broader system brought additional resources and capacities, there were ways that the structure of the

health component of the MHDP did not fit with the wider public health system.

So [mental health clinicians] sit within the acute care team, but the acute care team has their own business rules. So you

can only be associated with the acute care team for X number of weeks and then you have to go into a continuing care

team. Technically, [MHDP] clients don’t meet the criteria to be in the continuing care team (non-DHPW Stakeholder)

In practice, stakeholders had developed strategies to work around and to ensure the MHDP fits within the Queensland

Health systems.

2.2.1.3 Housing

The role of the DHPW pervades all aspects of the MHDP; the DHPW plays a key role identifying and referring tenants.

The DHPW’s role is also to continue with the provision of housing. Given that the DHPW will have a relationship with

participants after they exit the project, the DHPW’s interest in and involvement with tenants transcends the project

duration. Thus, the DHPW will play a key role assisting in the realisation of the exit plan. From a day-to-day



perspective, housing officers and the housing service integration coordinator (HSIC) are directly involved in the

Stakeholder Meetings and the CAIRT. The HSIC also plays a key role in project management, case management, and

as a link between housing officers and the MHDP.

2.2.1.4 CAIRT

A key way that person-centered case-coordination was operating in the MHDP is through the Cross-Agency Intake

and Review Team (CAIRT) and CAIRT meetings. MHDP stakeholders describe the CAIRT meetings as the key

vehicle for referral, planning, case management and assessment. Beginning February 3rd, the CAIRT meetings are

held fortnightly on Wednesdays. Chairing is shared between the two Housing Service Center Area Managers, and the

Housing Service Integration Coordinator as Secretariat. As one non-DHPW stakeholder described “we meet every

fortnight in a formal capacity with Department of Housing to one, review existing participants, but also, when capacity

allows, to introduce new participants to the project. That’s been the flagship, that’s been the go-to and 100%

attendance and that’s great.”

A DHPW stakeholder observes that “the CAIRT meeting is an internal meeting. It’s just Footprints, Health, and

Housing and this is where we discuss client circumstances, the ways to go forward, et cetera. The stakeholder

meeting is a meeting where there is the tenants in the room and there are all the other agencies who are working with

the tenant and people are pretty open.”

In practice, it appears that CAIRT meeting provides an ongoing and structured process for representatives from the

three key service stakeholders to share information, jointly assess and prioritise referrals, jointly plan integrated

service responses to participants’ individual needs, problem solve and discuss circumstances around participants,

allocate or demarcate roles and responsibilities of the services, monitor progress and review and revise case plans.

The literature suggests that successful case-coordination as requiring a facilitator to organise and chair meetings,

drive the development of protocols, monitor progress and maintain records (e.g. Mosley and Oliver 2008; see Interim

report for the detailed literature review). This role appears to be filled by the DHPW Area managers and HSIC during

CAIRT meetings.

The functioning of the CAIRT meeting has been refined over the duration of the project operation. A stakeholder

pointed out that the CAIRT meetings initially had a duration that far exceeded the Service Delivery Model, but, with the

support of the three partners, the operation of the CAIRT meeting had improved:

Whilst it’s been effective we’ve had to work really hard at trying to reduce the length of those meetings. They were

touching nearly six hours. We narrowed it down to about a two to three hour process. So there’s been some ongoing

refinements and that’s great and that’s been a learning curve for us all is to try and get through that in an efficient manner

(non-DHPW Stakeholder)

2.2.1.5 Stakeholder Meetings

Another key element of collaborative case-coordination was stakeholder meetings (Mosley and Oliver 2008). In

practice, the stakeholder meetings are coordinated by the lead agency and involves a meeting that brings together the

various services or workers involved with the participant, and usually the tenant themselves, to discuss the tenant’s

support needs and housing support plan. Overall, the majority of MHDP stakeholders held the view that stakeholder

meetings were a key and useful element of case-coordination. One stakeholder reported that the ideal would be to



have stakeholder meetings after initial engagement, around the middle of the support period, and towards the end. In

practice, each tenant has at least on stakeholder meeting.

Participants Stakeholders reported stakeholder meetings as a helpful process for tenants, but they expressed concern

if the stakeholder meeting was established as a procedural matter rather than a necessity. A stakeholder, who

appraised stakeholder meetings as generally positive, described a specific stakeholder meeting that was deemed

superfluous. The usefulness of stakeholder meetings and stakeholder’s willingness to engage is compromised when

people believe the meetings to be motivated by compliance with governance processes rather than to assist the

tenants.

2.2.2 Brokerage

The brokerage component of the MHDP is highly regarded as effectively assisting tenants address problems that

undermine their capacity to sustain their tenancies.

The MHDP Service Delivery Model describes limited brokerage funding to be used:

To purchase specialised or top up psycho-social and/or tenancy support services. The services purchased with brokerage

funds will be driven by participant goals and will be tailored specifically to tenant-need identified through individual

Housing Support Plans (p. 10)

The Service Delivery Model says that brokerage funding is up to approximately $500 per participant. It goes on to

specify that:

All use of brokerage funds must be for the purpose of assisting participants to sustain their tenancies (p. 30)

In theory, brokerage represents a meaningful resource to demonstrably contribute toward achieving MHDP objectives.

Stakeholders from both within and external to the DHPW reported that the brokerage has been a useful element of the

project with the potential to achieve meaningful impacts.

Brokerage funding was identified as a critical ingredient to operationalise the good will and optimism into practical

support. Consistent with the policy intent, stakeholders described brokerage as a resource to action the Housing

Support Plan. Brokerage was perceived to be an advantageous resource because the funding, if used, would enabled

the flexible and quick access of bespoke resources that have an impact on tenant’s capacity to sustain housing.

Brokerage has the potential to be significant because it enables the service response to move beyond the profound

complexity that can characterise a person’s life and focus instead on immediate practice solutions. There are likely to

be myriad complex and interacting issues that underpin challenges maintaining a property. Brokerage offers the direct

means to help mitigate the problems, as a DHPW stakeholder reported, the purchase of a lawn mower for instance.

Used in collaboration with broader clinical and non-clinical support, brokerage can not only provide a successful

means to meet the immediate needs of tenants, but it is likewise significant in demonstrating to tenants a commitment

to support them in a positive manner. During the latter stages of the research we will engage with tenants to identify

and assess their perspectives of and experiences with brokerage.

Despite brokerage being perceived as an advantageous resource, MHDP stakeholders saw brokerage as one tool to

be used in case management. Moreover, and drawing on the guidelines set out in the Service Delivery Model,

stakeholders approached brokerage as a last resort resource. A non-DHPW stakeholder described her/his approach to

brokerage, noting that “brokerage is”:



A good tool. Brokerage is the last resort. It is nice to have as a fall back; but that’s what it is; it’s a fall back (non-DHPW

Stakeholder)

The stakeholder said that brokerage was not seen as a blank cheque. Indeed, whenever considering putting a request

in for brokerage funding, she/he would ensure that alternative options were sought in the general service system: “if

counselling was required we would look for a public counsellor rather than asking for brokerage to pay for a private

counsellor.” The stakeholder argued that a “thrift” approach to brokerage was required in order to be consistent with

the guidelines, but also to ensure that tenants did not become dependent on brokerage.

Analysis of funding approved for brokerage expenditure suggests that stakeholders have taken a last resort to using

brokerage. As of 17th of November 2017, $28, 886 had been spent on brokerage. This spend constitutes a small

portion of the initial $150,000 brokerage funding allocated for the MHDP (at the conception of the project), and less

than allowed $57,500 of the brokerage budget would be expected if each participant had accessed the allowed

approximately $500 per person. After the findings in the Interim Report were presented, the DHPW reduced the

available funding for the MHDP from $150,000 to $50,000.



Figure 2. Governance and Operation Framework



2.3 EVALUATION OF THE MODEL

2.3.1 Appropriate to Address Unmet Need

Stakeholders from the DHPW, Queensland Health, and Footprints widely perceived the MHDP as playing a critical role

in addressing service gaps. They argued that the MHDP represented an ideal solution to meet the housing, support,

and health needs of social housing tenants with mental illnesses and complex needs. Stakeholders couched the

appropriateness of the MHDP with an assessment of the limitations in the mainstream service system.

I can see great benefit in [MHDP], especially with the fact that clinical and non-clinical services are working really closely

together in an integrated fashion, which somewhat breaks down the barriers, the obstacles, the time delays and if you’re

working as a standalone service that doesn’t have those MoUs or those partnership agreements, where you can call on

them and they’re signed up to reply and respond in a swift way. So I see it breaking down those response barriers, which,

in turn, then provides a more swift and timely response to those clients that need that support. So I see [MHDP] as having

a great need (non-DHPW Stakeholder)

The enthusiasm and support for the MHDP sits in a practice context of massive unmet tenant need and housing

officers without the time, resources, or qualifications to meet the health and support needs of tenants with mental

health problems and complex needs:

Our Housing officers manage something of upwards of 500 tenancies. Only 10 per cent of them will be causing issues,

but even with those 10 per cent it’s a lot to be case managing individual tenants, especially with such complex needs. I

think the [MHDP] has been able to take at least some of the burden off and just, “Here, can you take this one?” and

they’ll, with supports, manage that, be able to case manage (DHPW Stakeholder)

Another DHPW stakeholder not only lauded the MHDP because it provided additional staffing and resources, but also

because the MHDP brings to the DHPW additional expertise and perspectives to help address problems the DHPW

has otherwise struggled to address. Referring to cleaning properties for people who have hoarding and squalor

problems, a DHPW stakeholder observes:

So we’ll get their consents, we’ll get skips in, and we’ll get somebody to do a big clean of the unit. [MHDP] has really

brought it home to us that that’s not necessarily the best approach. So [with the MHDP we’re] coming at it with a little bit

of smarter heads. More experts. It’s then trying to learn from Footprints and Mental Health about systems, supports with

the tenants, and ways of engaging with the client and how to do that better (DHPW Stakeholder)

Outside of the DHPW there was similar views that the MHDP was a vital resource to assist the DHPW develop a

greater awareness of tenants. A non-DHPW stakeholder outlined the importance of not simply providing psychosocial

and health services to address tenancy problems, but rather of changing the way the DHPW understands tenants:

Another success is, again, comparing to previously, allowing the Department of Housing, the landlord, to be closer to that,

to know that tenant more. Not just a number or checking for rent. To actually have a little bit more insight into that tenant,

the challenges, the journey they’re on, and their wants. I see that as success as well (non-DHPW Stakeholder)

The MHDP was also seen as highly appropriate because it enabled the DHPW to overcome some of the limitations

that the former anti-social behaviour policy presented in meeting the needs of tenants with complex needs. As one

DHPW stakeholder explained, the MHDP was a positive resource that took account that people’s behaviours are

complex and the DHPW needs similarly flexible approaches, especially compared to the former anti-social behaviour

policy:

As I say, [MHDP] gives us more wiggle room, it gives us our own interpretation on what we should do. As senior housing

officers/managers, it allows us to do more things and provide more options than just a straight line (DHPW Stakeholder)

With recognition that the MHDP fills significant gaps in service and practice responses, stakeholders expressed

optimism and excitement for the project:

This project has come with a tremendous amount of goodwill from service partners. People believe in this project and

want to see this project as a success, because the need is so great, and finally we’ve got the ability and some funds and



not only the financial contribution, but the social capital that has come with it to hopefully affect some change (DHPW

Stakeholder)

As we elaborate below, the optimism that the MHDP would fill a service gap by meeting the clinical and non-clinical

support needs of social housing tenants fed into broader aspirations that the MHDP would help create systems and

cultural change.

2.3.2 Inter-Department and Interdisciplinary Access

Developing the argument that the MHDP filled a significant service gap (Section 2.4.1), stakeholders consistently

identified that the project had benefited from, and been successful because of, enhanced inter-department and

interdisciplinary access. All stakeholders expressed the view that they had long understood that their tenants, clients,

and patients experienced problems and required solutions that crossed departmental and disciplinary boundaries. It

was the MHDP, however, that represented, or at least that they anticipated would represent, a practical mechanism to

access inter-department and interdisciplinary resources.

Prior to the MHDP stakeholders from the DHPW experienced barriers and frustration at accessing the non-clinical and

clinical support that they assessed tenants needed. Within the constraints of managing approximately 500 tenancies,

prior to the MHDP housing officers still attempted, albeit often unsuccessfully, to link tenants who experienced

problems with external service providers.

I think that [MHDP has made it] easier for [housing officers] with this project because before this project we would have to

be vague, we would have to be calling Mental Health. Then you’d be trying to call the support organisations. I mean,

some of these people don’t get back to you for a week, two weeks. That’s the problem. Then we feel like Housing are

always chasing up people. We talk about it all the time, that we’re the ones that are calling Mental Health, calling Health,

calling the organisations and sometimes you just might not even hear back. So with this project [MHDP] those orgs have

to get back to us… the project has created some accountability for Mental Health and Health and for some of the

organisations (DHPW Stakeholder)

The DHPW stakeholder lauded the MHDP because it provided confidence to the DHPW that tenants, when problems

had been assessed and agencies referred, would be supported:

So if we give them a referral, they have to do something with it. We know it’s not just going to fall through the cracks,

because there’s these meetings, they go over things. So it’s a bit more structured (DHPW Stakeholder)

The MHDP did not simply enable the DHPW to refer tenants to non-clinical and clinical support services. Housing

officers have long been referring their tenants to organisations with the aim of tenants receiving support. DHPW

stakeholders argued, however, that prior to the MHDP they experienced problems having referrals followed up on;

from the perspectives of DHPW representatives working at the tenant interface, the MHDP was a valuable initiative

and helpful to tenants because it meant that referrals would be actioned. Because of funding arrangements and a

structured agreement (i.e., the DHPW is co-funding the non-clinical provider), DHPW stakeholders had confidence that

the support would be provided. The provision of support, and the psychical manifestations of activities through CAIRT

meetings, for instances, represented the antithesis to the experiences of housing officers trying to access services

prior to the MHDP. Even without commenting on whether they assessed tenants had improved their situation or

mitigated housing risk because of the MHDP, the DHPW stakeholders could clearly identify, in contrast to what they

had previously experienced, organisations that they had referred to providing support to tenants.

At a management level, similarly, the DHPW perceived that the MHDP brought external stakeholders, and their

expertise, to bear on tenancy issues. A DHPW stakeholder reports:

I can see a small bit of success because earlier we wouldn’t have ever done this, working collaboratively with agencies.

The intention is for us all to exchange information.” So I think it’s useful. Yeah, I wouldn’t have had that. I went to a recent

case conference meeting where the Adult Guardian usually doesn’t attend those meetings, but she actually did because

this is a [MHDP] client” (DHPW Stakeholder)

Inter-department and interdisciplinary access extended beyond the DHPW having enhanced capacities to draw on

clinical and non-clinical support. Inter-department and interdisciplinary access meant that clinical and non-clinical



providers benefited from the resources of each other as well as the resources the DHPW provided. A Queensland

Health stakeholder observed:

It’s just been so nice to have a non-government organisation on tap. It’s just been incredible. It’s been quite a privilege,

really, and they have been amazing. They have done some incredible stuff. I think it’s been that combination, of doing the

mental health assessment, identifying stuff that previously these people have flown under the radar, and then either being

able to refer them to [non-clinical provider] who’ve picked them up or being able to refer them to other services and

sometimes it’s just simple things that just need ironing out. A lot of things that we’ve found is a lot of medical

comorbidities that can be addressed and also keeping people in the private sector, ensuring that GPs who are treating

their stuff. The collaborative thing has been fantastic (non-DHPW Stakeholder)

The three lead agencies, Footprints, Queensland Health, and the DHPW not only draw on each other’s resources and

expertise, but the MHDP is a mechanism for these agencies to draw on additional external resources. Because the

Queensland Health component of the MHDP is located within the acute mental health team, the majority of their

activities focus on linking people to mainstream service systems, for example General Practitioners. A DHPW

stakeholder articulated the importance of the Queensland Health partner in the MHDP engaging across a wide range

of services:

Because it’s just not those two clinicians, those two clinicians have got to work with the acute care team and perhaps the

inpatient team and all of the other service providers in the Mental Health Metro North area. So it’s not just up to [clinical

workers] to meet all the mental health needs of the individuals. They need to be connecting them through. When

someone needs inpatient care that they are able to easily facilitate that as well (DHPW Stakeholder)

2.3.3 Systems and Cultural Change

Stakeholders from both within and external to the DHPW saw the MHDP as a mechanism to support the DHPW move

toward, and see itself as, a human service organisation. A non-DHPW stakeholder observes:

Another really big key thing is that Housing are now seeing themselves more in that human services line rather than

purely a provider of bricks and mortar and being a rental agency, which I think was their old thinking, that rental agency

thinking. They are moving into the human services mould which helps, I think, helps with how they see themselves; [it

helps] housing being able to offer that assistance to people in social housing, creates a better role for people at the

housing service centres, as well as a better outcome for the individuals in the housing (non-DHPW Stakeholder)

The stakeholder went on to say that the goal of the MHDP is systems change whereby the DHPW has a better

understanding of the complex issues experienced by tenants and a better capacity to respond to those issues:

There’s positives for Health and Housing as well and a greater understanding of how each other operates within the

system (non-DHPW Stakeholder)

Another non-DHPW stakeholder argued that the DHPW had long been perceived by tenants as disengaged and that

tenants only heard from the DHPW if there was a problem or for bi-annual property inspections. Because of the

MHDP, however, the stakeholder believed that the DHPW would be seen by tenants:

As a more human service based, rather than just a landlord, I think that’s got to be considered a success, a good

outcome (non-DHPW Stakeholder)

In addition to intended systems changes about how housing is positioned as a human service organisation,

stakeholders saw that the MHDP would offer an opportunity to not only provide direct support to tenants, but also to

help tenants change their perception of the DHPW. A DHPW stakeholder stated, for instance, that the MHDP would be

successful when it created the conditions for tenants to feel comfortable to engage with the DHPW:

So, you know, there’s other ways that you can measure the success of the program, not just by how many people clean

up their property or how many people stop their disruptive behaviour or how many people start paying their rent. It’s

around just the subtle things like, “Hey, that person would never have picked up the phone and rung us and said there’s

an issue.” But with support, with encouragement, with strategies that they’ve been taught through the [MHDP], they’re at

a point now where they’ll ring us (DHPW Stakeholder)



Another DHPW stakeholder involved in the direct management of properties expressed likewise. For this stakeholder,

the MHDP is about “improving relationships” between tenants and the DHPW:

A lot of people don’t trust us or believe we’re helpful. “You can’t do anything for us.” So I think a part of this is proving that

we can help people. I think it’s just making people feel like we’re there to help them, rather than we’re just tenancy

managers (DHPW Stakeholder)

If the MHDP is able to identify tenants with unmet clinical and non-clinical support needs that places their tenancies at

risk and then if the project can provide a positive intervention to those tenants it is indeed probable that tenants will

both improve their life conditions and change their perceptions of the DHPW. The activities of the MHDP are

consistent with the aspiration of the DHPW becoming a human service organisation.

Summary Points

Overall, the deliverance of the MHDP has been congruent with the Service Delivery Model.

Eligible social housing tenants are being referred into the MHDP because of experienced or predicted tenancy

problems due to a range of reasons, including and extending beyond mental health issues. The referral

process suggests the scope of the project has been established, in practice, in broad ways to encompass the

variety of issues that can impact housing tenancies, rather than a project specific to people with mental health.

Housing Support Plans (HSP) constituted a significant area of confusion, debate, and resultant concern

among stakeholders from the DHPW, Queensland Health, and Footprints. Confusion, debate, and concern

about the HSP is threefold: (1) no shared understanding of purpose or information to be included; (2)

disagreement about whose task it is to complete the HSP; and (3) lack of clarity about how, if at all, the HSP

will be used post-MHDP.

Obtaining tenants informed and voluntary consent was seen to be an important but challenging aspect of the

MHDP. Stakeholders widely endorsed the necessity of tenants being afforded the opportunity to give informed

consent to enable voluntarily participation in the MHDP. However, there were perceptions that tenants who

needed the project often did not consent or did not engage. Further, when tenants consent was not well

informed or completely voluntary, this was perceived to negatively impact upon engagement with the project.

Clinical and non-clinical support was provided as per the formal model. The non-clinical support provided by

Footprints is experienced by all MHDP stakeholders as achieving a significant impact. The HSIC was also

seen as an important role to facilitate cross-agency collaboration. CAIRT and stakeholder meeting were also

seen as key elements of the model in practice.



2.4 MODIFICATIONS SINCE INTERIM REPORT

Stakeholders at practice and management levels actively expressed that the MHDP was a trial initiative. As such, the

Interim report was used as a way of identifying the early challenges and barriers to achieving project success, and

stakeholders expressed an understanding that the challenges should be expected as it was a trial and error initiative.

The interim report outlined that different organisational and professional expectations, the limits to what the MHDP can

achieve including the limited services available outside of the program, challenges changing systems, and heavy

governance and management structures all represent barriers to the MHDP achieving success. Additionally, questions

were raised as the why there were no community housing referrals made.

Discussion with stakeholders revealed the following key changes in the operation of the MHDP since the publication of

the interim report:

2.4.1 Shared Information Platform

At implementation and for the initial six months of the MHDP operation, there was no technology for a shared

information system among the project partners. The absence of technology to share information about tenants and

their engagement with the MHDP caused inefficiencies in practice integration, constituted a huge workload for the

housing service integration coordinator, and meant that partners could not easily access information they required to

achieve the MHDP objectives.

Mid-way through 2016 a shared information system for the MHDP went live. The comments on the shared information

platform were positive, and it was seen as improving the implementation of services, as illustrated below:

So this is brilliant because if we want to add something to the support plan, we add it and just send it up there. So we’ll all

have access and all be able to add to documents and things like that, which is just absolutely brilliant, because the

thought of how this whole thing of updating those support plans and version control was going to happen, I’ve got no idea

(non-DHPW Stakeholder)

The portal’s really good. It’s really good that three agencies can get onto the same site, into data, check records, et

cetera. It’s really good. The portal has huge capability. But all three agencies, we don’t have that capacity to use it.

But yeah, all our referrals are up there, all our Housing support plans, meeting notes, but it can be all doubling up.

(DHPW Stakeholder)

Although the addition of the shared platform was seen as an improvement, there were still barriers associated with its

use. One such barrier was that the platform did not work consistently across the three core agencies. Specifically, it

was reported to us that users on a Qld Health system were unable to access and work on the shared information

platform documents online.

Additionally, information contained in the shared information platform (described as the portal) would replicate on

information stored elsewhere (such as the individual agencies case notes). Further, there were concerns that the

shared platform may not be utilised by HSC staff, as described below:

I don’t believe [HSC staff] use it as much as I would have liked them to use it. So it’s a bit of hit and miss. There

are some officers who use it fairly well and jump onto it as their first point of call, whereas some forget, and I think

maybe even training HSC staff will take a long time. (DHPW Stakeholder).



2.4.2 Governance Structure

The interim report described how some stakeholders expressed the view that the project’s focus on governance was

too time-consuming, and importantly, they observed that the focus on project governance detracted from the capacity

of the service integration coordinator to conduct service integration. As a consequence, stakeholders commented that

after the Interim Report, a number of changes were made which reduced the governance structure (i.e. there were

less groups within the structure, compared to Figure 2) and created a more streamlined approach to governance

meetings. The operation of the CAIRT meetings also changed, from a fortnightly meeting that was attended by the two

HSC Area managers, HSIC, mental health clinicians, and Footprints workers (as per Figure 2) to a weekly meeting

conducted separately for the two HSCs. This was perceived to be a positive by Housing staff, as it allowed a focus of

the clients of a specific service. It was reported that one of the reasons for doing this was to allow more time for an

educational component to the meetings and to facilitate attendance of other Housing staff for them to learn more about

the project, but that these additions did occur as planned, for the remaining duration of the project.

It was also reported that this also had the effect of increasing the workload of attendees who were required to attend

weekly meetings, rather than fortnightly meetings, without a corresponding reduction in the time duration of the

meetings.

2.4.3 Organisational and Professional Expectations

In the Interim report, it was highlighted that Inter-department and interdisciplinary integration is a critical contributor to

the MHDP successful implementation and early operation but that in practice, inter-department and interdisciplinary

integration also represented a challenge to project success. The Interim Report described how bringing different

stakeholders together highlighted conflicting expectations and understanding of what tenants needed and how the

project should function.

When asked what has changed from the Interim Report, both a DHPW stakeholder and non DHPW stakeholder

perceived that there has been an increased shared understanding of the MHDP approach and objectives, and

increased shared understanding and appreciation of the roles, languages, and skills amongst the three main

organisations (DHPW, QLD Health, and Footprints).



3 TENANCY DATA

The following chapter examines data from the DHPW to answer the questions of a) who was referred into the project

and what was the reason for the referral; b) was the MHDP effective in improving tenancy outcomes; c) was the MHDP

equally effective for different groups of participants. The chapter begins with a snapshot of the MHDP participant

characteristics, before examining the tenancy data of participants before, during, and after their participation in the

MHDP.

3.1 PARTICIPANT CHARACTERISTICS

3.1.1 Participant Demographics

The background demographic information of the tenants who participated in the MHDP is summarised in Table 2.

There were more females than males referred in the project. The most commonly occurring family type was single

person, followed by single person with children. Thirty-nine project participants had children, while 65 were without

children. There was a higher proportion of participants referred from the Chermside HSC, compared with the Fortitude

Valley HSC (Χ2 [1, N = 112] = 4.32, p = .038).

3.1.2 Participant Project Information

Table 3 summarises the referral information and completion rates of the MHDP, as of 31st of July 2017.

People were referred into the project for three stages of tenancy risk, these are: early intervention, prevention, and

crisis. The process evaluation outlined how tenancy risk stage were described by project stakeholders as important in

assessing and organising who accesses the project. The tenancy risk status was already indicated in the data given to

us, and uses the definition from the Participant Referral Form:

Prevention – mitigate risks identified at commencement of tenancy (no breaches or warnings issued);

Early intervention – prevent recurrence or exacerbation of tenancy issues (already has some breaches or

warnings);

Crisis – address significant issues to sustain tenancy (tenancy is at risk due to multiple or serious breaches).

The process evaluation also outlined that there was no indication that the tenancy risk stage determined the nature or

duration of support provided, referral reasons were broad and that reasons for referrals were not determined by an

assessment of severity of mental illness or complex needs.

Relatively equal numbers of people were referred in at the three different tenancy risk stages (crisis, early intervention,

and prevention). The most commonly occurring reason for referral was for “neighbourhood issues”, with 42% of the

sample having this listed as a presenting concern. The second most common reason was “personal issues” (30%),

followed by mental health issues (24%).

Overall, the majority of participants who were referred and accepted into the project completed, that is entered the

project, engaged in some capacity, and exited the project. Six were still involved with support at the when the

researchers received the data (31st of July 2017), fourteen never participated, and sixteen initially participated before



withdrawing from the project. A participant was considered withdrawn from the project when they either explicitly

withdrew their consent, or implicitly withdrew by not engaging with support (e.g. not answering phone calls or home

visits, becoming uncontactable). Two participants withdrew from the project due to their tenancy being vacated; we do

not have information to determine whether the tenancy vacated was voluntary or involuntary.

Although initially the majority of participants in the project were in the crisis stage of tenancy risk (see Interim report for

descriptions), by the end of the project, the majority of participants were referred in the prevention stage of their

tenancy risk. This suggests that although the MHDP initially took a crisis reactive approach, across the longer duration

of the project, a planned preventative approach was also delivered.



Table 2. Participant demographics table

Frequency

Percent N = 115

Gender

Unknown 4 3.48

Female 70 60.87

Male 41 35.65

Housing Service (at project entry)

Churches of Christ 2 1.74

Chermside 67 58.26

Fortitude Valley 46 40

Family Type

Couple Only 3 2.61

Couple Only Over 55 2 1.74

Couple, 1 Child 2 1.74

Couple, 2+ Children 3 2.61

Other 9 7.83

Single Parent, >2 Children 7 6.09

Single Parent, 1 Child 13 11.30

Single Parent, 2 Children 14 12.17

Single Person 36 31.30

Single Person Over 55 24 20.87

Unknown 2 1.74

Number of Occupants in House

1 60 52.17

2 25 21.74

3 17 14.78

4 7 6.09

5+ 4 3.48

Unknown 2 1.74

Income

Age Pension 13 11.30

Disability Support Pension 57 49.57

New Start Allowance 24 20.87

Parenting Payment 19 16.52

Youth Allowance 2 1.74

Ethnic Background

Aboriginal or Torres Strait Islander 17 14.78

Not Aboriginal or Torres Strait Islander 72 62.61

Other 7 6.09

Not disclosed 5 4.35

Unknown 14 12.17



Table 3. Participant Project Information

Frequency Percent

Tenancy Risk Stage

Crisis 38 33.00

Early Intervention 34 29.60

Prevention 43 37.40

Status as of 31st July 2017

Active 6 5.20

Completed 73 63.50

Never Participated 14 12.20

Re-engaged 4 3.50

Withdrew Disengaged 16 13.90

Withdrew Tenancy Vacated 2 1.70

Referral Reason*

Hoarding and/or Squalor 22 19.13 Poor property Conditions 23 20.00 Mental Health Issues 28 24.35 Personal issues 34 29.57 Neighbourhood Issues 48 41.74 Rent Arrears 12 10.43

Length of Stay in Project

< 1 month 10 8.70

1 - 4 months 39 33.91

4 - 6 months 16 13.91

6 - 8 months 19 16.52

8 - 10 months 10 8.70

10 - 12 months 10 8.70

>12 months 1 0.87

No current end date 10 8.70

* Referral reasons are based on categories provided in the Portal Data, and specific

details of the referral question are not known. Participants often had multiple referral

reasons, thus percentages do not add to 100%

There were no significant differences between percentage of males and females on different tenancy stages (crisis,

early intervention, and prevention). That is, the same rate of males and females were referred at crisis stage, early

intervention, and prevention (see Table 4). There were no statistically significant differences between stages of

tenancy and Housing Service Centres (HSC). Participants from the Chermside HSC were no more or less likely to be

in any of the tenancy stages compared to the Fortitude Valley HSC (Table 4).



Table 4. Number of males and females by tenancy stage

Stage

Gender Crisis Early Intervention Prevention

n % n % n %

Female 24 34.30 18 25.70 28 40.00

Male 12 29.30 16 39.00 13 31.70

Chi-square Test of Independence (2, N = 111) = 2.18, p = .337

HSC

Chermside 23 34.32 17 25.37 27 40.30

Fortitude Valley 15 33.33 17 37.78 13 28.89 Chi-square test of independence (2, N = 112) = 2.35, p = .308

3.1.3 MHDP Engagement Status

For the purpose of evaluation (due to statistical reasons), we examined engagement status by distinguishing between

people who engaged versus people who did not engage. Engaging with the project included people who had

completed, re-engaged or were still active (Engaged), whereas people who did not engage with the project included

those tenants who never participated, withdrew engagement or disengaged, or withdrew due to vacating their tenancy

(Not engaged).

There were no statistically significant differences between stages of tenancy and status of engagement with the MHDP

(at time of data collection). That is, stages of tenancy (crisis, early intervention, and prevention) did not predict whether

people were still active, completed, engaged, or withdrew (see Table 5). Gender, family type, ethnic background, and

referral reason also did not predict who engaged versus who did not engage.

Table 5. Stage by Status

Status Total

Active Completed Never

Participated Re-engaged

Withdrew Disengaged

Withdrew Tenancy Vacated

Stage:

Crisis 2 25 6 2 3 0 38 Early Intervention

1 24 2 2 4 1 34

Prevention 3 24 6 0 9 1 43

Total 6 73 14 4 16 2 115

Chi-square Test of Independence (10, N = 115) = 8.98, p = .534

There was a statistically significant difference between the two HSCs on project status (engaged vs not engaged).

Participants from the Fortitude Valley HSC were significantly more likely to have withdrawn or not participated in the

project compared to the Chermside HSC (Table 6). Specifically, 40% of participants from the Fortitude Valley HSC did

not engage (not participate or withdrew) compared to 21% of participants from the Chermside HSC.



Table 6. Housing Service by Engagement Status

Housing Service Centre

Chermside (n = 67)

Valley (n = 45)

Total

Status

Engaged 53 27 80

Not engaged 14 18 32

Chi-square test of independence (1, N = 112) = 4.81, p = .028

3.1.4 Duration of Time in Project

The total number of months a person was active in the project for is summarised in the table below. For people who

engaged with the project, participants’ duration of time in the project ranged from 1 to 18 months. The average level of

support was approximately 7 months.

Table 7. Duration of time in project by engagement status

Status as of 31st of July

Total

Active* Completed Never

Participated Re-engaged* Withdrew

Time in Project

< 1 month 0 0 8 2 2 12

1 - 4 months 0 22 4 0 13 39

4 - 6 months 0 13 1 1 2 17

6 - 8 months 1 18 0 0 1 20

8 - 10 months 2 10 0 0 0 12

10 - 12 months 3 9 1 0 0 13

>12 months 0 1 0 1 0 2

Total 6 73 14 4 18 115

* Length of support received as of the 31st of July, 2017

There were no significant differences between males and females and between Indigenous and non-Indigenous on

duration of time in project. There were also no significant differences between HSCs. People in the crisis stage had a

higher mean level of support, compared to people in the early intervention, but this did not reach statistical

significance. People who were referred for personal reasons spent significantly less time in the project, compared to

people who did not have personal issues as a referral. There were no other differences on duration of support for other

referral reasons.



Table 8. Duration of time in project by demographic factors, housing factors, and referral reason for people who completed

Duration of Time in Project (in months)

Range Mean SD Median

Gender

Males 1 to 11 months 5.66 2.96 4.74

Females 1 to 18 months 6.77 3.29 6.74

Indigenous

Aboriginal or Torres Strait Islander 1 to 11 months 4.95 2.48 4.29

Not Aboriginal or Torres Strait Islander 1 to 17 months 6.57 3.19 6.55

HSC

Chermside 1 to 17 months 6.34 3.18 6.32

Valley 1 to 11 months 6.31 3.27 6.29

Stage

Crisis 3 to 17 months 7.56 3.23 7.19

Early Intervention 1 to 11 months 5.28 2.79 4.26

Prevention 1 to 11 months 6.17 3.24 6.13

Referral Reason

Hoarding and Squalor 4 to 11 months 6.87 2.00 7.19

Poor property Conditions 3 to 17 months 7.31 4.10 6.74

Mental Health Issues 1 to 11 months 6.16 3.25 5.81

Personal issues 1 to 9 months 4.86* 2.73 4.32

Neighbourhood Issues 1 to 17 months 6.59 3.46 6.66

Rent Arrears 2 to 11 months 7.16 3.53 6.68

* Mean is statistically significantly lower than participants who did not have personal issues as a referral reason



3.2 PARTICIPANT HOUSING OUTCOMES

Improved housing outcomes is one of the key objectives of the MHDP and thus an important indicator of project

success. We measured housing outcomes by analysing the frequency and change in incidences recorded on the

DHPW tenant database that indicate tenancy problems, which we refer to throughout the report as a “housing code”.

The incidences (housing codes) that we measured and analysed include: breaches, arrears, notices to leave,

warnings, and antisocial behaviour notes. When the DHPW verify information about these incidences they are

recorded with corresponding codes of the tenants housing record. Incidences recorded in the DHPW tenant database

that were examined were grouped into four categories: a) complaints (specifically, behaviour complaints, complaints

actioned, occupancy complaints, property condition complaints, property structures complaints, illegal use of property,

and maintenance complaints); b) arrears, breaches, notices to leave (including notice to remedy for arrears, notice to

remedy for reasons other than arrears, and notice to leave issued); c) warnings (including notes relating to antisocial

behaviours, warning notices for anti-social behaviour, strikes, and serious disruptive behaviour); and d) referrals and

tenancy management plans. The specific housing codes are reported in the tables below.

To understand the differences between the number of housing codes experienced by participants before and after

participating in the project, we examined the housing codes entered for participants in the 6 months entering the

project, and the 6 months after exiting the project. Fifty-two tenants had the required information (6 months before and

6 months post): 28 participants in the crisis stage, 21 participants in the early intervention stage, and 3 participants in

the prevention stage. Forty participants did not have sufficient housing history in the 6 months prior to entering the

project to be included, 33 participants exited the project less than 6 months ago, and six tenants were still active in the

project, when the data was received by the researchers. Thirty-one of the participants with insufficient housing history

in the 6 months prior to entering were in the prevention tenancy risk stage. As such, we are not properly able to

understand the effectiveness of the project, as operationalised as examining changes in their recorded tenancy

incidences from pre to post project participation, for participants who were referred into the project as preventative.

There were significantly less total housing codes entered (the total of housing codes across all areas), complaints (the

total of all complain types), warnings (the total of notes relating to antisocial behaviours, warning notices for anti-social

behaviour, strikes, and serious disruptive behaviour), notices to remedy (arrears and non-arrears), and notices to

leave (arears and non-arrears) in the 6 months following the completion of the project compared to the 6 months

before the project (see Table 9). The majority of participants in the project received fewer codes in the 6 months after

exiting the project, compared to the 6 months prior to the project (79% received fewer total codes, 58% received fewer

complaints, 52% received fewer arrears or breaches, and 65% received fewer warnings). Figure 3 shows the

percentage of participants who had either a decrease pre to post, and increase, or no change.

There were no differences in rates of referrals to other agencies in the 6 months before and after. There were

significantly more tenancy management plans entered in the 6 months after the project, compared to the 6 months

before the project. On the whole, this suggests that for most tenants, housing situations improved as a result of the

project. It is worth noting that tenants who experienced no change or an increase in housing codes often had either no

housing codes to begin with, or a small number.



Figure 3. Changes in number of housing codes from pre to post project participation.

3.2.1 Housing Codes by Tenancy Risk Stage

We also examined the number of housing codes received for each tenancy risk stage (crisis, prevention, and early

intervention). The differences in the 6 months before are shown in Table 9. There was no significant difference in

number of complaints, warnings, and arrears or breaches between tenants who were referred at the early intervention

and crisis stage in the 6 months prior to entering the project. Tenants referred in at the prevention stage had fewer

codes compared to early intervention and crisis.

The differences in the 6 months after were also examined, shown in Table 9. There was a significant reduction in

housing codes for tenants in the crisis risk stage and early intervention stage. As described above, tenants referred

into the project at the prevention stage did not have enough data to compare housing codes in the 6 months before

and 6 months after project participation. However, participants in the prevention stage had relatively few codes

entered in the 6 months after exiting the program. Although both crisis and early intervention groups had a decrease in

housing codes across all area, tenants in the early intervention stage had significantly more warnings entered in the 6

months after exiting the project, compared to the prevention and crisis stages. This difference does need to be taken

with a grain of salt – as we are not able to take into account changes that are due to tenants being evicted, leaving

their tenancy, or still being active in the project.

3.2.2 Housing Codes by Gender

We also examined the differences in the 6 months before for different demographics. There was no difference in

housing codes between males and females either before or after the project. That is, males and females had similar

number of housing codes when referred into the project, and the reduction in housing codes was similar across males

and females.

3.2.3 Housing Codes by HSC

Participants in the Fortitude Valley HSC had significantly more total housing codes entered in the period before the

project compared to the Chermside HSC. In particular, the Fortitude Valley HSC participants had significantly more

complaints and slightly more warnings compared to the Chermside HSC participants. There were no significant

differences between the two offices on arrears/breaches.

There were no significant differences between the two HSC on number of housing codes received by participants in

the 6 months following exiting the project. The reduction in number of housing codes for participants was greater for

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Total

Complaints

Arrears and Breaches

Warnings

Decreased pre to post No change Increase Pre to post



the Fortitude Valley HSC, compared to the Chermside HSC. This is likely due to the Fortitude Valley HSC participants

having a greater number of complaints when referred into the project.

3.2.4 Housing Codes by Ethnic Background

There were no significant differences between tenants who identified as Aboriginal or Torres Strait Islander in the

number of complaints, arrears/breaches, or warnings in the 6 months prior to entry to the project or in the 6 months

after exiting the project. The improved housing outcomes were thus equally experienced among Indigenous and non-

Indigenous people who participated in the project. This is a significant finding as the literature and policy often

demonstrates that mainstream programs and support services do not work well for, or are not accessed by,

Indigenous people. The evidence about housing outcomes demonstrates that Indigenous people benefited from the

project in the same way that non-Indigenous people did.

3.2.5 Housing Outcome by Status

There were no differences in the number of complaints, arrears/breaches, or warnings in the 6 months prior to entry to

the project for tenants who were referred into the project and completed, compared to tenants who were referred into

the project and withdraw, disengaged, or never participated. Tenants in the project who completed had a significantly

greater reduction in housing codes pre to post, compared to tenants who did not complete (withdrew, disengaged, or

never participated).



Table 9. Housing Codes – Summary of Total 52 Participants (N = 52)

Before During After

Code Description Range Total Mean SD Range Total Mean SD Range Total Mean SD Total Codes 61 564 10.85 10.49 89 454 8.73 16.64 26 213 4.10 6.37

Complaints 39 202 3.88 6.17 25 126 2.42 5.16 14 84 1.62 3.08

COBHV Behaviour 26 108 2.08 3.94 21 82 1.58 3.62 6 37 0.71 1.49

COMPA Complaint Actioned 10 57 1.10 1.86 4 24 0.46 0.90 5 25 0.48 1.09

COOCP Occupancy 2 7 0.13 0.40 9 10 0.19 1.25 1 2 0.04 0.19

COPCO Property (Condition) 4 23 0.44 0.80 3 8 0.15 0.54 3 10 0.19 0.60

COPTY Property (Structures) 1 2 0.04 0.19 0 0 0.00 0.00 0 0 0.00 0.00

COILL Illegal use of property 1 1 0.02 0.14 0 0 0.00 0.00 2 4 0.08 0.33

COMNT Maintenance 0 0 0.00 0.00 1 1 0.02 0.14 1 1 0.02 0.14 Arrears, Breaches, Notices to Leave 5 74 1.42 1.64 7 23 0.44 1.13 7 30 0.58 1.51

Notice to Remedy (Any) 5 59 1.13 1.31 5 18 0.35 0.81 6 23 0.44 1.24

NRD Notice to Remedy (Arrears) 4 29 0.56 1.04 5 10 0.19 0.74 5 16 0.31 0.92

BNRD Notice to Remedy (Other than Arrears)

4 30 0.58 0.80 2 8 0.15 0.42 4 7 0.13 0.63

NLS Notice to Leave Issued 3 15 0.29 0.61 2 5 0.10 0.41 2 7 0.13 0.40 Warnings, Strikes, Antisocial behaviours notes

18 232 4.46 5.16 59 207 3.98 10.64 12 66 1.27 2.83

NOTEY Notes relating to ASB 17 216 4.15 5.07 58 205 3.94 10.52 12 64 1.23 2.72

UAFT Application to Tribunal 1 4 0.08 0.27 0 0 0.00 0.00 0 0 0.00 0.00

WARN Warning notice for ASB 1 7 0.13 0.35 1 2 0.04 0.19 0 0 0.00 0.00

STRK Strikes 1 5 0.10 0.30 0 0 0.00 0.00 0 0 0.00 0.00

FEOBS Serious disruptive behaviour 0 0 0.00 0.00 0 0 0.00 0.00 1 2 0.04 0.19 Referrals and Tenancy Support Plans 2 9 0.17 0.43 2 52 1.00 0.40 2 5 0.10 0.36

REF Referral made to another agency

TMP Tenancy Management Plan 1 2 0.04 0.19 3 27 0.52 0.73 1 12 0.23 0.43 Tenancy Terminated

TERM Tenancy Terminated 0 0 0.00 0.00 1 3 0.06 0.24 1 7 0.13 0.35


Table 10. Comparison of Housing Codes received in the 6 months before entering the MHDP and 6 months after exiting the MHDP

Crisis Prevention Early Intervention

Before n = 37 n = 10 n = 26

Code Description Range Total Mean SD Range Total Mean SD Range Total Mean SD

Total Codes 41 358 9.42 8.93 30 63 6.30 9.06 61 290 11.15 13.03

Complaints 13 103 2.71 3.51 10 15 1.50 3.06 39 127 4.88 8.06

COBHV Behaviour 7 49 1.29 1.87 6 9 0.90 1.91 26 73 2.81 5.24


COOCP Occupancy 1 3 0.08 0.27 0 0 0.00 0.00 2 6 0.23 0.51


COPTY Property (Structures/Fixtures) 1 2 0.05 0.23 0 0 0.00 0.00 0 0 0.00 0.00


COMNT Maintenance 0 0 0.00 0.00 0 0 0.00 0.00 0 0 0.00 0.00

Arrears, Breaches, Notices to Leave 5 50 1.32 1.47 5 17 1.70 1.89 5 26 1.00 1.57

Notice to Remedy (Any) 5 40 1.05 1.16 5 15 1.50 1.65 4 22 0.85 1.32


BNRD Notice to Remedy (Other than Arrears) 4 28 0.74 0.89 1 1 0.10 0.32 1 7 0.27 0.45

NLS Notice to Leave Issued 3 10 0.26 0.64 1 2 0.20 0.42 1 4 0.15 0.37

Warnings, Strikes, Antisocial behaviours notes 26 160 4.27 5.81 15 17 1.70 4.69 18 116 4.46 0.43


UAFT Application to Tribunal (Urgent) 1 2 0.05 0.23 1 1 0.10 0.32 1 1 0.04 0.20


STRK Strikes 2 9 0.24 0.49 0 0 0.00 0.00 1 1 0.04 0.20

Referrals and Tenancy Support Plans

REF Referral made to another agency 2 7 0.18 0.51 1 5 0.50 0.53 2 7 0.27 0.53

TMP Tenancy Management Plan 1 1 0.03 0.16 2 3 0.30 0.68 1 1 0.04 0.20

Institute for Social Science Research Draft report: MHDP Final Report


Crisis Prevention Early Intervention

After n = 29 n = 27 n = 26

Code Description Range Total Mean SD Range Total Mean SD Range Total Mean SD

Total Codes 13 50 1.72 2.93 14 73 2.70 3.38 26 174 6.69 7.80

Complaints 6 19 0.66 1.61 3 15 0.56 0.85 14 65 2.50 3.86

COBHV Behaviour 4 10 0.34 1.08 2 6 0.22 0.51 6 27 1.04 1.73


COOCP Occupancy 0 0 0.00 0.00 1 1 0.04 0.19 1 2 0.08 0.27


COPTY Property (Structures/Fixtures) 0 0 0.00 0.00 0 0 0.00 0.00 0 0 0.00 0.00


COMNT Maintenance 1 1 0.03 0.19 0 0 0.00 0.00 0 0 0.00 0.00

Arrears, Breaches, Notices to Leave 7 10 0.34 1.34 3 6 0.22 0.70 5 23 0.88 1.66 Notice to Remedy (Any) 6 8 0.28 1.16 2 4 0.15 0.46 5 18 0.69 1.35


BNRD Notice to Remedy (Other than Arrears) 4 4 0.14 0.74 1 1 0.04 0.19 2 3 0.12 0.43

NLS Notice to Leave Issued 1 2 0.07 0.26 1 2 0.07 0.27 2 5 0.19 0.49

Warnings, Strikes, Antisocial behaviours notes 3 5 0.17 0.66 8 24 0.89 1.89 12 63 2.42 3.64


UAFT Application to Tribunal (Urgent) 0 0 0.00 0.00 0 0 0.00 0.00 1 1 0.04 0.20


STRK Strikes 0 0 0.00 0.00 0 0 0.00 0.00 0 0 0.00 0.00

0 0 0.00 0.00 0 0 0.00 0.00 1 2 0.08 0.27

Referrals and Tenancy Support Plans

REF Referral made to another agency 2 5 0.17 0.54 2 5 0.19 0.48 1 2 0.08 0.27

TMP Tenancy Management Plan 1 6 0.21 0.41 2 11 0.41 0.57 1 9 0.35 0.49


3.3.1 Tenancy status at end of project

The majority of participants sustained their tenancy across the duration of the project. Of the total participants, 27 had

their original tenancy terminated. We have data on the reasons for tenancy termination for 13 people; of these, nine

transferred to a new tenancy with the DHPW (tenancy transfer; according to DHPW data), one transferred into a

private rental property (according to Footprints information), two were evicted, and one withdrew from the project and

vacated their tenancy.

3.4 SUMMARY

There were more females than males referred in the project. The most commonly occurring family type was

single person, followed by single person with children.

Relatively equal numbers of people were referred in at the three different tenancy risk stages (crisis, early

intervention, and prevention). The most commonly occurring reason for referral was for “neighbourhood

issues”, with 42% of the sample having this listed as a presenting concern. The second most common reason

was “personal issues” (30%), followed by mental health issues (24%).

The majority of participants in the project, for whom we have the complete data set for, improved their housing

circumstances in the six months after the project compared to the six months prior. Specifically, 79% received

fewer total codes, 58% received fewer complaints, 52% received fewer arrears or breaches, and 65%

received fewer warnings.



project, there were no differences between the two HSC on number of housing codes.

Demographic factors, including Indigenous status and gender, did not predict who engaged and who did not

engage with the project. Furthermore, these factors did not predict outcomes – that is, the same pattern of

outcomes were achieved by Indigenous and non-Indigenous tenant participants, and male and female tenant

participants.

Number of housing codes prior to entering the project, and tenancy risk stage did not predict who engaged or

did not engage in the project. Housing Service Centre was a predictor of who engaged and who withdrew; a

greater proportion of participants who were referred from the Fortitude Valley HSC withdrew or did not

participate compared to the Chermside HSC.



4 HEALTH DATA

The MHDP was established to address service provision and systems gaps evident in meeting the needs of

social housing tenants with mental illness or complex problems. As such, in addition to addressing housing

concerns, the MHDP aimed to improve mental health outcomes, and improve access and engagement with

required clinical services. This chapter examines the impact the MHDP had on participants’ mental health and

Queensland Health service usage. The following section details the mental health service usage, health

outcomes (as measured by assessment measures), alcohol and drug service use, and emergency department

and hospital admissions.

4.1 CONSUMER INTEGRATED MENTAL HEALTH APPLICATION DATA

4.1.1 Queensland Health Mental Health Service Usage

The average number of services, duration of services, and service type are recorded in Table 11 for all participants

with available health data for the period of 6 months before the participant entered the project (before), during a

participant’s time in the project (during), and for the 6 months following participants exit from the project (after).

Table 11. Mental health service usage before, during, and after participating in the MHDP.

Before

During

After

Total Mean SD Total Mean SD Total Mean SD

Intervention Duration (minutes)

Average per intervention

907 15.63 20.08

3233 55.74 44.70

1178 20.32 31.21

Sum per person 14886 256.66 627.91

114035 1966.12 2089.57

14789 254.98 591.49

Service Type

Conducting Assessment

118 2.03 4.68

164 2.83 4.23

70 1.21 2.70

Case formulation and case plan

39 0.67 1.78

78 1.34 2.50

45 0.78 1.72

Interventions or Therapy

109 1.88 5.94

350 6.03 8.18

76 1.31 3.88

Medication or Drug Monitoring

37 0.64 2.86

14 0.24 0.88

27 0.47 2.05

Service coordination

82 1.41 3.12

965 16.64 18.81

129 2.22 5.01

Review 61 1.05 1.91

262 4.52 5.69

45 0.78 1.63

Although there was a slight decrease across several types of mental health service use between the 6 month period

before and 6 month period after a participant was in the project, this was not statistically significant (see Table 12

below). This suggests there was no meaningful difference in number of services provided and duration of intervention

before and after tenants were in the MHDP. While tenants were participating in the MHDP, they had significantly

higher contact with the mental health system. In Table 12, the difference Before and After participating in the project is

included (number Before minus number After), with a minus difference score number indicating that there were more

incidences of the intervention occurring after exiting the MHDP compared to before entering the MHDP.



Table 12. Differences in the Total service usage (intervention duration and services received) in the 6 months before entering the MHDP and 6 months after exiting the MHDP

TOTALS Before During After Difference

(Before minus After)

Intervention Duration (minutes)

Average per intervention

907 3233 1178 -272

Sum per person

14886 114035 14789 97

Service Type

Conducting Assessment

118 164 70 48

Case formulation and case plan

39 78 45 -6

Interventions or Therapy

109 350 76 33

Medication or Drug Monitoring

37 14 27 10

Service coordination

82 965 129 -47

Review

61 262 45 16

Total Number Services

446 1833 392 54

We also examined the mental health service treating unit that delivered the support described above. Table 13

summarises the number of incidences of support provision by different Queensland Health mental health treating units,

across the duration of the project (During), and the 6 months before (Before) and after the project (After). The

Queensland Health Mental Health Acute Care Team and Housing Demonstration team1 were the predominant treating

units while participants where in the project. This is consistent with the service delivery model of the MHDP, whereby

the clinical support occurs within the framework of Acute Care Teams in the Metro North Hospital and Health Service

(Royal Brisbane and Women’s Hospital [RBWH] and The Prince Charles Hospital [TPCH]). As expected, this reduced

dramatically when participants exited the MHDP. Community Mental Health services increased in the Chermside Adult

Mental Health Service, and the RBWH Community Southern Team. Older Persons Mental Health service usage also

increased, pre to post project participation. Inpatient Mental Health Services and Emergency Services use decreased

pre to post project participation. This suggests that, in accordance with the framework of the MHDP, the clinical

support provided involved acute care while participants were in the project, and transitioned tenants who needed

ongoing care into community mental health services. The majority of tenants who were receiving mental health

services during the project were not involved with the mental health system in the 6 months after exiting the project.

Patients accessing after care services (other than emergency department) are not able to be discerned from the

information provided to the researchers.

1 The treating units recorded in CIMHA that the MHDP mental health clinicians were required to enter codes under were Acute Care Team for the Prince Charles Hospital, and Housing Demonstration (RBWH) for the Royal Brisbane and Women’s Hospital.



Table 13. Instances of services utilised by project participants in the 6 months before, during, and 6 months after the MHDP

Change

Before - After

Before During After

Housing Demonstration (RBWH) 0 352 25 -25

Acute Care Team (ACT) Services

ACT Intake and Assessment team (RBWH) 38 227 39 -1

Acute Care Team 46 964 32 14

Community Mental Health Services

Chermside Adult CMHS 92 98 120 -28

Community Northern Team (RBWH) 50 0 39 11

Community Southern Team (RBWH) 5 27 32 -27

Older Persons Mental Health (TPCH) 0 31 43 -43

Older Persons Outpatients (RBWH) 0 70 20 -20

Older Persons Outreach Service (RBWH) 1 48 0 1 Older Persons MHS South (WB) 1 0 0 1

Homeless Health Outreach Team (RBWH) 38 0 0 38

Nundah Community MHS 94 10 47 47

Consultation Liaison Services

Consultation Liaison Service (TPCH) 1 6 0 1

Consultation-Liaison Service (RBWH) 18 12 2 16

Inpatient Mental Health Services

Inpatient Mental Health Unit (TPCH) 12 14 0 12

Inpatient (RBWH) 5 22 0 5

Inpatient - Older Persons (RBWH) 0 16 0 0

Emergency Services

Acute Care Team Psychiatric Emergency Centre (RBWH) 17 15 9 8

Acute Care Team Emergency Department - Other 9 4 0 9

Resource and Access Services (RAS) Academic Clinical Unit Emergency Dept - PAH (MS) 3 0 0 3

Other 0

Resource and Access Services (RAS) MH CALL (MS) 1 4 3 -2

Transitional Treatment Coordination (RBWH) 14 17 0 14

Perinatal Mental Health (MNMH) 2 4 0 2

Community Forensic Mental Health Service 2 1 2 0



4.1.2 Health of the Nation Outcome

We analysed the Health of the Nation Outcome Scale to identify and measure tenants’ mental health, and any

improvements associated with their participation in the project. Health of the Nation Outcome Scale (HoNOS) is a

clinician rated tool developed by the United Kingdom Royal College of Psychiatrist’s Research Unit to measure the

health and social functioning of people experiencing severe mental illness. HoNOS measures the symptom severity

and social functioning across time. It has 12 items that measure behaviour, impairment, symptoms and social

functioning. The items are rated on a scale of 0–4 and the results or changes in ratings are known as outcomes and

may be attributed to services provided.

Typically, the measure is administered at the start of mental health services, case review points, and at the end of

service use. The following table reports average scores of HoNOS in the 6 months before an individual entered the

project, average score during the project, and average score in the 6 months after the project.

Table 14. Average score on the HoNOS across domains for 6 months before entering the MHDP, during the MHDP, and 6 months following MHDP

Before During After

n = 8 n = 37 n = 10

HoNOs Domain Mean SD Median Mean SD Median Mean SD Median

1. Overactive, aggressive, disruptive or agitated

0.88 0.72 0.83 0.50 0.65 0.00 0.35 0.67 0.00

2. Non-accidental self-injury 0.27 0.47 0.00 0.32 0.84 0.00 0.10 0.32 0.00

3. Problem drinking or drug-taking

1.28 1.13 1.17 0.81 1.33 0.00 0.75 1.03 0.25

4. Cognitive problems 0.35 0.58 0.00 0.55 0.80 0.00 0.77 1.32 0.00

5. Physical illness or disability problems

1.11 0.75 1.25 1.40 1.25 1.50 1.48 1.13 1.67

6. Problems with hallucinations and delusions

1.03 0.99 1.00 0.35 0.95 0.00 0.70 1.09 0.00

7. Problems with depressed mood

1.30 1.11 1.06 1.43 0.83 1.50 0.98 1.07 0.75

8. Other mental and behavioural problems

2.86 1.48 2.83 1.81 1.18 2.00 1.69 1.04 1.75

9. Problems with relationships 1.77 1.13 1.42 1.14 0.93 1.00 0.78 0.72 0.75

10. Problems with activities of daily living

1.07 0.88 0.83 0.94 0.94 0.75 0.65 0.63 0.75

11. Problems with living conditions

0.64 0.62 0.67 0.58 0.84 0.14 0.66 0.69 0.63

12. Problems with occupation and activities

1.67 1.49 1.40 0.21 0.44 0.00 0.58 1.25 0.00

We also examined participants’ HoNOS scores within a month of entering the project (Start) and within a month of

exiting the project (End), summarised in Table 13. Across 11 of the 12 domains, more people reported symptom

improvement from start to end of the project participation, compared to symptoms getting worse. Participant’s reported

significant level of improvement on the scales for the domains of non-accidental self-injury, problems with depressed

mood, other mental and behavioural problems, and a marginally significant level of improvement for relationships with

other people. Participant’s had worse cognitive problems over time. This may be due to progressive neurological

decline associated with an organic-basis or age.



Table 15. HoNOS score changes from Start to End of MHDP

Improved Worsened No change

Start > End End > Start Start = End Z p

1. Overactive, aggressive, disruptive or agitated 6 5 21 0.273 0.785

2. Non-accidental self-injury 6 1 25 2.047* 0.041

3. Problem drinking or drug-taking 8 3 21 1.281 0.200

4. Cognitive problems 4 11 17 1.955* 0.051

5. Physical illness or disability problems 11 6 15 0.734 0.463

6. Problems with hallucinations and delusions 4 3 25 0.172 0.863

7. Problems with depressed mood 17 3 12 2.054* 0.040

8. Other mental and behavioural problems 17 3 12 2.845* 0.004

9. Problems with relationships 14 5 13 1.820^ 0.069

10. Problems with activities of daily living 12 7 13 0.410 0.682

11. Problems with living conditions 8 6 18 1.187 0.235

12. Problems with occupation and activities 4 5 23 0.787 0.431

NB: Z and p values are based on a two-tailed repeated measures Wilcoxon’s test * Is a statistically significant difference (a difference that would occur less than 5% of the time by chance)

^ a marginally statistically significant difference (a difference that would occur less than 7% of the time by chance)

4.1.3 Life Skills Profile

In addition to improved mental health and wellbeing, as measured through the HoNOS, the project aims to contribute

to participant’s life skills and general functioning. To assess life skills and general functioning we sought to analyse the

Life Skills Profile. The Life Skills Profile - 16 (LSP - 16) was developed by an Australian clinical research group to

assess a consumer’s abilities with respect to basic life skills. Its focus is on the consumer’s general functioning and

disability rather than their clinical symptoms.

Thirty-four individuals had data for the LSP measure. Of those, half (17) only completed the measure at one time-

point, often mid-way through their time in the MHDP. Other participants were administered the measure as part of a

case-review, or at the end of their project. We therefore have insufficient data to use this measure as an indicator of

change in abilities of general functioning and life skills across the duration of the project. Therefore, we cannot make

meaningful conclusions about the life skills, general functioning, and projects capacity to enhance these abilities of

tenants.

4.2 DIAGNOSES

The CIMHA data also included the Primary Diagnosis given when accessing mental health services. The number of

people receiving a diagnosis, number of diagnoses, and diagnosis type, are shown in the table below. Twelve

participants had received a diagnosis before entering the project, 32 participants of the MHDP received a diagnosis

during the project, and 5 received a diagnosis after exiting the project. Of those 32 who received a diagnosis during

the project, 4 had also received a diagnosis in the 6 months before entering the project. Of the five participants who

received codes after exiting the project, two had received diagnoses before the MHDP, and three had also received a

diagnosis during their time in the MHDP.



Table 16. Primary diagnosis given during 6 months before entering the MHDP, during the MHDP, and 6 months after exiting the MHDP

Time

Before During After

Number of people receiving diagnoses 12 32 5

Number of diagnoses 21 61 7

Diagnoses Type (counting repeated diagnoses)

Depressive episode (including mild, moderate, and severe) 0 10 0

Recurrent depressive disorder, currently in remission or unspecified

0 4 0

Mixed anxiety and depressive disorder 0 4 0

Bipolar affective disorder, current episode 0 1 0

Bipolar affective disorder, currently in remission 0 2 0

Other persistent mood [affective] disorders 0 1 0

Post-traumatic stress disorder 2 7 1

Adjustment disorders 3 1 0

Other reactions to severe stress 0 2 0

Personality disorder (including borderline type, mixed, and traits) 2 5 1

Schizophrenia (including Paranoid Schizophrenia) 4 6 0

Mental and behavioural disorders due to drug use 3 7 2

Mental disorder, not otherwise specified 0 1 0

Psychosis or acute psychotic Disorder 1 0 1

Delusional disorder 0 2 0

Observation or screening for suspected mental and behavioural disorders

1 2 0

Suicidal ideation 4 0 1

Intentional self-harm by knife 0 0 1

Asperger's syndrome 0 2 0

Huntington's disease 0 2 0

Psychosocial (including homeless, discord with neighbours) 1 2 0

4.3 ALCOHOL TOBACCO AND OTHER DRUGS

We also endeavoured to assess tenants’ engagement with service about alcohol, tobacco, and other drugs use, and to

determine whether their use of these services changed in accordance with participation in the project. Only 10

individuals had information recorded in the Alcohol, Tobacco and Other Drugs (ATOD) database for the period of time

examined (6 months pre MHDP to 6 months post MHDP). Of those 10, four individuals were involved with assessment

before entering the MHDP only, one was involved with assessment and counselling before entering and during the

MHDP, four were involved in assessment and treatment (including one person undergoing withdrawal management)

during the time in the MHDP, and one was involved with assessment after exiting the MHDP.



This is a significant finding, as it demonstrates that tenant’s mental health and assessed complex needs – the factors

that led to them participating in the project – were not associated with tenants accessing services from alcohol and

drug use. We do not have any data about the rate, or change, of tenant’s alcohol and drug use, but our findings about

service usage suggest that if tenants do misuse alcohol and substances, the overwhelming vast majority are not

accessing formal ATODs support, either before, during, or after the project.

4.4 EMERGENCY DEPARTMENT DATA

A significant role of both the clinical and non-clinical support provided for tenants involved addressing the physical

health care needs of participants, who often were not accessing the support they need. As described in the interim

report, a key role of the mental health clinicians was to assist participants to have improved and more appropriate

engagement with primary care. This process is described in more detail in Chapter 4. Unaddressed health problems

(both physical and mental) can lead to expensive acute and unplanned care. Thus, we also examined public

emergency hospital presentations, comprising the number of people presenting, length of stay, number of admissions,

transport mode of arrival, triage category, and departure information (presented in Table 17). The changes from pre to

post are presented in Table 18.

Table 17. Emergency Department Presentations Information

Before During After

Range Total Median Range Total Median Range Total Median

Number of People 42 37 17

Length of Stay

Average per visit (per person) 743 9762 206 985 10341 237 287 4066 232

Sum for each visit (per person) 3587 31425 348 4198 34545 483 7309 15466 394

Number of Admissions 18 144 2 28 140 2 36 72 2

Arrival

Admission from Ambulance 17 82 1 19 85 1 26 47 1

Walked in 11 54 1 10 51 1 11 25 0

Police or Correctional Services 1 7 1 1 1 0 0 0 0

Other 1 1 1 2 3 0 0 0 0

Episode End Status

Admitted 21 1 31 1 18 1

Admitted to observation ward 2 0 3 0 3 0

Admitted to Short Stay Unit 14 1 17 1 4 0

Did not wait 13 1 10 1 4 0

Emergency service episode completed and discharged

79 1

69 1

39 0

Left at own risk after treatment commenced

14 1

10 1

4 0

Transferred to another hospital

1 0 0 0 0 0

The total number of people accessing the emergency department decreased significantly in the period after exiting the

project (17), compared to the period before entering the project (42). However, participants of the project who

continued to access the emergency department did so at a significantly higher frequency, as can be seen by

comparing the range of number of admissions per person in the time before compared to time after, with 18 being the

highest number of admissions in the period before entering the MHDP, and 36 being the highest number in the period



after exiting the MHDP. The emergency department data provided for the evaluation did not include reason for

presentation.

Table 18. Changes Pre to Post in Emergency Department Presentations

Difference Pre to Post*

Number of People 25

Length of Stay (in minutes)

Average per visit (per person) 5697

Sum for each visit (per person) 15959

Number of Admissions 72

Arrival

Admission from Ambulance 35

Walked in 29

Police or Correctional Services 7

Other 1

Episode End Status

Admitted 3

Admitted to observation ward -1

Admitted to Short Stay Unit 10

Did not wait 9

Emergency service episode completed and discharged 40

Left at own risk after treatment commenced 10

Transferred to another hospital 1 * Changes pre to post are total number for 6 months pre MHDP minus total number for 6 months post MHDP. A negative number means there were a greater number post MHDP compared to pre MHDP participation.

The hospital admission data did not have the necessary information to allow an analysis of hospital admissions before,

during, and after participating in the MHDP.

4.5 SUMMARY

There was a significant increase in the use of mental health services during the period that MHDP participants

were active participants of the project.

A surprisingly few had any contact with mental health care system prior to the project, given the remit of the

MHDP was to assist people with mental health or other complex problems.

The majority of mental health services provided during the project was service co-ordination. This support

predominately came from the Acute Care Team services, which is consistent with the Service Delivery Model

(where the MHDP mental health clinicians worked within the Acute Care Teams at TPCH and RBWH). In the

six months after exiting the project, service-coordination remained the largest type of service received, though

the number of episodes of support had dramatically reduced. Emergency presentations for mental health

services reduced from pre to post project participation.

A number of MHDP participants were diagnosed with mental health conditions after entering the project,

suggesting that there were diagnosable issues affecting their lives.

Outcomes of a clinician rated measure of health and social functioning taken at commencement of project and

end of project demonstrated that there was an improvement in most areas of health. Specifically, non-

accidental self-injury, problems with depressed mood, other mental and behavioural problems, and problems

with relationships significantly decreased from start to end of project participation.



There was insufficient data to determine if the positive outcomes were sustained in the longer term, once

participants were no longer receiving support.

The number of people accessing the emergency department (ED) decreased from pre to post participation in

MHDP. The total length of stay in the ED and total number of presentations to the ED presentation also

decreased. This suggests there was a reduction in unplanned and acute care needs for the majority of

participants. There were a minority of participants who were accessing the services at a high frequency, even

after exiting the MHDP.



5 TENANT INTERVIEWS

In this chapter, we present the perspectives of perhaps the most important stakeholders in the MHDP – the tenants

themselves – to explore their experiences of being in the project; the support they received; and their reflections on

what difference, if any, it has made to their lives, their health and wellbeing, and their tenancies. The chapter begins

with a brief overview of the tenants who agreed to share their experiences of the project via a semi-structured

interview and their reasons for being referred. Tenants themselves often had their own explanations for why they had

been approached about the project and while these did not always match those documented in DHPW records, they

give insight into the nature of the personal and tenancy challenges that participants in the MHDP encounter.

The next section of the report presents tenants’ accounts of why they agreed to sign up for the MHDP and what they

thought might be involved. This is followed by a discussion of the kinds of support provided to tenants in the form of

connecting them to other services; assisting with the development of coping mechanisms and life goals and skills;

clinical mental health support; and assistance with issues that were placing tenancies at risk. As this chapter shows

later, tenants spoke positively about their experiences in the project, and the people they met along the way.

Importantly, there is evidence, from the tenants’ themselves, that the MHDP has made some difference to their lives

already by improving their housing situations; their mental health and general sense of well-being; their perceived

competencies in managing their lives and tenancies; and their relationship with DHPW. Nevertheless, there is a small

number of tenants who reported that they did not find the project useful, and their accounts are important for

understanding both the limitations of the project and the structural forms of disadvantage that some tenants face which

cannot easily be resolved through a one-off project. Even those who spoke highly of their experiences identified some

aspects that they found challenging, and these critical reflections are provided. The chapter concludes with a focus on

the process of tenant exit from the project and the diverging experiences of that process as one of natural closure and

one of abandonment.

5.1 THE MHDP TENANT INTERVIEWEES

A total of 21 tenants (seven men and 14 women) who were enrolled in the MHDP agreed to be interviewed about their

experiences of the project (two were a couple). The interviews took place between March and June 2017 and while

most were held in tenants’ homes, some interviews took place in a café at the request of the tenant. The tenants

ranged in age from 21 to 78 years and three were Aboriginal. Most of the participants suffered from challenging mental

or physical health conditions and 13 of the 21 were on disability support pensions. Two tenants were still involved with

the MHDP at the time of interview and another had recently been re-enrolled following ongoing difficulties with

hoarding and squalor. In this report, tenants are provided with pseudonyms to protect anonymity and confidentiality

and these are used throughout the chapter.

Tenant interviewees fell into the three referral categories of tenancy risk status: seven were designated as early

intervention; five as prevention; and nine as crisis. As outlined in the Interim Report for this project, there appears a

lack of clarity in tenant assessments as either early intervention or prevention, such that it is unclear from tenants’

accounts why they have been categorised as one at-risk status rather than the other. For example, new tenants were

assessed as both early intervention and prevention and both groups appear equally likely to have encountered some

breaches or warnings.

5.1.1 Early intervention

Among those enrolled for early intervention, the majority were referred because of neighbourhood issues, such as

antagonistic relations with, or complaints from, neighbours which were often serious enough to induce breach notices.

These neighbour tensions were often compounded by personal issues such as mental health challenges that made

managing these neighbour tensions potentially more fraught. Some tenants, such as Lachlan, had been transferred to

a new property at least once for neighbour problems, but the issues seem to continue. In Lachlan’s case, his social

worker suggested that the pattern of problematic neighbour relations was down to Lachlan himself, but he insisted that

tensions were inevitable given DHPWs’ tendency to ‘chuck’ everyone into an apartment block together and expect



them to get along. Lachlan had been homeless for many years prior to being given a social housing property and

suffers from anxiety, panic attacks and alcohol dependency. Complaints from neighbours about his old street friends

dropping in to see him and tensions with other tenants have left him feeling unsettled in each place. As a result, he has

been transferred to three separate properties in recent years. At the time of interview, he was clearly unsettled in his

current unit, which he said is located in an area that is well-known for drug dealing and while he tries to keep to

himself, as his social worker had suggested, he finds the other tenants to be noisy, intimidating and aggressive.

Cindy is another tenant who was recruited onto the project for early intervention. Cindy has previously lived with her

teenage son whose behaviour was so unruly that DHPW received weekly complaints about him. As a result, Cindy’s

own tenancy was at risk – a situation she described as being highly stressful:

I had been given a warning from Housing on my son’s continued behaviour and then he breached it and they sent

the Housing team as well as Red Cross around. The Housing team only came once. The Red Cross guy came

multiple times. Did some really great ongoing activities on how to try and better my son’s relationship and all that

and that was really good for a few months, but he unfortunately didn’t hold onto it. Socially he was still very much a

teenage boy with some really bad friends socially. So it did arise again where Housing were going to evict me

(Cindy).

5.1.2 Prevention

Five interviewees were recruited onto the project for preventative reasons, often due to personal or family issues that

require them to need additional support in managing their tenancies. This includes Desiree, a young mother in her 20s

with a young child who has a disability. Desiree had recently moved out of an abusive family environment and had just

been issued her first DHPW property. It was at that point that she was referred to the MHDP because her own anxiety,

her daughter’s disability and her lack of prior experience of managing a home meant that she was likely to need

additional support:

It’s my first time moving out of home. I think they thought I needed the help. I did need the help (Desiree).

Bianca is another young woman who was referred onto the project for prevention, although her reasons for referral

were not related to any new tenancy, but rather to ongoing issues in her tenancy for which she needed help. Bianca

had lived in her DHPW unit for four years, but she was the only young person in a complex of over 50s and, as a

result, was often the subject of complaints for neighbours who felt she did not belong there. She described the

situation, and her need for support, as follows:

I’m the youngest one in my unit complex and everyone is over the age of 50. I’m like obviously only [in my 20s]. So

they’re a bit like, you know, with my age being here and stuff, so they kept complaining about me and Housing put

me onto sustaining young tenancies, but then they ended up helping me with a lot of other stuff too because I

wasn’t very well when I went there with them. I was going through domestic violence and they were really good

(Bianca).

5.1.3 Crisis

The largest proportion of tenant interviewees in the project were there because they had been assessed as being in

‘crisis’ as a result of having complex needs and issues that placed the tenancy at risk and for which they had already

received some breaches or warnings. In the majority of cases, the issues manifest themselves in poor property

condition, squalor and hoarding which results in multiple failed property inspections. One tenant was in arrears with

her rent at the time, and another has complex and ongoing problems including poor mental health, a physical condition

that leaves him in chronic pain and multiple neighbour problems that are often violent and cause damage to property.

Most – although not all – tenants who had reached a crisis point in their tenancies were well aware of the seriousness

of their situation. For example, Desmond – a tenant in his mid-50s with a history of problematic alcohol and other drug

use and a range of resulting health problems – described his living conditions prior to the project as ‘dangerous’:

At first I denied access to one of the inspections and when I opened the door and I saw what I’d done to myself in

the flat, because they weren’t allowed in because it was too dangerous, not broken bottles, but alcohol bottles

everywhere, nearly this high (Desmond).



Nina, was also enrolled into the project because her tenancy risk placed her in a ‘crisis category’. She too was referred

for neighbourhood reasons as a result of ongoing problems with a neighbour who, she said, had yelled obscenities at

her from the day she moved in and who she accused of killing her cat. Retaliation on her part involved throwing ‘stuff’

over her balcony onto his property below, which led to her receiving multiple breach notices and threats of eviction.

5.2 SIGNING UP TO THE PROJECT

On the basis of the risks to their tenancies and/or the complex issues they face that make managing these risks all the

more challenging, all 21 tenant interviewees were signed up to the project. Signing up is an active process that occurs

after tenants have been referred and then approached by their housing office / community housing provider who

explains the project to them, provides them with an information pack and then asks them to sign a consent form.

Consent is necessary for client data to be shared across the tenants’ team of stakeholders and all tenants were

required to provide informed consent, in writing, prior to the commencement of the project. Given the changes to the

tenant consent form in the early days of the project, some tenants would have signed multiple consent forms.

When asked about their experiences of being approached about the MHDP and their reasons for signing up, tenants

fell into two clear groups. The first comprises those who fully understood that they had signed up to some kind of

project, even if there were unclear what this entails or what the project itself is called. For tenants, the project was

referred to as the ‘Tenancy Support Project’ rather than the MHDP to avoid any sense of stigma associated with being

involved in a mental health initiative. During interviews, then, tenants were asked to explain how they came to be

involved in the Tenancy Support Project. Among those who understood they had been involved in a designated

project, some explained that they were at a point in their lives where they needed additional support and this had

coincided with a new initiative that DHPW was offering up:

I said, ‘Right, I don’t like this’. So a couple of weeks they came to me and they gave me some pieces of paper

which were basically release forms for help. So I signed the forms, which I could barely do at the time, and then it

all started happening. I had people turning up and cleaning the flat out, they laid new vinyl down, and threw out

what was supposedly a stove. It hadn’t worked for a few years. Threw that out and put in a new one for me. They

put locks on my doors as well (Desmond).

I got a breach from the neighbours and Housing had recommended them and they gave me a call and so it just

happened from there (Bianca).

Deliah, for example, has a range of physical and mental health conditions that make life challenging for her, but she

was also encountering problems with a neighbour which resulted in her receiving letters from DHPW warning of

tenancy breaches and, previously, an ABS strike. Her brother advised her to contact her housing office and advise

them that she was not doing well and needed some support. It was when she finally approached the office that she

learnt of a new project being set up:

I think I got another letter and that was about 6 January or something last year. So I went in and I said, ‘Look, I

want to talk to a social worker’, and they said, ‘We don’t have them here’. Anyway, next thing you know, [name of

DHPW staff member] came in and she said, ‘Look, I’m trying to start up this new thing between clients and

Housing. I think you’d be one of the perfect cases for me’ and I said, ‘Well, yeah’ (Deliah).

Others explained that DHPW had approached them offering support, either at the point of signing up to a new tenancy

or property, or quite unexpectedly. In these cases, tenants were unclear of what the offer involved, or even what extra

support they needed, but signed up anyway with a view that they had nothing to lose:

I moved house a year ago and when I was signing the tenancy things they asked if I wanted to and that’s why, I

already said, I had heaps of funding from the government so I didn’t know if you could even help me with anything.

So I decided just to try and I’m glad I did because it was helpful (Briony).

Q: So how did you get involved in the tenancy support program?

A: Through the Department of Housing. They just offered to help and I said, ‘Okay, no worries’. I wasn’t expecting

as much help as they did, but they did it.



In most cases, tenants signed up to the project willingly because they understood they needed help and were glad to

receive it, or were open to the idea of increased assistance:

I really appreciated the fact that Housing offered it. When all this happened I was really concerned that I was going

to end up homeless (Cindy).

‘Oh please. Please. Gimme, gimme, gimme, gimme, gimme, gimme, gimme. Please, please, please. Please,

please, please’. I just knew I’d cooked my goose (Desmond).

I was kind of blessed. I was really happy because I knew that things were getting out of hand and it was really

stressing me out and I was in a bad place. So I really needed it. I was unsure, but I knew it was the right thing. As

soon as I got into the program I was like, ‘It’s definitely something I need to do. It’s a place I need to be right now’

(Bianca).

Two tenants admitted that they had signed up for the project thinking that it would place them in a more favourable

position with DHPW and thus potentially mitigate any further tenancy problems, but only one tenant believed her

tenancy was contingent on agreeing to being involved, or that refusal to participate would have a negative impact. This

tenant, Angela, indicated that the project had been thrust on her although she ultimately reflected that it had actually

been highly beneficial:

Q: Did you feel forced at all to participate in the program?

A I’m pretty sure we could have said, ‘No, go away and leave us alone’, and I’m pretty sure they’d say, ‘well your

tenancy agreement’s going to be torn up’ [laughter]. They didn’t say that, but, yeah (Angela).

Others expressly said that they had not felt compelled to join the project in any way, even if that had been an initial

concern:

I think, if I remember correctly, it was [name of DHPW staff member] that called to say, ‘Hey, we’ve got this. You

don’t have to do it’. But in the back of my mind it was like, ‘It’s going to look a lot better if you do it’ kind of thing. I

think if I had have said no they may have been a little bit more, ‘Okay, we’re just going to keep a quiet eye on you’,

kind of thing. That’s how I felt. But [name of Qld Health staff member] never made me feel that way (Cindy).

Q: Did you feel in any way that you were forced to sign up?

A: No, I didn’t. I didn’t feel like that. It was an offer that was made and I accepted, I guess. It went from there.

The second group of tenants consists of those who appear unaware that they had even been part of a project. The

following excerpts are illustrative of the six tenants who could not recall any memory of having been involved in the

project and unclear of what the Tenancy Support Project was:

I don’t really know the support program. I don’t know what they even do (Gavin).

I don’t know. I’m kind of confused. I forgot that I was in it (Rebecca).

This lack of recall is understandable given the high prevalence of mental health and other challenges among tenants

that are likely to impede memory or cognition. Once the project was explained to them, however, most recalled signing

up to something, even if they were not aware of the specific detail or the name of the initiative. Further, all recalled a

point over the last year where the provision of support, and the number of visitors, suddenly seemed to increase, even

if they could not explain why this support had suddenly mobilized:

Q: Did anyone from Housing, like your Housing officer, come to you initially and say, ‘Hey, there’s a program. Do

you want to sign it and get involved?’ or something like that?

A: Maybe.

Q: Did you get offered any support from Housing?

A: Yes, I did. I got offered support with Footprints and Housing combined to apparently help me (Nina).

Only in two cases did tenants appear to know nothing about the project or why they would possibly be involved in such

an initiative. Lesley, for example was referred into the project for poor property condition but felt that she had no

tenancy issues and believed that the support had been mobilised after she had been in hospital for surgery because

she needed help while she recuperated. Similarly, Arthur, whose tenancy was assessed as in crisis due to hoarding



and squalor, denied any problem with his tenancy and became angry during interview at what he perceived as an

insinuation that he was not a good tenant.

5.3 THE PROVISION OF SUPPORT: A TENANT PERSPECTIVE

While the project was prescribed to run for four months with each tenant, in many cases it continued for much longer

than that depending on the perceived needs of the tenant and how well he or she was progressing. Among the tenants

interviewed, the shortest period was for two months – for a tenant who was referred to the Brisbane Youth Service

who could provide her with a support worker until she was 25 – and the longest was 11 months. As is the nature of the

project, support was tailored to tenants’ specific needs as outlined in the Housing Support Plan. Despite this, it was still

difficult to ascertain the nature and extent of support provided to each tenant, for a number of reasons. One is that

tenants themselves had trouble recalling which agencies they had been connected to, and for what purpose,

especially when there were multiple agencies and stakeholders involved. In addition, and as outlined earlier, tenants

often encountered memory problems, especially when asked to describe people and events of more than a year ago.

Further, it was often unclear which support organisations tenants were already connected to prior to the

commencement of the project and which came on board as a result of it. Many tenants, for example, already had

support workers through organisations such as the Red Cross, Mental Illness Fellowship Queensland (MIFQ) and

Micah, or were already connected to their own mental health professional, and even they had difficulty distinguishing

between ongoing support mechanisms and those specifically occurring through the project. One tenant, for example,

was unaware that he had even signed up to a project and thus believed that the support he was receiving was ‘for life’.

Some tenants explicitly recalled early meetings with their stakeholder teams, around the table at home or in the DHPW

housing office, so that their needs and goals could be identified:

… she organised a meeting with me, acute care, at the Footprints office, and then Housing and we all came out

and sat around and had a talk about what was going on here and how it was affecting me mentally and the doctors

had a talk to Housing and everything (Bianca).

They showed up here and we made a time for them to come around and talk to me (Marie).

As per the service delivery model, this support largely came in the form of a package comprising non-clinical support

(by Footprints) and clinical mental health services (by staff from Queensland Health). Key areas of non-clinical support

provided by Footprints included: support and counselling on a one-on-one basis; advocacy service and support in

connecting up with other service providers; guidance on general home care, such as meal preparation, budget

management, cleaning, shopping and nutrition; assistance with job-seeking; assistance in enrolling in social or

recreational project and activities; and assistance in setting up and travelling to appointments. Tenants spoke highly of

the support they received from Footprints, and the staff members involved, and described the different forms of

support they received as follows:

They organised Ozcare, that they come to me and they do my catheter. But any other time the cleaners help me

with the cleaning, Footprints did, so did the Churches of Christ, they’ve supported me and everything else… They

take me to the hospital and they’re back and forward. If there’s an appointment for the hospital they’ll take me up

and stay with me, at the doctors, and everything else. If there’s anything that I need to do with anything, Footprints

has been there (Lesley).

Even when I was having trouble with food and stuff they would try and go out of their way to get you food and your

medications. They were just really helpful, especially with everything and everybody, even money and stuff. It’s just

been great. Always had time to drive us to appointments and check up on us and if we didn’t want to talk they’d call

and call and call just to make sure that we were okay. It was good (Bianca).

Tenants also reported the significant degree of support they received from Footprints around tenancy issues. Four

tenants reported that Footprints helped them move to a new property (involving packing and unpacking their

belongings, organising removalists and assistance in procuring new furniture). Others described how Footprints helped

to mediate between themselves and DHPW by advocating on their behalf or pursuing emergency property transfers

when a transfer was thought necessary. One tenant described how much easier it was for her to interact with a



support worker in her own home around tenancy issues than it was to visit the impersonal and bureaucratic offices of

DHPW to meet with a housing officer:

Because it wasn’t such a business type perspective. When you’re at the Housing office, they’re in an office, they’re

at work, heaps of people are around. Whereas [name of Qld Health worker] is a social worker, she come for the

visit here. So I was content in my environment. I wasn’t, ‘Oh my god, everyone’s looking at me, all these

professional people’. It was really a more relaxed approach (Cindy).

Queensland Health took responsibility for meeting the broad mental health needs of tenants within the project, which

included mental health assessments, mental health treatment and facilitating access to mental health support. The two

mental health clinicians who worked full-time on the project were referred to frequently by most tenant interviewees,

who spoke highly of the services they provided. While this could involve connecting them up to other mental health

services, tenants most commonly referred to the clinicians as regular visitors who simply dropped in to see how they

were faring and to listen to them whenever they need to talk:

They come here every fortnight and they ask, ‘How are you going Lesley?’ (Lesley).

A: Well, she [name of Qld Health staff member] gave us a lot of support actually.

Q: In what ways?

A: Just talking to us, showing a bit of sympathy (Mary).

Even on the weekend, they’d come Saturday or Sunday, or just ring up on the weekend, ‘Do you want me to come

out? Is everything all right? I’ll come out and have a chat’ (Angela).

In this respect, the support provided by the mental health clinicians appears to extend beyond a purely clinical remit to

incorporate broader forms of case support, including connecting tenants to more mainstream forms of primary care, as

well as dealing with issues where mental health challenges impact upon tenancies. In one instance, for example, a

tenant reported how it had been the Queensland Health staff who had encouraged her to see that she needed to

declutter her property and consider transferring to a smaller one that was more accessible and easy to manage. As

with other tenants, she spoke highly of both clinicians.

5.4 TENANT EXPERIENCES OF THE MHDP

This section examines tenants’ views and experiences of the MHDP. Aside from reporting on their general reflections

of the project and the staff they encountered, it also focuses on specific components of the project that have previously

been identified as important to its operation. In particular, this relates to the question of whether tenants felt they had

some autonomy in the project, notably the extent to which they felt listened to by their stakeholder team and whether

they felt they had a say in the decisions that were made.

The majority of tenant interviewees spoke of the project in highly positive terms. Even those who criticised some

aspect of it were still happy with other components and with the support they had received overall. When asked about

their experiences, tenants spoke enthusiastically about the additional support they had received – often at a time in

their lives when they felt they needed it most – and, in particular, about the staff involved. Below is a selection of

statements from tenants that illustrate their high levels of satisfaction with the project:

Generally speaking I would say that they’re pretty good. Yeah, with regard to interacting with them they seem to be

quite excellent really because you realise that they’ve got a job to do and they’re not rude and they’re very patient.

So that’s pretty good, I think (Arthur).

I wouldn’t have had any problems dealing with them because they’re just damn nice people doing a good job

(Brian)

They’ve been very, very supportive and I’m over the moon that I’ve got that support (Lesley).

Everyone I’ve seen has had a lot of good support. I wouldn’t say anything bad about them because they went

above and beyond anything that I thought they would or could do. I wouldn’t say they could do it any better

because it’s just been more than I thought that would have happened (Desiree).



They’ve been the best thing that’s happened to me in a really long time. Yeah, they helped me get on medication

and everything as well, like the right medication and getting the right diagnoses and helping me find new doctors

and having faith to get the help that I need. It’s been great (Bianca).

Nobody ever talked down to us as if we were stupid or something, which people do. It was a really good experience

and I would want those people as friends. Yeah. They were very supportive (Angela).

I didn’t feel intimidated and I definitely wasn’t made to feel some kind of less of a person socially because of it.

They let me know that they appreciated my time (Cindy).

Nothing but support and decency, which is great. Couldn’t say enough (Desmond).

They were really, really great. I’ve got so much respect for them (Andrew).

5.4.1 Tenant autonomy

In addition, tenants were asked about specific aspects of the support provided, including the extent to which felt able to

exercise some autonomy in the process. This was covered by two specific interview questions which were broadly

worded as: a) did you feel your support workers listened to you?; and b) how much of a say did you have in the

decisions around the type of support you received? Approximately one third of tenants interviewed indicated that they

did feel that their support team had listened to them, as the following excerpts illustrate:

Q: Did you feel they listened to you?

A: Oh god yes. Yeah (Arthur).

A: Yes, they do (Lesley).

A: Yeah (Briony).

A: Yeah (David).

A: Yeah. And not being told. It was, yeah, talked about and not being told, which was good (Angela).

A: Yes, I felt like they did. Anything I had to say they certainly were open and listening to what I had to say and

then offering any kind of help or ideas that they had in response to anything that I said (Marie).

Similarly:

Q: How much of a say do you have in the decisions around the type of support that you get?

A: A lot. They actually listen to me and then if I feel that something’s wrong I’ll let them know and everything else

and then they’ll fix it. But no, I have not had any problems (Lesley).

A: Yeah, they never once said, ‘you’re now classed as a bad tenant and we’ve got a whole set of rules you have to

follow now’. They let me know that, ‘yes, it is okay. We do understand that you’ve got all these health issues as

well’. They didn’t want to overload me. But at the same time, they just gave me so much opportunity to call

other people or to call them again (Cindy).

A: Yes, I did. I really did. They were lovely with me. Everything worked out lovely (Sarah).

A: Yeah, definitely. [name of Footprints support worker] would always ask me what I wanted to do first and if I

didn’t want to go to one of my appointments or something she would happily call up for me and cancel and

reschedule and everything, which is really good, if I was having a hard day and I didn’t want to socialise

(Bianca).

A: Yeah. Yes, I did. Yes, I did feel I could have a say (Lorelei).

A: Yeah, I have. Yeah (David).

Around five tenants reported that they had not been listened to by their support team and they gave different reasons

for this. These tenants, as outlined later, were generally those who also felt that the project had not led to any positive

changes in their lives and this was usually for the same reasons. In two cases, tenants reported that they were



unhappy in their current properties and that they had repeatedly told both DHPW and their support workers that they

wanted to transfer to somewhere new. One such tenant is Lachlan, described earlier, who has consistently

encountered problems with neighbours in every property he has lived in, and is now living in an apartment block that

he actively dislikes with neighbours who he says are continuing to cause him trouble. In an attempt to avoid his

neighbours, and as a result of increasing anxiety and panic attacks, Lachlan said he no longer has any desire to go out

and feels increasingly isolated. He reported that he is miserable in his unit; has no peace and quiet and ‘hates it’, but

felt that his support team neither understood nor cared how he was feeling:

Q: Did you feel your support team or the people from the program listened to you or understood you?

A: Not really. I don’t think they even cared. I don’t think they believed anything I said (Lachlan).

Similarly, Nina also complained that no one listened when she tried to tell Footprints and DHPW that it was her

neighbour who was causing her tenancy problems, not her, and that the issues would be resolved if only they would

agree to a transfer for her:

Q: What about Footprints? Did you feel they listened to you?

A: No. They weren’t there much either. They didn’t help much, the situation, at all. I just wanted a transfer. I

wanted to get out of that particular complex, into another complex or a house somewhere. But no, just, ‘Get

out’.

Valerie was another tenant who felt no one had listened to her or understood her needs. She had been referred to the

project because of hoarding problems that were acute enough for her tenancy risk to be classified as crisis. Valerie

could not accept that she has a hoarding problem; rather, she complained that her unit is too small, dark and

unhealthy. She too wishes to move, but described how, instead, she had been subjected to a team of support workers

whose goal was to ‘force’ her to part with her belongings and who were ‘not interested’ in allowing her to move:

Q: Did they listen to you?

A: They listened, but they know what they want and that’s it.

Q: So do you think they understood where you were coming from?

A: I don’t think they understand the way you are, feel, no. They just want things out. ‘That’s how it is or you’re out’.

I didn’t that attitude. I just wanted to move. No. As I said, ‘If I move you can do it up’.

Q: So did you feel you had a choice in what was happening last year?

A: No choice, no (Valerie).

The final tenant who suggested that her views had not been heard justified her assessment for quite different reasons.

As outlined below, tenants often complained that one of the few frustrations of the project had been the sheer number

of people they encountered, which they found confusing and overwhelming, and which sometimes led to a duplication

of activity. Deliah was one such tenant who spoke at length about there being ‘too many’ people involved in the

project. In her view, this precluded her from developing any real connection with any of the support workers, such that

none of them really got to understand her or what it was that she needed:

Q: And so did you feel listened to or understood by your support team from the tenancy support program?

A: I don’t think so, in a way… there was just too many and I made no real connection when it was SHouT, with any

of them (Deliah).

5.4.2 ‘Too many people’

Deliah’s experience of the MHDP above echoes that of other tenants who also commented on the sheer number of

people involved in the project and the (sometimes) detrimental effect this had on their ability to be heard, to connect

with people and to even know who they were or what role they played. Arthur, who appeared to have no knowledge

that he was in a project described how a range of different people would come knocking at his door and, while he had

no idea who they were, he was happy to accept the support they offered:

Now, this is where it becomes a joke. There are so many people who come knocking at the door and saying hello

and sometimes you don’t know if they’re from Footprints or they’re from some other organisation. To be honest with

you, you don’t really care because they’re coming to help you (Arthur).



Other tenants also reflected on the complexity of the project in terms of the range of people involved and the difficulty

they encountered in knowing who was who:

Every person I met was really, really nice, except I saw a fair few different people each time. So there was probably

about at least five different names I had in my phone. So that could get a bit confusing (Briony).

A: I had so many people in and out. I’ve even had guys knock on the door and say, ‘How’s your new apartment?’

and you just take their word for it and they just run in and take a thousand photos of everything. ‘Have a nice

day’.

Q: So lots of people in and out and you’re not really sure?

A: Lost track of them (Desmond).

Additionally, the high volume of visitors, particularly during stakeholder meetings where tenants would meet with the

various services or workers engaged in their case, created additional challenges for those with mental health

conditions. Some tenants reported feeling ‘overwhelmed’ during stakeholder meetings or heightened levels of anxiety

at having to interact with so many people in one space:

It’s a bit overwhelming when you’re getting different people, where you’re also being a bit of an agoraphobic and

don’t want anyone or anything in your life because you’re also going through problems, your neighbour and things

and physical things, but you’re also going through, up in here, ‘I’m finally getting help and I’ve got to accept this

help. But I want someone, some one or two’. But this is just too many people coming into my life and I’m trying to

stop that (Deliah).

At one stage there in the meeting I had 10 people in the meeting. So was kind of all a bit overwhelming (Lorelei).

My daughter didn’t do so well, of course, because of the fact that she suffers with anxiety. So she didn’t do so well

with so many people around and she would tend to hide a bit more (Lorelei).

Losing track of the different agencies and individuals involved in their case also means that some tenants felt they

were unable to build rapport with their support team, not only because they struggled to acquaint themselves with

everyone involved, but also because some of the visitors came so infrequently – and in some cases for only a short

time of 15 to 30 minutes – that there was no opportunity for them to develop an ongoing relationship. Tenants who

relied almost entirely on one or two key workers described their relationship with those workers as close and

supportive, while those who were engaged with a greater number of support staff reflected that a smaller team would

have been preferable to allow a closer relationship to foster, or at least a staged approach where one set of support

workers would hand over to another set once their own work was done:

But I was finding that I was getting too many different people happening in that period. … I just thought some of

these girls I only met on one occasion, come with someone, and I thought that it would have been better if I met

them more often. So they got to know me and a bit more of a repertoire or whatever (Deliah).

I think that was the only negative would be it was at least five different people I saw instead of sticking just to the

one or two people (Briony).

I think it would have been better had it been just a couple ongoing. ‘Well, we can do this for you. Then once we’re

done they will come in and they will do this and then once they’re done…’ It might have been better if I just had a

couple in stages rather than a whole heap in one go (Lorelei).

Finally, tenants reflected that the size of their stakeholder team inevitably led to some doubling up of activity, as

Angela noted:

There was a bit of doubling up with phone calls to different people, but they probably needed it to prompt things to

be done and yes and no answers on other things, because we did have a lot of people involved with us (Angela).

5.4.3 A lack of follow-through

A second more critical reflection of tenant’s experiences of the MHDP came from one tenant only, although it is worth

reporting nevertheless. This tenant, Lorelei, expressed disappointment with two aspects of the project. The first, as

outlined later, is that, from her experience, the project ended ‘suddenly’ with no follow-up support, despite receiving



assurances that support staff would check in with her occasionally. The second is that, in her view, plans were

formulated to assist her, but were not followed through:

Do you understand what I mean? There was just so many things that were mentioned that they were going to do

for me, and they just never did. I think that was the frustrating part, because they said they’re going to do this, and

they’re going to do this, and they’re going to do this, and I’m thinking, ‘Oh great’, and it just never happened. It was

like, ‘Well, that was a bit sad’, because it was going to be good, what they were going to do (Lorelei).

Lorelei provided two examples where, from her perspective, this had occurred: first, a plan to connect her to a

counselling service that she and her teenage son could attend together as a way of resolving behavioural issues

prompted by a learning difficulty on his part; and second the pursuit of assisted living options for her son so that he

could live independently of her. She was tearful during her interview when recounting her disappointment that these

plans had not come to fruition or been followed up. It is highly feasible, of course, that Lorelei’s distress comes from a

misunderstanding on her part rather than a lack of follow-through on that of her support team, particularly since this

complaint was not shared by any other tenant. However, Lorelei’s experience of the project and the way – in her view

– it suddenly ended are revisited later in this chapter when tenants’ views and experiences of project exit are explored.

5.5 CLIENT OUTCOMES RESULTING FROM PARTICIPATION IN THE MHDP

An important part of the summative (outcome) evaluation of the MHDP is to identify client outcomes resulting from

their participation in the MHDP as a way of determining whether the project has met its goals and objectives in

preventing tenant eviction and promoting the conditions for positive and sustainable tenancies for project participants.

DHPW tenant housing records provide an objective assessment of the pre- and post-project housing outcomes of

participating tenants to discern changes in, for example, the number of breaches, rent arrears, problems with

neighbours etc., while Queensland Health data indicate any changes in health and wellbeing, and hospital admissions

among participating tenants. In contrast, the interviews with tenants give rich, subjective insight into tenants’ own

reflections on whether the project has made any difference to their lives and tenancies, and in what ways. Four

(positive) areas of impact have been identified by tenants themselves: improvements to their housing situation;

improved mental health; an increased sense of personal competency in managing a tenancy, dealing with life’s

challenges and knowing when to ask for help; and an improvement in their relationship and interactions with DHPW.

Each is explored in turn.

5.5.1 Improved housing outcomes

On the whole, most tenants indicated that their housing situations have improved as a result of the project, although

some continue to be unhappy with where they live, while others have subsequently received eviction notices. At the

most fundamental level, three tenants reflected that the project has improved their housing situations simply by the fact

that they are still housed. None of these tenants fell into the crisis category, but rather had been assessed as needing

the project for early intervention or prevention. Two had previously been in receipt of breach notices for tenancy

problems: Cindy as a result of destructive and unruly behaviour on the part of her teenage son, and Marie who

received a breach notice for undeclared occupants after a neighbour complained about a friend who had moved into

her apartment with her. In both cases, the risks to their tenancies posed by these issues was a considerable source of

anxiety and both reflected on the impossibility of finding affordable housing in the private rental market if they were

ever evicted from the social housing sector. When asked if the Tenancy Support Project had improved their situation,

both responded that it has enabled them to retain their tenancies:

For me, I participated simply because I really need the roof over my head. I have got some pretty major health

issues. So that was the biggest support that I can honestly say is that I’m still housed. Because I can’t work at the

moment there’s no way I could afford to go into the private rental market. Because of the eviction, to continue living

with my son I would have had to go to the private market and I would probably be homeless by now because

there’s no way I can afford the rent on a disability pension (Cindy).

Well, it improved it is how I honestly feel at this stage. It helped me out by way of my breach and that type of thing

because what I do remember now is when you do get a breach, if you get in trouble in any way within the next 12



months then it could terminate your tenancy and that type of thing. So they were giving me all the right information

and all that type of thing. So, god forbid, that didn’t happen (Marie).

A third tenant also reflected that having a home at all was the most important outcome of the project. Andrew has

spent many years homeless and signed up to the MHDP when he was given his first social housing property. At the

time, he had very few personal belongings so Footprints helped him furnish his apartment, put him in touch with a

counsellor and helped him develop skills managing a budget and goal setting. When asked how his life is different as a

result of the project, he replied:

How? I’m not on the street. I’m not on the street. I have a roof over my head, not keeping one eye open and one

eye closed to keep an eye on everything. Being on the street was very hard for me. I was often on the street for

years (Andrew).

In addition, Andrew also indicated that since being housed, he has also been permitted to see to his children again

and he described himself as being ‘a lot happier now than I ever have before’.

Some tenants moved property as part of the project and while not all were happy with the move, two indicated that

their new homes were better suited to their needs because they were smaller and more accessible. Prior to joining the

project, Gavin lived in a first floor apartment which was challenging for him because of mobility impairment, but he was

also embroiled in frequent disputes with his neighbours. As a result, he requested a transfer and Footprints helped him

move to a new, ground floor apartment. He reflected during interview that he is happy with his new apartment and

thought that moving had been good for his mental health:

A: I reckon it really helped me. It’s helped my mental health.

Q: It’s helped your metal health?

A: Yeah, because I’d have stayed at [name of suburb] I think I would’ve been a fully nutcase by now (Gavin).

Angela was also transferred to a new property as part of the project, although at the time she had not been happy

about moving. Angela’s housing situation had been classified as crisis because she and her husband were living in

poor conditions induced by poor mental health and what appeared to be a tendency for hoarding. At the time, Angela’s

husband, who also had a serious health condition, was sleeping in the garage because he could not tolerate the living

environment of the house. The Queensland Health clinical support workers encouraged Angela to consider downsizing

to a smaller property – something Angela was very resistant to. During her interview, Angela said that she had initially

felt very angry about the project because she had been ‘forced’ to sign up and then ‘forced’ to move, but she gradually

came to realise that moving was indeed necessary. Now that she was settled in her new place, she reflected that it

has ‘worked out really really good’:

It was a big thing. It turned out to be a very big thing because they came, [name of Qld Health staff] and they were

involved with us just for the setup and everything and then we moved to here. It worked out really good because

we not only got rid of a lot of stuff, we downsized and everything because we went into a smaller place (Angela).

Finally, there were other tenants who believed their housing outcomes had improved simply because they felt more

secure in their tenancies. These tenants were typically those who had received breaches for poor property condition or

failed housing inspections, often because physical or mental health problems left them feeing unable to cope.

Receiving support in the form of general counselling, coaching, new connections with service providers and, in some

cases, assistance with cleaning, meant that they were better able to manage their properties which, in turn, led to a

reduction in breach notices and improved outcomes with inspections:

Things with the tenancy seem to be actually going well. I had an inspection not that long ago and that went really

well. That was the first one in ages where they said they were happy with everything and, yeah, ‘See you later’.

Whereas usually they tell me, ‘we’ll see you in two weeks because we’re not happy with this, this, and this’, which I

was expecting again. So I was completely blown away when they told me it was all good (Rebecca).

Yet there were some tenants who reported no improvements in their housing outcomes, either because the situation

simply had not changed very much, or because their tenancies were at greater risk than previously. Among those who

fell into the former group were tenants who either felt that the MHDP had not made much difference to their lives (as

outlined later) or – more typically – who wanted to transfer to a new property and had so far not been able to. Lachlan



and Lesley, described earlier, were two such tenants. During interview, for example, Lachlan was insistent that he

‘hates’ where he is living and remains concerned about getting evicted because the neighbours are still causing him

problems:

I just want to be left alone, basically. You know what I mean? That was the plan. Anyway, yeah. I don’t know what

else you could say. I’m miserable here. I hate it. No peace and quiet …. I’ve been getting more isolated the longer I

live here (Lachlan).

In the latter group are Nina and Sarah, both of whom were referred to the Tenancy Support Project after being

identified as crisis category tenants: Nina for neighbourhood issues and Sarah for rent arrears. While in the project,

Nina was evicted from her DHPW home for property damage and unpaid debts and was living in a caravan park at the

time of her interview. She expressed anger that she was the one to have been evicted while her troublesome

neighbour had been allowed to stay:

I wasn’t very happy, but I was happy with the location. Just one particular neighbour, the guy downstairs. From day

one he would just yell at me, scream at me obscenities. I never thought that could happen like that and I can’t

believe he got away with it and I got booted out and he got to stay. I don’t understand it one bit. I lost my Housing

Commission. I got a bad name out of it, a bad reputation out of it, and he just gets a goody little two shoes rap

when it’s all absolutely wrong (Nina).

Sarah said she her relationship with DHPW has generally been good although she has received various notices to

remedy the poor state of her garden and was in rent arrears when she signed up to the MHDP. She explained that life

had become difficult after a long period of hospitalisation following a serious accident and various challenging events

in her life that left her with serious depression, anxiety and difficulty coping. Sarah had been involved in the project for

almost a year and explained her rent arrears in terms of her personal challenges and a series of administrative errors.

But she was in rent arrears again at the time of interview some 15 months later and had ignored all correspondence

from DHPW until she finally received a notice to leave from her housing officer. At the time of interview, Sarah was in a

high state of distress about the prospect of being evicted:

So I was in a major panic attack yesterday. I couldn’t see straight for a good seven hours and I didn’t come right

until about 4:00 pm. Now, it’s been a long time since I’ve needed any medication. I had to go get that (Sarah).

What this suggests, of course, is that there are some tenancies that remain difficult to sustain even under a project

such as this, and some tenants for whom eviction cannot be prevented. Indeed, stakeholders in the Interim Report

indicated a tendency to ‘hold off’ on breaches and evictions for tenants within the MHDP if other mechanisms are

available to assist them. That Nina was evicted while formally enrolled in the project suggests tenancy problems that

were significant and difficult to manage any way other than eviction. Similarly, that Sarah should receive a breach

notice some three months after 11 months within the project provides further evidence to stakeholders’ own

acknowledgement that the MHDP is not a panacea and cannot prevent problems from recurring after a tenant has

exited from the project. What it does raise, though, is the question of whether all tenants are given sufficient support

post-exit – a question we return to later in this chapter.

5.5.2 Improved mental health

The second set of client outcomes explored here relates to mental health. The relationship between housing and

mental health is mutually reinforcing in that just as poor mental health diminishes housing choices and outcomes (in

terms of troubles sustaining a tenancy or meeting rent payments) so poor housing (unsafe, insecure, lacking privacy

etc.) can impact upon well-being and exacerbate mental health conditions. The MHDP was designed to help improved

mental health in two ways: first directly through the provision of mental health clinical support workers who provided

counselling and support to tenants with mental health problems and referrals to other mental health providers as a way

of avoiding mental-health related tenancy issues; and indirectly through assistance with tenancy management so that

stresses arising from tenancy problems would not increase the incidence or severity of existing mental health

conditions. While Chapter 3 provided an objective assessment of any changes in tenants’ mental health outcomes as

a result of the project, in the interviews tenants were invited to describe in their own words whether, and how, the

project had made a difference.



Tenant such as Lachlan and Sarah who described worsening housing situations invariably felt that their mental health

was deteriorating as a result. As outlined above, Sarah, explained how her eviction notice had led to a panic attack

and required her to resume medication that she has not taken for some months. Similarly, Lachlan described how his

housing situation has become detrimental to his mental health, such that he has resumed drinking again:

Yeah, just been struggling a lot lately. I’ve started drinking heaps. I was getting pretty healthy and stuff before I

moved in here and then I just started drinking a lot (Lachlan).

In contrast, seven participants not only indicated that their mental health has improved, but they also attributed these

improvements directly to their involvement in the MHDP. They described feeling happier and more confident and

expressed appreciation for the support and counselling they had received from the Footprints and Queensland Health

support workers:

The best impact. Before I moved here, before I got support, I was in a really bad place with my daughter, living in

my mum’s house, but she’s abusive and stuff. So since I’ve started with this everything’s gone up. Just my general

mood and wellbeing, health, safety, everything… My confidence has gone up since I’ve had these people in my life.

I think it’s also because I’m healthier, just happier, the confidence just - Yeah, I don’t know (Desiree).

Yeah, well just stayed sane. Just being around adults, because I’m just at home with kids most of the time (Briony).

A: It gives us someone to talk to when things get tough, if I have an argument difference with mum, because my

mother is not the best person to talk to. When you’re depressed you end up twice as bad. Then I end up

popping more Mersyndols and knocking myself out because I get so many headaches from stress.

Q: Has that helped with the stress?

A: The Mersyndols?

Q: No. Getting that support.

A: Getting [name of Qld Health staff member] support, yes, it has.

Mental health? Bit happier and brighter that I can walk into a room that can actually have visitors now (Desmond).

Yeah, I’ve come so far. I feel normal sometimes now. I’m not crazy all the time and I’m not suicidal. Yeah, they’ve

had a really big impact on my life and my health and everything, my housing, everything in my life… When I first

went onto the program with them I wasn’t talking, I was really shaken off, I was just really shut down, and just

depressed and sad. I’ve come a really long way, as you’ll probably see (Bianca).

I’m really in a good place. Physically in a good place and mentally in a good place, which is the best thing for me

for a long time (Andrew).

While tenants considered their mental health to have improved, there was, inevitably, acknowledgement of ongoing

health issues that could not be addressed through an intervention of this kind. Tenants continue to struggle with

mental health challenges and continue to have bad days, while some reported physical health conditions that are

worsening. Desmond, for example, reflected that despite feeling much happier about the condition of his apartment

and appreciating the efforts of his support workers to help him find work, there was little anyone could do to arrest the

decline of his health and he was pessimistic about his chances of securing a job.

5.5.3 Perceived competency

Since the MHDP could only run for a limited period of time, a key aim of the project has been to assist tenants in

developing their own competencies for tenancy management so that tenancies can be sustained after the project is

complete. As a result, the Footprints team, in particular, spent time with tenants assisting them in building skills in

home management and maintenance (budgeting, bills, food preparation, property care), communicating effectively

with DHPW and other housing agencies, and seeking support from other social, health and community service

providers. Positive outcomes arising from these efforts are evident in tenants’ self-reported improved competency

around four key aspects of their tenancies and lives.

The first broadly relates to the progress tenants have made in identifying goals in their lives and working towards them.

Some, for example, have resumed study as a result of the project or are now seeking work, while others have

commenced an exercise program, joined a social club or feel more confident about signing children up to day care.



Second, and related, is an improved sense of confidence in being able to manage a home and meet their tenancy

obligations. For some, this has come about through being transferred to properties that are more suited to their needs;

or having been able to de-clutter and receive counselling to manage hoarding tendencies. For others – particularly

younger tenants in their first homes – it is about developing skills and confidence in managing a home and all that

goes with it:

Now I have everything I need, I know what I’ve got to do. I’m starting to keep on top of bills. I’m a lot more confident

now. My daughter just started day care a month and a half ago. So confidence and actually being an adult, actually

doing the things I have to do, actually keeping a house without crumbling. I haven’t been so bad lately. I can go to

the shop when I need to go without freaking out. So yeah, a lot more confidence in keeping my tenancy now I have

everything I need (Desiree).

Third, tenants indicated that they now have more confidence dealing with DHPW and their housing officer, which

means that they feel more comfortable seeking help when they need it. Tenants often spoke of feeling daunted or

intimidated by the monolithic structures of DHPW and often felt reluctant to contact them, visit the office or even draw

attention to themselves for fear of increased scrutiny and reprimand. However, the support workers of the MHDP

helped tenants navigate DHPW more easily, often by liaising with the Department on their behalf, but also by offering

guidance on how to approach the Department so that it could better understand their tenancy challenges in the

broader context of what else was going on in their lives. Two tenants explained this improved competency with the

Department as follows:

I don’t really know how to handle Housing properly. I don’t know what to say. I don’t understand it all. I can’t

process it and I go into panic mode. I’m just like, ‘Oh my god, what is happening?’ It’s been really good because

they’ve [the Footprints team] helped me, they’ve taught me a lot of different ways to handle it and how to speak to

them and it’s okay to speak to them, and introducing me to them and showing me it’s okay, they don’t bite. So it’s

been really good… I still have my bad days, but I can call up Housing now and have more of a confident

conversation with them rather than being really nervous and stuff (Bianca).

They made it much more of a relief to deal with Housing and it made Housing feel not so daunting. A government

department, it was just like, ‘Oh my god. They’re never going to see the whole picture’. Whereas having that

contact I was able to reiterate on the whole situation in a relaxed environment rather than, as I say, just the

pressure of talking to the one who can sign the eviction there and then. So it was a good relay (Cindy).

Fourth, and related, tenants also noted that they now have a better understanding that they need help with tenancy

and health matters and subsequently feel more comfortable asking for, and accepting help, when it is offered.

Previously, they said, they tended to refuse offers of assistance but had learn through the project that it is ‘ok to ask for

help’ when they need it:

I’ll take whatever I can get now. I’ve decided. No more saying ‘No, no, no’ (Deliah).

I know my limits now. If I need help so I get it, ask for it and get it (Angela).

5.5.4 Improved relationship with DHPW

Finally, and importantly, tenants reported that a key outcome of the MHDP has been an improvement in their

interactions and relationships with DHPW. All but one of the tenants interviewed have their tenancies managed by

DHPW and while some (notably older) tenants felt that their relationship with DHPW has always been positive and

civil, approximately one third of those interviewed explained that they had previously had a difficult relationship with

their housing provider. As outlined above, this was often due to tenants feeling ill-equipped to deal with the

Department on equal terms given its vast bureaucratic structures and processes, but it was also the result of tenancy

problems which meant that tenants’ interactions with the Department were often negative and a source of anxiety –

breach notices, failed inspections, rent arrears, letters reporting of neighbour complaints and the seemingly constant

threat of eviction.

Yet they also reflected that the MHDP has helped change these dynamics in several key ways. To begin with, and

outlined above, they feel better equipped to deal with their housing office, but they also believed that they now have a

better understanding of the Departments’ perspective on tenancy management, realising that its ambition is not to



evict them when things go wrong, but to try and keep them housed by working with tenants and other support staff to

resolve problems as they arise:

I was able to see Housing’s side from [name of Qld Health support worker’s] view. She was able to explain, ‘Look,

they do try to keep people housed. They do try to help the situation. They don’t want to see you lose your housing’.

It was much more personal than before (Cindy).

I think it’s helped Housing to understand me a bit more. It’s helped me to perhaps, not have a rapport or a

friendship with Housing, but I think it’s just helped us understand one another. Do you know what I mean? … I was

always fearful in the beginning that Housing were just going to kick us out without a problem. Like, ‘No problems,

you’re out of here. The house is a mess, you’re out of here’. I always thought they were just going to kick me out

and I was always really fearful of them, and it’s like, had I realised that they were going to be more understanding

and wanting to actually help by getting these services in, I probably would’ve actually allowed them to do all this

earlier in the piece, rather than being fearful of them and trying to keep them away, if you know what I mean

(Lorelei).

Related to this last comment, tenants also discerned a change in the demeanour of housing support staff while they

were in the project, which they defined as being more respectful, more understanding and more willing to see the

bigger picture:

I think they’ve [DHPW staff] got a newfound respect for people. If you do the right thing by them and respect them,

they’ll do the same for you. Yeah. I mean, we were never disrespectful or behind in rent or anything. I don’t know, I

just feel that it’s easier to ring up and talk to them or call in and talk to them if anything’s wrong (Angela).

I think they’re more aware of the situation around here, because they’ve noticed the complaints are coming from

the same people. They’ve stopped and stood back and looked at the situation. Whereas if it wasn’t for Footprints I

don’t think they would have done that (Bianca).

Another tenant reported that even though she interacts with DHPW infrequently, she has made friends with some of

the housing officers as a result of the project, such that whenever she visits her housing office, people remember her

and say hello:

I really don’t have a great deal of contact with them. But I actually made some friends through the whole thing. I

kind of go to the Housing office now and identify people by name and they give me a wave, ‘Hi Cindy’ (Cindy).

Even those who were critical of the project and felt it had done little to improve their housing situation described a

change in their interactions with the Department and a sense that housing officers are more sympathetic to the

broader challenges they encounter in their lives that often have a detrimental impact on their tenancies. Lachlan, for

example, had recently lost two family members. This loss has compounded his mental health problems which, in turn,

have led to an escalation in tensions with his neighbour and aggressive behaviour. In his most recent visit to the

housing office he described how the housing officer had been unexpectedly more understanding of his situation:

They said, ‘We know that you’re going through a hard time’. I think the lady I spoke to last time was actually pretty

fair and nice and understanding. She said, ‘Look, I know that there’s been a lot of complaints made about you in

April and May’, and stuff like that. And I said ‘Yeah. Around the time my [family member] passed away’… They

said, ‘you know that doesn’t excuse it, but we understand you had a lot of visitors coming around giving their

condolences and whatnot and your family members and stuff like that’ (Lachlan).

These findings confirm stakeholders’ own assessments of changed responses to tenants within the project as outlined

in the Interim Report. Yet, as signposted in that report, it is not clear from this data whether the observed changes in

DHPW’s interactions with tenant interviewees has occurred because the tenant is an active MHDP participant, or

because the project has led to enhanced capability across the Department, such that all tenants – including those who

are not actively engaged in the project are – receiving improved housing services.



5.6 EXITING THE PROJECT: TENANT EXPERIENCE

In the Interim Report, it was suggested that while the MHDP has been operating effectively, its time limited duration is

incongruent with the needs of some tenants for ongoing support that endures well beyond the life of any single project.

Stakeholders interviewed for the Interim Report also acknowledged the limited resources and supports that are likely

to be available when tenants exit the project despite the considerable planning for exit that has been built into the

MHDP right from its inception. In many ways, it is still too early to assess the long-term term outcomes of participating

tenants of the MHDP although the evidence from tenants themselves suggest that the outcomes for most– although

not all – have been positive, at least in the short term. Of key importance in post-tenant outcomes is the process of exit

itself and the extent to which tenants felt ready to leave the project; were prepared for the exit process; and were

provided with follow-up support as needed. This section explores tenant experiences of exiting from the project and

their views on whether they were sufficiently prepared to manage their own tenancies without the intensive support of

their stakeholder team.

The process of exit planning formed part of the service provision phase of the MHDP, with tenants generally identified

as three options after each CAIRT review: a) the project goals are achieved and the tenant no longer requires support;

b) the project goals are achieved but the tenant requires long-term/ongoing support; or c) the tenant is engaged and

making progress, but has not yet achieved his or her goals. In cases where the latter assessment was made, the

project was extended beyond its initial four month period. Of the 21 tenants interviewed, 11 were seen to require more

than four months with the project and their time was extended to anything from 6-12 months. On completion of the

project, tenants seen to require ongoing support were either connected to agencies that had been part of the project,

or to new agencies, or they reverted back to case workers and other organisations with which they had been

connected prior to enrolling in the MHDP. Twelve of the interviewed tenants were recorded to have exit agencies to

support them; seven had no agencies (or at least none recorded); and two were still enrolled in the project at their time

of interview. As each tenant exited the project, the exit plan was finalised and implemented in consultation with the

tenant.

On paper, this process of tenant exit appears well planned and ordered, with each tenant being assessed, prepared

for exit and consulted about the process. In practice, however, tenants reported a range of experiences of exiting the

project, from the ostensible ‘sudden’ and unexplained disappearance of the support team to an informed

understanding of when and how exit would occur and what would happen next. These diverging accounts are

reflective of the same kinds of divergences found in tenants’ experiences of the project per se, including their

awareness of having signed up in the first place what exactly they had participated in. For those with little idea that

they had been part of a project, the same lack of knowledge about exit could be discerned. Five tenants indicated that

they were not aware that their involvement in the MHDP had come to an end, primarily because they did not know they

had been involved in the first place but also, possibly, because they had been identified as needing ongoing support

and were still connected to agencies such as Red Cross and Footprints Actioning Recovery and Citizenship Program.

In contrast, there were tenants for whom an exit plan had been made apparent and for which they had been prepared

by their support team. These tenants had been aware from the outset that the project would run for four months only,

but also understood that it had been extended in their case. Briony, for example, remained in the project for a total of

eight months and was offered follow-up services but had indicated to her support worker that she felt need for

continuing support apart from Community Mental Health whom she had been seeing since before the MHDP

commenced. She, and Andrew, outlined in the interview described how they had been prepared for the process of

project completion:

I got told from the beginning it’s a short-term program, so I’m pretty all right. I did like them though. I liked all the

people, but they said if I have any problems I can even ring and they can try and get it started again. They’ll be able

to keep seeing me if I do feel I need them for anything (Briony).

They pretty much sat me down and explained to me on what’s going to happen and asked me what will I be doing

once the time is up and I was like, ‘Well, my plans are still the same. I’m still going to keep going day by day and

trying to deal with day by day pressure’ (Andrew).



Marie also indicated that the end of the project had been explained to her and said she was comfortable with this and

did not require further support, although she was connected up to various forms of disability support including

Footprints Community Care and Disability Services, along with a psychologist and employment agency:

I felt like they’d done all that they basically could do to help me out and all that type of thing. Yeah, so it’s not like I

felt like I still needed their help and they walked away from me or anything like that. No, it definitely wasn’t like that

(Marie).

Other tenants were equally comfortable with exiting from the project although they could not recall any specific exit

plan being put in place. When asked, some indicated that the support had ceased because they had told their support

team that they were now doing fine and no longer needed intensive case management:

Q: I’m just going to ask you one more question about when [names of Qld Health staff members] stopped coming

around. How did that come about?

A: Don’t know.

Q: Because you said they’re not seeing you at the moment.

A: No. Oh, because we said we were fine.

B: Yeah. No, they stopped the program.

A: Because I said we were coping fine. If I had any problems I ring her up (Mary and David).

For Desmond, who had abstained from alcohol for three months at the time of his interview and who was happily living

in an apartment that had been cleaned and repaired, it was simply a matter of knowing that his time was ‘up’ and he

did not appear anxious about the ostensible absence of any exit plan, nor about the project ending. Indeed, when

asked what life was like now he was no longer involved in the project, he described it as ‘peaceful’ because he was no

longer overwhelmed with visitors. Nevertheless, he also reflected how much he had enjoyed the visits from the two

Queensland Health clinicians and reflected that he would still enjoy the odd visit from them to help combat the

loneliness:

There’s a little boy in me that says, ‘Oh well, I wouldn’t mind having those two ladies just for company a couple of

times. Come visit Desmond. He’s lonely. He needs a cup of tea with you’. I wouldn’t mind that. It’s only because the

girls were just like so lovely (Desmond).

Other tenants expressed a sense of loss from the ending of the project even though they too had been prepared for it.

While the sudden – and sometime unexplained – influx of visitors and support was often overwhelming for tenants, the

disappearance of that support was also hard to manage, especially when close relationships had been formed and

trust established. This was true even for tenants identified as needing ongoing support from other agencies. Even

Angela, the one tenant who had been unhappy about joining the project but felt ‘forced’ to do so, expressed a sense of

sadness when the Queensland Health and Footprints team stopped coming around:

It was really sad to see [names of Qld Health staff] go, and the girls that were coming from Footprints. It was sad

that it was all at an end (Angela).

Similarly, Bianca said she had struggled after exiting the project even though she too had been advised that it would

come to an end and had subsequently been connected up with Brisbane Youth Service so that she could continue to

receive ongoing support. During her interview, Bianca spoke frequently and fondly about her Footprints support worker

who she described as ‘always there’, ‘amazing’ and ‘would just totally make my day’, and she described the impact

that leaving the project had initially had on her mental health:

I think the hardest part, for me, was letting go. Coming in in such a bad place, I think having that one person that

you rely on so much, like the one person that’s been there to help you when everything is just falling apart and then

having to be passed along when your time is up, I think that was the hardest part for me. That really brought on a

lot of anxiety and stuff because I wasn’t sure what my next caseworker was going to be like and I was more than

happy with [name of Footprints support worker] and I was comfortable with her. It was really hard for me (Bianca).

I went downhill I have to admit. I went downhill when I left a bit because everything was all over the place and it

was quite upsetting. It was just really traumatic. Everything was just everywhere. But, I think [it’s] pretty good. It

took me some time to get used to my new social worker, but we’re okay now (Bianca).



Finally, there were tenants who reported that the support they had been receiving just ‘fell away’ in that there appears

to have been no warning that the project would end and no follow-up support, at least in their view. The following

exchange between Lachlan and the interviewer are illustrative of this tenant perspective:

Q: Did the support team do anything else to give you support or was it really just the move here that they do?

A: No, it was just the move here. After that they said, ‘that’s all we can do for you. Good luck. See you later’.

Q: Have you heard from them since then?

A: No (Lachlan).

DHPW records indicate that some of the tenants in this category were assessed as needing longer-term support and

were transferred to other agencies once the Queensland Health and Footprints teams departed. In Lachlan’s case, the

project ended after the requisite four month period and was not extended, and although Lachlan continues to see his

social worker, he explained that he has recently been allocated a new social worker with whom he is yet to connect.

That he, and others, experienced what they saw as a sudden drop or disappearance of support is likely explained by

the fact that even though they were referred to other agencies, the scope and intensity of support provided by

mainstream service providers cannot match the intensive and personal case support provided within the MHDP. As a

result, some tenants expressed a sense abandonment after exiting the project, not simply as a result of the support

ending suddenly and with no explanation, but also that it did so at a time when they were not ready to let go of that

support.

They helped me with this Micah project and they got my teeth fixed and my glasses fixed and that’s all they sort of

did and then they dropped out of my life (Nina).

So Footprints left me to try and deal with my stuff. That’s what happened (Sarah).

Sarah’s time in the MHDP lasted almost a year, suggesting that she needed longer than other tenants to achieve her

personal and housing goals. DHPW records indicate that no follow-up support was provided to Sarah when she exited

the project, but Sarah herself felt that she needs ongoing support, at least when life becomes difficult. She recounted

how she called Footprints some three months after the project finished ‘because I needed somebody to talk to’ and

had been advised that Footprints could no longer help her. As a result, she was searching around for other support

services she could draw on:

The first long weekend, it must’ve been Easter, and she [the Footprints support worker] didn’t answer her phone,

and then come Tuesday after Easter Monday I called and I said, ‘I’d really love to speak to someone if that’s

possible’. I’m sorry Sarah, but our time with you has run out’. I don’t remember if she said I could sign up with her

again. I don’t remember that part. I think I rang someone online and spoke to someone online, like Beyond Blue,

someone like that and evened me out…

I was looking at Partners in Recovery and signing up with them because I believe that’s an ongoing service.

Whereas Footprints, they’re a short-term service. But I think what I really need is a need to go way back to Mental

Health and then go back to Prince Charles (Sarah).

Lorelei also reported a sense of abandonment when the project ended despite it being extended to a period of eight

months. As reported earlier, Lorelei’s overwhelming assessment of the MHDP is one of disappointment, despite a

promising early start where she was inundated with support. Lorelei’s own life is a challenging one: she suffers mobility

problems and poor mental health and her two teenage children also struggle with their own mental health conditions.

The family lived in a condition of squalor and were at crisis point when they signed up to the project. The instability and

challenges of life made the family a priority case for the MHDP, but those same challenges also made them unreliable

participants in that Lorelei would often cancel appointments, albeit for what she saw as legitimate reasons, prompting

warnings that the support services would cease if she cancelled again. She described receiving letters and phone calls

from multiple service providers informing her that they would not be coming any more, while others just failed to return:

[Name of support worker] had an appointment the following week or so. She phoned up and said she couldn’t

make it for some reason, because whatever the reason was, I can’t remember. Then she never turned up again. I

never even got a, ‘Well, we can’t come around anymore’, or ‘We can’t do whatever’.



Then [name of care provider] and the others said, ‘Well, that’s it’. So they cancelled on me altogether and never

came in. That lot went by the wayside too.

As a result, Lorelei said felt like a ‘lost cause’ who had been ‘left’ in that no one seemed willing to follow through and

help her, or to follow up and see how the family were faring once the project ended, even though she had been

advised this would occur:

Lovely people, but I just sort of felt, again, that you can be pleasant and you can call me beautiful and sweetheart

and you can be all pleasant, but then they just pull back and you just don’t hear anything. You get that, ‘Oh, we’ll be

in contact to see how you’re going and how you’re keeping up with things’, and I haven’t heard a peep (Lorelei).

Tenants’ experiences of exiting from the project also accord with their views on whether the project ran for a sufficient

time. Stakeholders involved in the design of the MHDP knew that four months would be an insufficient period of time to

provide all tenants with the support they need to sustain their tenancies, although some tenants do appear to have

flourished under the project even if it required an extension period to reach that point. Those who felt that they had

been supported for a sufficient period of time were generally those who were a) aware they had been involved in the

project and; b) were willing to see the project end because they felt they no longer needed support. Andrew, who had

joined the project when he signed up to his first DHPW tenancy, was one such tenant:

Q: For you, do you think that was enough time?

A: Yeah, I reckon it was. I reckon it was.

Others felt that the duration of the project was too limited and while they understood why projects of this kind cannot

continue indefinitely, they reflected that setting a time limit on the MHDP does not make sense given that many

tenants have complex issues that cannot be resolved quickly:

I think they give you about six months with SHouT and then, if need be, up to about 12 months. I’m just not sure

how they can put timelines on things. That I can’t work out either. So maybe that’s a bit of a concern (Deliah).

Don’t get me wrong, and it’s good because I know that if I still need to call her [Footprints support worker] up and

ask her for something, I can. But I honestly think for other clients in the future that may be going through a really,

really hard time, I think it would probably be better if they could have longer with Footprints - I just think, especially

ones with mental illnesses and stuff (Bianca).

No. I didn’t think four months was a long time to get support either. Four months (Nina).

I kind of thought they would be there to guide me a bit more, rather than come in and just fix me up and then let me

go. It was kind of fix me up and then give me the ongoing support to eventually cope on my own and I just found it

was a case of fixing me up and then saying, ‘Well we won’t be coming around anymore’ (Lorelei).

These experiences indicate that while the MHDP has generated a great deal of goodwill among most tenants and

provided important forms of support to deal with immediate and pressing tenancy issues, this goodwill has the

potential to be undermined, and the benefits short-lived, unless some ongoing post-exit support is sustained over the

long term. Among those whose lives are especially complex and challenging, the withdrawal of intensive support

provided by the MHDP has, in some cases, had an immediate impact, with tenants reporting no one to turn to when

new crises arise; a sense of personal failure for being ‘beyond help’; and new tenancy challenges that place their

housing at risk. But it is also likely that even those who are presently faring well will face new challenges in the future

that will test the skills and coping mechanisms that they have developed. With current resources and services for

people with complex issues being under-resourced and over-subscribed, the most obvious provider of support for

tenants in the future is DHPW itself, but this will also require cultural change within the Department so that housing

and non-housing support systems are properly integrated. Tenants’ experiences of dealing with DHPW as a result of

the MHDP suggest that this culture change is already beginning to take effect as interactions and understanding

between housing providers and their clients improves. What is not clear as yet is how far and deep this change

extends and whether it is sufficient to act as a platform for connecting tenants up to the services and support they

need over the long-term.



5.7 CONCLUSION

This chapter has presented the views and experiences of one of the most important stakeholder groups engaged in

the MHDP – the tenants themselves – so that their voices can be heard in this evaluation. The chapter has shown that,

among the 21 tenant interviewees, the experience of being engaged in the MHDP; of working with their stakeholder

team; and of receiving tailored and intense support from a whole range of service providers and support worker has

generally been a positive experience. Even the six tenants who could not recollect signing up to any such project

understood that they have been in receipt of extensive support, which they appreciated and benefitted from. In

particular, tenants spoke in positive terms about the support staff involved – especially the clinicians from Queensland

Health and the support workers from Footprints – and they affirmed that their team had listened to them and allowed

their views to be considered in the process.

In terms of the outcomes of the project, tenants reported that their housing situations have improved, either as a result

of simply having a tenancy which had previously felt precarious, or of being in an improved housing situation as the

result of a transfer or clean-up. Partly because of the reduced anxiety surrounding their tenancies and partly because

of the clinical and non-clinical health support they received through the project, tenants also reported improved mental

health outcomes as manifest in feeling happier, more confident, being less dependent on medication, having goals in

life that they are working towards, and feeling more competent in managing their tenancies and relationship with

DHPW. In return, they also noted a change in the attitude of DHPW staff towards them in the form of a greater

willingness to see the larger picture of their complex lives and to help them stay in their homes rather than to have

them evicted. For tenants with positive experiences of the project, the experience of exiting was a combined one of

being ready, or at least well-prepared for the cessation of the project and – in some cases – a sense of something

disappearing from their lives as ‘friends’ who had become such frequent and welcome visitors stopped coming. For

some it was a relief for life to revert to a state of peace from the overwhelming barrage of visitors, but for others the

sense of loss was palpable.

Yet these highly positive accounts of the MHDP were counteracted with more critical and negative reflections from

tenants who do not feel they have benefitted from the project, largely because they feel their voices have not been

heard and their requests have gone unmet. Primarily, these are tenants who are unhappy with their housing

arrangements, either because they are living among neighbours with whom they frequently come into conflict, or

because they are in homes that they believe are unsuited to their needs. Failing to recognise the way they contribute

to their own difficult housing situations, these tenants believe that a transfer will fix their housing problems; express

resentment that this has not occurred and see it as a sign of project failure. Their continuing unhappiness manifests in

an exacerbation of existing mental health conditions and increased anxiety around ongoing tenancy problems but, with

the MHDP now finished, also a sense of powerless and abandonment that there is no one to help. This sense of

helplessness was particularly profound among two tenants whose tenancy problems had continued to the point where

they had received eviction notices. Despite project stakeholders doing everything they could to avoid eviction, it could

not be averted when tenants reached beyond crisis point.

This sense of abandonment also extends to those who felt unprepared for the end of the project even though, in many

cases, it had been extended beyond the initial four month period. For this group, their experience was one of people

‘disappearing’ and of support being withdrawn, unexpectedly and without warning. While this left some tenants slightly

bemused or resentful, others felt that they have been left without adequate support provision – at least not to the level

they had become used to – and the sense of abandonment is more profound. Tenancy problems are already

beginning to resurface for at least two of the tenants while another lives in a state of precarity in a caravan park.

These diverging experiences speak to the thorny question of whether the positive outcomes of the MHDP extend

beyond the immediate achievements of a project that, for 4-12 months has provided tenants with an intensive,

personalised and integrated system of support to address emergent or acute personal and tenancy challenges. As a

one-off project, the benefits to tenants are immediate and obvious and for some, there is evidence of a new set of

capacities for managing a tenancy, including dealing with tenancy challenges as they arise. But the prospect of the

MHDP generating longer-term change is contingent on signs of capability enhancement among tenants themselves –

something that is difficult achieve among a social group characterised by challenging lives, poor physical and mental

health and relative powerless vis a vis the vast bureaucracy of DHPW – and DHPW itself. While there are signs of a



changed, and improved relationship, between tenants and their housing office which can be attributed to the MHDP, it

appears too soon to know whether broader capability enhancement within and across DHPW to encompass all

tenants, and not just those known to be in the project, has been achieved to the level required.



6 TENANT SURVEYS

The following chapter outlines the survey responses of tenants in the project to ascertain tenants’ perceptions of their

outcomes, perceptions of autonomy supportiveness of their support team, and sense of competency to maintain their

tenancy. The measures are shown in the Appendix. The measures were adapted from pre-existing scales - the Health

Care Climate Questionnaire (Williams & Deci, 2001) and the Perceived Competence Scale (Williams, Freedman, &

Deci, 1998). The questionnaires were adapted to have terminology that was appropriate to the participant group.

Footprints workers were consulted to determine the most appropriate terminology.

6.1 PARTICIPANT SELF-REPORTED PERCEPTIONS

6.1.1 Autonomy

The overwhelming majority of participants who completed the autonomy measure (n =13) reported perceiving their

tenancy support team as providing options, expressing confidence in person, being understanding and encouraging,

and listening. Specifically, 84% agreed or strongly agreed that they felt they had been provided with choices and

option in their action plan, 85% strongly agreed or agreed that they felt understood by their support workers, 92%

agreed or strongly agreed that their support workers encouraged questions, 100% felt they were listened to by their

support workers, and 92% agreed or strongly agreed that their support workers tried to understand how they saw

things before suggesting a new way to do things.

These results mirror the tenant interviews, suggesting that an overwhelming majority of participants perceived their

support team as providing an autonomous and collaborative climate of care.

Figure 4. Autonomy Perceptions

0 2 4 6 8 10 12 14

I feel that I have been provided with choices and options inmy action plan

I feel understood by my support workers

My support workers express confidence in my ability to makechange

My support workers encourages me to ask questions

My support workers listen to how I would like to do things

My support workers try to understand how I see things beforesuggesting a new way to do things

Number

Neutral Slightly Agree Agree Strongly Agree



6.1.2 Perceptions of Competency in Sustaining Tenancy

The mean level of competency in sustaining houses was relatively high at each time-point; that is, the majority of

participants reported high levels of perceived competence in maintaining their housing tenancy.

Figure 5. Mean level of perceived competency across time

Although there was, on average, a large proportion of participants agreeing and strongly agreeing with the competency

questions, there were fluctuations over time in an individual’s perceived competence.

Figure 6. Change in perceived competency over time

1

2

3

4

5

6

7

Start Close >3 months >6 months >9 months

Per

ceiv

ed C

om

pet

ency

(1

= v

ery

low

, 7 =

ver

y h

igh

)

0

10

20

30

40

50

60

70

Start to Close From Close to Check in

%

Increase Decrease Stay the Same



64% of participants had an increase in how competent they felt managing their tenancy from their entry time

point into the project to exiting the project, and 18% experienced a decrease in their perceptions of

competency.

After exiting the project, 44% of participants reported an increase in their perceived competence in sustaining

their tenancy, suggesting that for a large portion of people, their self-efficacy in ability to sustain tenancy

continued to grow, even after exiting the MHDP. However, 31% of participants reported a decrease in

perceptions of competence.

6.2 OUTCOME STAR DATA

In addition to measures created by the research team to assess participant perceptions, Footprints also conducted

assessments on tenants’ perceptions of their outcomes, using an Outcome Star Measure. The completed cases for

January 2016 to May 2017 are summarised below (n = 29).

Table 19. Recovery Outcome Star Measure means for initial and final review (n = 29).

Initial Final

t p

Recovery Outcome Star Strand Mean SD Mean SD

1. Managing mental health 5.21 2.18 6.14 2.03 2.182* 0.038

2. Physical health and self-care 5.59 2.16 5.86 2.13 0.516 0.61

3. Living skills 6.41 2.43 6.24 1.68 -0.452 0.655

4. Social networks 5.34 2.62 5.45 1.88 0.264 0.794

5. Work 5.28 2.09 5.48 2.01 0.42 0.677

6. Relationships 4.97 2.78 5.93 2.40 2.589* 0.015

7. Addictive behaviour 6.03 2.51 6.07 2.96 0.076 0.94

8. Responsibilities 6.34 2.27 7.07 1.79 1.392 0.175

9. Identity & self-esteem 5.24 2.60 6.17 1.93 1.672 0.106

10. Trust and hope 5.28 2.22 6.34 2.22 2.246* 0.033

Average 5.57 1.42 6.08 1.56 2.004^ 0.055

NB: t and p values are based on a two-tailed repeated measures t-test with 28 degrees of freedom * Is a statistically significant difference (a difference that would occur less than 5% of the time by chance) ^ a marginally statistically significant difference (a difference that would occur less than 7% of the time by chance)

Overall, the majority of tenants in the MHDP perceived they had improved outcomes, as measured by Footprints

administration of the Outcome Star Measure. The largest area of improvement was managing mental health, followed

by relationships, and trust and hope. Averaging across all the different areas, almost 70% of tenants had an increase

in outcomes over time, while 10% reported an overall decrease in their outcomes. There was no relationship between

outcome star data and housing variables. There was also no relationship between autonomy or competency

perceptions and Star Outcomes.



Figure 7. Change in outcomes (from initial review to final review) on Outcome Star measure.

6.3 OUTCOME SUMMARY OF FINDINGS The mean level of competency in sustaining houses was relatively high at each time-point; that is, the majority

of participants reported high levels of perceived competence in maintaining their housing tenancy. Thirty-one

percent of participants had a decline in perceptions of competency from exiting the project to a check-in point.

An overwhelming majority of participants perceived their support team as providing an autonomous and

collaborative climate of care. The largest area of reported improvement on the Recovery Outcome Star was in managing mental health,

followed by relationships, and trust and hope.

0%

10%

20%

30%

40%

50%

60%

70%

80%

Improved Declined No Change

Per

cen

tage

Change from Initial to Final review



7 E-MODULES

7.1 INTRODUCTION

One of the aims of the MHDP was capability building of frontline staff (DHPW staff, Queensland Health staff, as well as

service delivery staff across the broader local network) to engage and support people with mental illness, mental

health and wellbeing issues, or related complex needs. The Queensland Mental Health Commission provided funding

to the DHPW to support this aim, and a tailored online learning management system was developed by the

Queensland Centre for Mental Health Learning on behalf of the DHPW. Six e-learning modules were developed in

consultation with subject matter experts:

Module 1: Understanding the mental health system

Module 2: Suicide awareness

Module 3: Alcohol and other drugs

Housing module 1: Navigation Housing services

Housing module 2: Applicant processes

Housing module 3: Processes

Respondents were housing officers or senior housing officers, support workers, medical professionals, allied health

professionals, managers, and administrative staff. All respondents were from Queensland, with the majority from

South-East Queensland region. Other regions included North-West Queensland (Mount Isa and Cloncurry), Central

Queensland (Gladstone, Emerald, and Rockhampton) and North Queensland (Cairns). The following section evaluates

the pre to post e-learning module changes for people who completed the mental health modules between February

2016 and June 2017, and housing modules between July 2016 to June 2017.



7.2 MENTAL HEALTH MODULES

Table 20. Characteristics of respondents across the Mental Health Modules

Understanding Mental Health Suicide Alcohol and Other Drugs

Pre (N = 317) Post (N = 214) Pre (N = 223) Post (N = 192) Pre (N = 200) Post (N =

157)

GENDER n % n % n % n % n % n %

Male 59 19 34 16 39 17 33 17 17 26 17 17

Female 258 81 180 84 184 83 159 83 83 131 83 83

AGE

Under 25 years 30 9 25 12 27 12 25 13 12 17 11 12

26 - 35 years 80 25 54 25 55 25 51 27 26 44 28 26

36 - 45 years 85 27 56 26 62 28 49 26 26 42 27 26

46 - 55 years 73 23 45 21 48 22 38 20 23 35 22 23

56 - 65 years 42 13 30 14 26 12 25 13 12 16 10 12

Over 65 years 7 2 4 2 5 2 4 2 2 3 2 2

EDUCATION

Other 23 7 14 7 14 6 10 5 5 8 5 5

Completed Year 10 (Junior)

22 7 17 8 18 8 16 8 9 11 7 9

Completed Year 12 (Senior)

50 16 38 18 44 20 36 19 19 33 21 19

Vocational Education Training

88 28 61 29 59 26 55 29 28 43 27 28

Undergraduate University Degree

62 20 42 20 44 20 38 20 20 34 22 20

Postgraduate University 72 23 42 20 44 20 37 19 19 28 18 19

EMPLOYER

Other 27 9 8 4 11 4 11 6 6 4 6 4

DHPW 164 52 120 56 124 56 109 57 93 59 93 59

Queensland Health 6 2 3 1 4 2 3 2 2 1 2 1

DCCSDS 13 4 8 4 7 3 7 4 7 4 7 4

Health Practitioner 3 1 2 1 3 1 2 1 1 1 1 1

Community Housing Provider

12 4 9 4 11 5 9 5 5 3 5 3

Non-Government Service Provider

87 27 60 28 61 27 50 26 43 27 43 27

Other State Government Department

3 1 2 1 2 1 1 1 0 0 0 0

Other Commonwealth Department

2 1 2 1 0 0 0 0 0 0 0 0

EMPLOYMENT

Permanent full-time 153 48 100 47 103 46 88 46 74 47 74 47

Permanent part-time 60 19 42 20 40 18 33 17 29 18 29 18

Temporary full-time 66 21 46 22 50 22 46 24 40 25 40 25

Temporary part-time 9 3 5 2 7 3 6 3 4 3 4 3

Casual 17 5 11 5 13 6 11 6 5 3 5 3

Student Placement 12 4 10 5 10 4 8 4 5 3 5 3

DHPW= Department of Housing and Public Works; DCCSDS= Department of Communities, Child Safety and Disability Services



7.2.1 Module 1: Understanding the Mental Health System

The majority of respondents reported that they understood the issues faced by people living with mental illness, mental

health difficulties or other complex needs before completing the modules. However, this level of understanding

increased post-module. On average, respondents reported a greater level of understanding for issues faced by people

living with mental illness, mental health difficulties, or other complex needs after completing the modules (see Figure

8).

Figure 8. Level of understanding the mental health system pre and post module 1 completion

Factors affecting level of confidence in understanding

Module completers were asked to note which factors, if any, impact their level of confidence in understanding these

issues. Pre-module, the majority of participants were rating not having necessary knowledge as the main factor that

impacts confidence (90%), which decreased dramatically after completing the module (to 19%).

1 2 3 4 5

I understand issues faced by people living withmental illness, mental health difficulties or other

complex needs

I can identify and use acceptable language fortalking about a tenant that may be experiencing

mental illness, mental health difficulties, or other…

I can use a range of communication techniques thatsupport rapport building with tenants

I understand how to identify potential resources fortenants who may require additional support to

maintain their tenancy

Post Pre



Figure 9. Factors affecting understanding the mental health system pre and post module completion

7.2.2 Module 2: Suicide Awareness

Large increases were seen when comparing understanding of suicide pre to post-module completion. Before

completing the module, 81% of respondents agreed or strongly agreed that they could talk about suicide using non-

judgemental and non-stigmatising language. This increased to 91% post module. Pre module, the majority of

respondents agreed or strongly agreed they could recognise the early signs for suicide (64%) and respond

appropriately if they identified warning signs of suicide (72%). This increased to 98% and 96%, respectively, post-

module completion. The majority of respondents also agreed or strongly agreed that they knew when to ask direct

questions about suicide attempt and plans (61%) before completing the module, and this increased to 96% of

respondents after completing the module

Figure 10. Level of suicide awareness pre and post module 2 completion

0 20 40 60 80 100

I do not have necessary knowledge

I do not have necessary skills

I do not have necessary time

I do not have necessary resources (otherthan time)

The culture of my workplace does notsupport it

Other

Pre Post

1 2 3 4 5

I can talk about suicide using non-judgemental andnon-stigmatising language

I recognise the warning signs for suicide

I could respond appropriately if I identified thatearly warning signs of suicide were present

I know when to ask direct questions about suicidalintent and plans

Pre-module Mean Post-Module Mean




issues. Pre-module, the majority of participants were rating not having necessary knowledge as a factor that impacts

confidence, followed by not having the necessary skills. However, post-module, this dropped dramatically, and a large

portion of respondents were not indicating any factors have an impact on confidence in understanding.

Not having the necessary knowledge and skills and not having the necessary resources and time were also the most

commonly reported reasons for not having confidence and commitment in applying the learning from the module.

Figure 11. Factors impacting confidence in suicide awareness pre and post module 2 completion

Figure 12. Factors impacting confidence and commitment in applying knowledge learnt in module 2

0 20 40 60 80 100






Post Pre

0 2 4 6 8 10 12 14 16

I do not have necessary knowledge and skills




I do not have the support from myworkplace colleagues

Other

Confidence in Applying Course knowledge

Commitment in Applying Course knowledge



7.2.3 Module 3: Alcohol and Other Drugs

Before completing the alcohol and drugs e-learning module, the majority of respondents agreed or strongly agreed that

they were able to describe the effect of alcohol and other drug use on thinking, feeling and behaviour (80%); identify

behavioural indicators that indicate a person may require support from local agencies (81%); apply appropriate

communication techniques and strategies to use with challenging behaviours (77%); recognise actions that are

appropriate to use when dealing with intoxicated people (78%); and understand what positive actions they could take

when supporting a tenant when substance use is adversely affecting their tenancy (78%). On average, respondents

reported a greater level of understanding after completing the module. Post-module, level of agreement for each area

increased, with 97 - 99% of respondents either agreeing or strongly agreeing with each of the above statements.


issues. Pre-module, the majority of participants were rating not having necessary knowledge as a factor that impacts

confidence, followed by not having the necessary skills. However, post-module, the majority of module completers

reported that their confidence was not affected.

Not having the necessary knowledge and skills and not having the necessary resources and time were also the most

commonly reported reasons for not having confidence and commitment in applying the learning from the module.

1 2 3 4 5

I am able to describe the nature of alcohol and other druguse and its effect on thinking, feeling, and behaviour.

I can identify a range of behavioural indicators that indicatea person may require support from local agencies.

I can apply appropriate communication techniques andstrategies to use with challenging behaviours.

I recognise actions that are appropriate to use whendealing with a person who is intoxicated.

I understand what positive actions I could take whensupporting a tenant when substance use is adversely…

Pre Post

Figure 13. Changes in level of understanding factors associated with alcohol and other drugs



Figure 14. Factors affecting level of confidence in understanding

Figure 15. Factors impacting confidence and commitment in applying knowledge learnt in module 3

0 10 20 30 40 50 60 70




I do not have necessary resources (other than time)

The culture of my workplace does not support it

Not affected

Post-Module Pre-Module

0 1 2 3 4 5 6 7 8 9





I do not have the support from my workplacecolleagues

Other

Commitment Confidence



7.3 HOUSING MODULES: INTRODUCTION TO THE HOUSING AND HOMELESSNESS SYSTEM

In addition to the Mental Health E-learning Modules, three Housing E-learning Modules were also developed as part of

the capability building aspect of the MHDP. The aim of modules was to provide an introduction to the housing and

homelessness system to enhance the capability of the housing, health and community who are working with social

housing tenants and create a shared understanding of the DHPW approach and processes. A snapshot of who

completed the modules is presented in Table 21. Interestingly, the largest portion of respondents who completed the

housing modules were from non-government service providers (43-45%), followed by employees of Department of

Housing and Public Works. In Housing Module 1, 61% of respondents who began the module completed it (which

ranged from 43% of respondents from DHPW, 45% of respondents from Queensland Health, 75, 69% of non-

government organisations, and 75% of respondents from Department of Communities, Child Safety, and Disabilities).

Similarly, 60% of respondents who began Module 2 completed it, and 74% of respondents who began Module 3

completed it. There were no statistically significant differences between people who started the modules and did not

complete, and people who started and completed the modules.



Table 21. Characteristics of respondents across the three modules

Housing Module 1 Navigating Housing Services

Housing Module 2 Applicant Processes

Housing Module 3 Tenant Processes

Pre (N = 121)

Post (N = 74)

Pre (N = 73)

Post (N = 44)

Pre (N = 50)

Post (N = 37)

Gender

Male 19 16% 16 22% 16 22% 11 25% 13 26% 11 30% Female 102 84% 58 78% 57 78% 33 75% 37 74% 26 70%

Age Under 25 years 10 8% 6 8% 8 11% 5 11% 5 10% 5 14% 26 - 35 years 38 31% 29 39% 26 36% 14 32% 20 40% 14 38% 36 - 45 years 31 26% 12 16% 15 21% 8 18% 8 16% 6 16% 46 - 55 years 24 20% 14 19% 12 16% 8 18% 7 14% 5 14% 56 - 65 years 14 12% 11 15% 8 11% 5 11% 8 16% 5 14% Over 65 years 4 3% 2 3% 4 5% 4 9% 2 4% 2 5%

Educational Qualification

Other 4 3% 3 4% 4 5% 1 2% 3 6% 1 3% Completed Year 10 (Junior) 1 1% 1 1% 2 3% 2 5% 1 2% 1 3% Completed Year 12 (Senior) 10 8% 6 8% 5 7% 4 9% 4 8% 3 8%

Vocational Education Training e.g. TAFE

25 21% 18 24% 19 26% 11 25% 12 24% 9 24%

Undergraduate University Degree

38 31% 22 30% 25 34% 13 30% 16 32% 14 38%

Postgraduate University Diploma/Degree

43 36% 24 32% 18 25% 13 30% 14 28% 9 24%

Employer

Other 18 15% 13 18% 14 19% 8 18% 5 10% 3 8% Other - Centacare 2 2% 0 0% 2 3% 2 5% 1 2% 0 0% Other - Salvation Army 5 4% 0 0% 5 7% 4 9% 3 6% 2 5%

Department of Housing and Public Works

23 19% 10 14% 12 16% 10 23% 9 18% 9 24%

Queensland Health 11 9% 5 7% 5 7% 4 9% 4 8% 4 11% Office of the Public Guardian 1 1% 0 0% 0 0% 0 0% 0 0% 0 0% DCCSD 8 6% 6 8% 4 5% 1 2% 1 2% 1 3% Health Practitioner 3 2% 2 3% 2 3% 1 2% 2 4% 1 3% Community Housing Provider 6 5% 5 7% 8 11% 1 2% 6 12% 1 3%

Non-Government Service Provider

48 40% 33 45% 26 36% 17 39% 21 42% 16 43%

Other State Government Department

3 2% 0 0% 2 3% 2 5% 2 4% 2 5%

Employment Status

Permanent full-time 49 40% 24 32% 22 30% 14 32% 15 30% 10 27% Permanent part-time 36 30% 26 35% 29 40% 18 41% 18 36% 13 35% Temporary full-time 9 7% 7 9% 5 7% 4 9% 4 8% 4 11% Temporary part-time 7 6% 4 5% 3 4% 0 0% 3 6% 2 5% Casual 11 9% 5 7% 7 10% 3 7% 4 8% 3 8% Student Placement 9 7% 8 11% 7 10% 5 11% 6 12% 5 14%



7.3.1 Housing Module 1: Navigating Housing Services

The first housing module was designed to provide an introduction to the Department Housing and Public Works

(DHPW), including the various products and services relating to housing and homelessness, the collaborative and

integrative approach to housing, health, and welfare service delivery model and how DHPW fits into that system. The

level of agreement to each of the responses targeting understanding of navigating housing services are shown in the

Figure below, with 1 corresponding to Strongly Disagree, 2 to Disagree, 3 Neither Agree nor Disagree, 4 Agree, and 5

Strongly Agree. Before completing the module, the majority of respondents were indicating neither agree nor disagree

to questions regarding understanding the services and practices of the DHPW, which increased to the majority

agreeing with the statements after completing the module. The majority of respondents agreed that they recognised

the need for a collaborative and integrated housing, health, and welfare system prior to completing the module.

Figure 16. Changes in level of understanding for factors related to navigating DHPW

Respondents were also asked their level of confidence in understanding the housing and homelessness system.

Responses pre and post module completion are shown in Figure 16. Respondents reported higher levels of

confidence after completing the module, with the number of respondents reporting above neutral levels of confidence

increasing from 60% pre-module to 82% post-module.

1 2 3 4 5

I can recognise the vision and direction of the Department ofHousing & Public Works (DHPW) and understand how this

applies to frontline service delivery

I am able to assess the impacts of housing instability on anindividual, whole of government and the human services sector

I understand where DHPW fits in the Human Services sector andthe role in which it is responsible for

I recognise the need for a collaborative and integrated housing,health and welfare service delivery model

I am able to differentiate the various products and servicesrelating to housing and homelessness, offered by DHPW

Pre Post



Figure 17. Level of confidence in navigating the DHPW pre and post module 1 completion

When asked what affected their level of confidence in understanding the housing and homelessness system, before

completing the module reported the majority of respondents (39%) said they did not have the necessary knowledge.

After completing the module, the majority of respondents (45%) reported their confidence was not affected.

Figure 18. Factors affecting confidence in navigating the DHPW pre and post module 1 completion

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Not at allConfident

2 3 Neutral 5 6 ExtremelyConfident

Per

cen

tage

Level of Confidence

Pre

Post

0% 10% 20% 30% 40% 50%

Other






Confidence not affected

Percentage

Post Pre



Figure 19. Commitment and confidence in applying course knowledge for Module 1

Figure 20. Factors affecting commitment and confidence in applying course knowledge for Module 1

7.3.2 Housing Module 2: Applicant Processes

The second housing module was designed to provide an overview of the application process involved in the DHPW.

The average level of understanding before completing the module was below the mid-point of the scale, suggesting

that, on average, respondents did not have a good understanding of applicant processes. After completing the module,

this increased across all areas examined. However, the average level was just above the mid-point, suggesting that

there was not a thorough understanding of the processes, even after completing the module.

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Not at allConfident




0% 20% 40% 60% 80%

Other



I do not have the support from my workplace colleagues



Not affected

Percentages





Figure 21. Mean level of understanding of applicant processes pre and post module completion.

Respondents were also asked their level of confidence in understanding applicant processes. Responses pre and post

module completion are shown in the figure below. Respondents reported higher levels of confidence after completing

the module, with the number of respondents.

1.00 2.00 3.00 4.00 5.00 6.00 7.00

I can describe the client intake and assessment process for publichousing including identifying the eligibility criteria and

understanding the intent of the Housing Needs Assessment (HNA)…

I am able to recognise relevant priority segments as determined bythe HNA and the necessary evidence required

I am able to identify all relevant Inter-Agency Priority (IAP) groupsand understand the eligibility criterion which enables an applicant

to be assessed under an

I can describe how household roles are determined including howthis could impact bedroom entitlements and housing types

I am able to assess locational preference and understand how thisimpacts the Housing Register

I am able to understand the Housing Register and how allocations of housing are determined, including the order of allocation and

how the “matching for success" methods works

I can determine how rent is calculated for clients and how thesubsidy is applied to new tenancies

I am able to understand the sign up process for new tenantsincluding the intent and purpose of the State Tenancy Agreement

I am able to identify the relevant forms and procedures to accessand update information on behalf of a client

Overall confidence in understanding the application process

Post Mean Pre Mean



Figure 22. Level of confidence in understanding applicant processes

Not having the necessary knowledge was the largest factor affecting level of confidence pre-module, and this was

dramatically reduced after completing the module.

Figure 23. Factors impacting confidence in understanding pre and post module completion

As with Module 1, not having the necessary time, knowledge, and skills were the most prevalent factors that affected

respondents’ confidence and commitment in applying the information learnt in the module.

0

5

10

15

20

25

30

35

40

45

50

Not at allconfident


Per

cen

tage

Pre Post

0 20 40 60 80 100






Confidence not affected

Percentage

Post

Pre



Figure 24. Factors affecting confidence and commitment in applying course knowledge, post module 2 completion

7.3.3 Housing Module 3: Tenant Processes

As in module 2, the average level of understanding before completing the module was below the mid-point of the

scale, suggesting that, on average, respondents did not have a good understanding of tenant processes. After

completing the module, this increased across all areas examined. However, the average level was just above the mid-

point, suggesting that there was not a thorough understanding of the processes, even after completing the module.

Figure 25. Mean level of confidence in understanding processes and procedures pre and post module 3 completion.

0 10 20 30 40





I do not have the support from my workplacecolleagues

I did not fully understand the content of the course

Not affected

Confidence in Applying Course knowledge Commitment in Applying Course knowledge

1.00 2.00 3.00 4.00 5.00 6.00 7.00

I am understand the policies and procedures related to socialhousing tenancy management including Complaints

Management, Fair Expectations of Behaviour, Inter-AgencyPriorities and the Fairness Charter

I am able to identify the roles and responsibility of tenants andnetwork partners in sustaining tenancies, ongoing eligibility,

under-occupancy and abandoned properties

I am able to determine the processes to apply formaintenance, home modifications, temporary absences and

transfers

Confidence in understanding

Pre Mean

Post Mean



Respondents reported higher levels of confidence after completing the module, with the number of respondents

displaying above neutral level of confidence shifting from 38% to 91%.

Figure 26. Level of confidence in understanding tenant procedures and processes

The majority of respondents reported they were both confident and committed to applying the course knowledge.

Figure 27. Confidence and commitment in applying Module 3 knowledge

The main factors that respondents indicated impacted their commitment and confidence in applying the learnings of

the module were not having the necessary resources or time. The majority of respondent, however, reported that their

commitment and confidence was not affected.

0

5

10

15

20

25

30

35

40

Not at allconfident


Per

cen

tage

Response

Pre %

Post %

0

5

10

15

20

25

Very low 2 3 Neutral 5 6 Veryhigh

Nu

mb

er o

f re

spo

nd

ents

Response

Confidence in Applying Courseknowledge

Commitment in Applying Courseknowledge



Figure 28. Factors affecting commitment and confidence in applying Module 3 knowledge

7.4 SUMMARY

The e-learning modules was implemented and completed across Queensland, by a range of different government and

non-government agencies, and across a number of different professions. The e-module learning data shows that

respondents reported either modest or significant improvements in their understanding of and capacity to respond to a

number of key issues. The data does not indicate to what extent, if at all, respondents changed their practices.

However, the reported improved knowledge and confidence does represent a positive indicator that can lead to

systems change.

0 20 40 60 80 100





I do not have the support from my workplace…

I did not fully understand the content of the course

Not affected

Percentage

Commitment in Applying Course knowledge Confidence in Applying Course knowledge



8 OVERALL CONCLUSION

The preceding chapters provide a detailed analysis of the outcomes and workings of the MHDP to outline the range of

tenant and service system outcomes the MHDP has achieved. The following section integrates these findings to

provide an overview and reflection of the key areas of the MHDP, followed by key lessons and recommendations for

future directions.

8.1 REFLECTION OF KEY AREAS OF MHDP

8.1.1 Capability Enhancement

The DHPW identified that strengthening the capability of HSC staff to engage and support people with mental illness,

mental health and wellbeing issues, or related complex needs, was a key element of the MHDP. While there are signs

of a changed, and improved relationship, between tenants and their housing officers which can be attributed to the

MHDP, it appears too soon to know whether broader capability enhancement within and across DHPW to encompass

all tenants, and not just those known to be in the project, has been achieved to the level required.

It is clear from the data and analysis identified in both the process and outcomes evaluation that the key people within

the DHPW involved in the day-to-day operation of the project have a clear understanding of the intended capability

enhancement, and describe changes in practice and responses to tenants of the project. Relatedly, our examination

of tenant perspectives indicate that a large portion of tenants interviewed perceived there was a change in the

practices of housing support staff while they were in the project, which they defined as being more respectful, more

understanding and more willing to see the bigger picture. Even those who were critical of the project and felt it had

done little to improve their housing situation described a change in their interactions with the Department and a sense

that housing officers are more sympathetic to the broader challenges they encounter in their lives that often have a

detrimental impact on their tenancies.

Tenants also reflected that their perspective of the DHPW had changed as a consequence of the MHDP, which had

the flow on effect of strengthening their perceived ability to engage with HSC staff. Where previously the department

was seen as a vast bureaucratic department that they were ill-equipped to deal with, engagement with the project

provided an opportunity for tenants to develop a different, often positive, relationship with the DHPW.

The qualitative data suggests there was a change between tenants and HSC staff, at least within tenants who were

active participants in the MHDP. We are not able to determine, however, if this different response and engagement to

mental health and wellbeing issues, or related complex needs are because tenants are active MHDP participants, or

whether this reflects a broader and systemic change in the capability and practice.

It is also important to note the practical considerations faced by HSC staff when discussing capability enhancement.

The workload of HSC is often immense with a large portfolio of tenancies, and HSC staff are often not qualified as

social workers or mental health workers. An additional difficulty that was noted by a DHPW stakeholder was that the

transient nature of staff working on the ground impeded achieving the systemic changes the MHDP aims for:

“I think maybe even training HSC staff will take a long time. Another thing which happens in the HSC is that

there’s quite a lot of instability, staff changes.” (DHPW Staff).



We have no quantitative data to understand how this assertion about staff turnover is representative across the DHPW.

Capability enhancement and E-modules

One mechanism through which the MHDP attempted to enhance the capability of HSC staff outside of tenants who

were active participants of the project was through development of an online Learning Management System with e-

modules designed to increase understanding and confidence in dealing with mental health related issues, in the areas

of understanding the mental health system, suicide awareness, and alcohol and drug use. Before completing the

modules, a vast majority of respondents indicated that not having the necessary knowledge was a factor that affected

their confidence in understanding and acting upon the mental health issues described above. The e-modules

appeared to have their designed effect - completers of the modules perceptions of their competency and confidence

was improved in the areas targeted by the modules. That is, participating in the mental health, suicide and alcohol and

other drugs training was associated with reported improvements in participant’s awareness and understanding of

mental health, suicide, and alcohol and other drugs. However, not having the necessary resources, time, and skills

remained factors that impacted commitment and confidence in applying this knowledge.

Similarly effects were found for the housing modules. The aim of the housing modules was to provide an introduction

to the housing and homelessness system to enhance the capability of the housing, health and community who are

working with social housing tenants and create a shared understanding of the DHPW approach and processes.

Responses were primarily from community organisations, and the modules seemed to address areas that respondents

were lacking in knowledge and understanding; responses before completing the housing modules show that

respondents did not have a clear understanding of the housing system before completing the modules. Completing the

housing modules was associated with reported improvements in understanding the DHPW housing system, approach,

and processes. It is worth noting that while confidence and understanding increased after completing the module,

people’s understanding of housing was still middle of the range. Additionally, respondents reported greater degrees of

confidence in their understanding of the housing system and applying this knowledge, than their actual reported level

of understanding of the housing system. As with the mental health modules, the biggest factor that impacted

respondents’ confidence and commitment in applying what they learned was having the necessary resources and

time. This suggests that there are practical considerations that remain an issue in building capabilities for working with

social housing tenants with mental health issues or complex needs. Further developments in this area are necessary.

8.1.2 Service Integration and Support

The MHDP is widely perceived as appropriate and desirable to address a significant service and system gap for social

housing tenants with mental illness and complex issues, by key stakeholders and a number of tenants themselves.

Even for tenants who entered the project with pre-existing support services, the MHDP provided a way to deliver

services in an integrated fashion. That is, the MHDP represented an inter-department and interdisciplinary approach

that is necessary to holistically support the needs of tenants with mental health or other complex problems, rather than

the siloed approach to care a tenant may have been involved with before. The three lead agencies, Footprints,

Queensland Health, and the DHPW, not only draw on each other’s resources and expertise, but the MHDP is a

mechanism for these agencies to draw on additional external resources. Additionally, a shared information platform

was introduced around mid-2016. This was in the form of an online portal that contained tenant information, referrals,

Housing support plans, brokerage details, and meeting notes. This allowed for more effective service integration and

practice.



The portal’s really good. It’s really good that three agencies can get onto the same site, into data, check

records, et cetera. It’s really good. The portal has huge capability. (DHPW stakeholder)

Thus, the unique contribution of the MHDP was the capability and resources to deliver integrated services and as a

result of the project, tenants identified with complex needs within social housing are receiving a more holistic approach

to the management of their tenancy and linked to appropriate and targeted supports.

However, there was still a sense from tenants that the MHDP meant there were an overwhelming number of people

involved in their case. Losing track of the different agencies and individuals involved in their case also means that

some tenants felt they were unable to build rapport with their support team, not only because they struggled to

acquaint themselves with everyone involved, but also because some of the visitors came so infrequently – and in

some cases for only a short time of 15 to 30 minutes – that there was no opportunity for them to develop an ongoing

relationship. This reiterates the point that more is not necessarily better, but rather it is about having the ability of the

services to work together to support the person’s, often complex and multi-faceted, needs in a holistic and integrated

way. A barrier to providing integrated support identified by stakeholders was difficulties in coordinating support with

funded services and government agencies outside the three core agencies of the MHDP that a tenant may have been

involved with, such as child safety, disability services, and public guardians.

Related to the comments above, data accessed from the CIMHA database of mental health access suggest the

majority of support provided was service co-ordination. Based on both stakeholder and tenant perspectives, the

support provided by the mental health clinicians appears to extend beyond a purely clinical remit of addressing acute

mental health issues and interventions to incorporate broader forms of case support, including connecting tenants to

more mainstream forms of primary care, as well as dealing with issues where mental health challenges impact upon

tenancies. As described below, one of the functions of the acute care team is to refer patients into supports and

services in the mainstream systems, including general practitioners. In addition to providing actual direct clinical

supports, the clinical support providers dedicate considerable responses to referrals on to other systems.

A key concern with the role of the mental health clinicians – that was also raised in the process evaluation – is that the

clinical support was delivered within an acute care team in mental health services (see Section 2.3.1). Although this

provided access and resources to clinical support, the majority of tenants had problems and complexities that were not

the core client group of Queensland Health acute care team or community care teams. It was highlighted by

stakeholders that in a number of cases, the mental illness is not sufficiently severe to qualify for ongoing engagement,

or that the difficulties a person is experiencing is not typically addressed by those services (e.g. hoarding and squalor).

Thus, question remain moving forward of the way clinical support is delivered in projects The combined evidence

described in the Process and Final evaluation outline that the MHDP clinicians had the ability, relationship, and

resources to support mental and physical health for social housing tenants. It appeared important, and indeed

necessary, component of the MHDP that mental and physical health concerns were being addressed within the

context of a supportive and autonomous environment.

However, there is less clear evidence that providing this clinical support within an acute care team setting is

necessary, as described in detail in Section 2.3.1. A large portion of the mental health clinicians’ roles involved service

coordination and linking people to appropriate services, in a way that incorporated or integrated with housing. As

stakeholders pointed out, the project was designed to fill the gap and provide support for people who often did not

have severe enough mental health issues to qualify for ongoing acute care or to stay in the mental health care system.



There were some views expressed by stakeholders that enhanced housing capacities within Queensland Health, and

enhanced social support and mental health capacities inside DHPW (ideally in HSCs), would represent a successful

means to meet the needs of social housing tenants with both health and support requirements.

The perceptions of these stakeholders reflect the challenges faced by the DHPW that necessitated the development of

a project like the MHDP. As described in Section 1, the DHPW does not have the internal capacities to identify or to

respond to the health and social needs of tenants. Specifically, Housing Officers are employed to manage tenancies,

and are often required to manage approximately 500 tenancies at a time. Although they work with tenants

experiencing health and social problems on a day-to-day basis, they often do not have the resources, time, or formal

qualifications to address complex social and health needs.

8.1.3 Duration of Support

Of the 73 participants who were considered “completed” as of the 31st of July 2017, approximately 70% received

support for over four months (n = 51), including 14% (n = 10) who had received support for over 10 continuous or

cumulative months. This suggests that the four month duration of need initially outlined in the Service Delivery Model

is an insufficient length of time for the majority of tenants accessing and engaging with the project.

Being a demonstration project, the project parameters were able to be flexibly adapted as necessary to meet the

needs. That is, rather than being prescriptive, the four months outlined in the service delivery model was a guideline

and an area of learning. The project parameters have evolved, and the support model, in practice, was adapted to the

needs of tenants involved in the project.

The question of what comes after the project remains. Tenants were linked in to other agencies, but a large portion

were not (40 tenants had None recorded as exit agencies, 5 had Not disclosed, and 10 had no information recorded).

We also have no evidence whether a referral into another agency was associated with the other agency engaging with

the tenant and providing them services. Tenants perceived this as a falling off of support. This was particularly

problematic when they were not expecting the changes. Although some participants of the project that were

interviewed believed the exit planning from the project was sufficient, a number did not have a clear understanding of

their exit from the project. Qualitative interviews suggest that while the MHDP has generated a great deal of goodwill

among most tenants and provided important forms of support to deal with immediate and pressing tenancy issues, this

goodwill has the potential to be undermined, and the benefits short-lived, unless some ongoing post-exit support is

sustained over the long term. This was also reflected in perspectives of stakeholders working closely with the project; a

stakeholder from DHPW reflected that “Many clients have chronic conditions and the time limited support may only

delay further issues”. Another DHPW also reflected that the form of intensive support for four months was not

sufficient:

“But from what I see, I think that this form of intensive support, I don’t think it really works. It’s a little bandaid.”

(DHPW Stakeholder)

Another DHPW stakeholder also reflected that the MHDP cannot address the needs of all tenants:

“Even with supports, some tenants cannot cope well in independent social housing. Hence we feel there is a

clear need for other more supported housing options like Common Ground” and “for the HSC’s I think there

has been a reduction in the number of clients who are significantly problematic. We have also moved on

several of these clients whether through a move to aged care, supported accommodation, eviction. There



have been a couple of tenancies that failed despite some engagement with the project. This makes it clear

that social housing in its current form is not suitable for all vulnerable people and that other housing options

are required (e.g. supported housing).”

8.1.4 Informed Consent and Engagement

The process evaluation outlined how obtaining tenants’ informed and voluntary consent was seen to be an important

but challenging aspect of the MHDP (Parsell et al., 2016b). Formal procedures dictate that participation in the MHDP

requires tenants to be fully informed of the project so that they can provide voluntary consent, or conversely,

voluntarily refuse to participate. Stakeholders widely endorsed the necessity of tenants being afforded the opportunity

to give informed consent to enable voluntarily participation in the MHDP. However, there was also a perspective

amongst some stakeholders that tenants who were most in need of the project had a lack of engagement or full

informed consent, for the same reasons that their tenancy was at risk.

The issues of insight and willingness to change was described as one stakeholder as being a key factor of whether a

participant engages with a project or not, particularly given the time-limited nature of the support offered:

“So what happens is that people who are thrown into this project don’t have insight. Most of them lack insight,

so they are not willing to change because they don’t have that insight, they don’t understand their behaviours

are poor or they’re hoarding, et cetera. So really, this project doesn’t seem to fix that. It helps people who are

inside and those who are willing to engage and willing to change. So there’s this large cohort of the population

of the tenants who don’t have insight. So I think the way to go is you have to have some kind of support for life

model.” (DHPW Stakeholder)

It was a perspective amongst several stakeholders that tenants who are referred without truly consenting or truly

feeling that they have a need for the MHDP routinely disengage and do not benefit from the MHDP. The broad themes

of informed consent and difficulties with informed consent and lack of engagement were a stronger and more prevalent

theme amongst the Fortitude Valley HSC, from both stakeholders within the Fortitude HSC and other DHPW and non

DHPW, at both the process and outcomes evaluation time-points. This is congruent with the findings in Section 3,

which demonstrated that participants from the Fortitude Valley HSC did have lower levels of engagement and

participation.

The qualitative interviews with tenants also explored the importance of informed consent and understanding. In most

cases, tenants signed up to the project willingly because they understood they needed help and were glad to receive

it, or were open to the idea of increased assistance. Some tenants did indicate that they signed to place themselves in

a more favourable position with DHPW and potentially mitigate any further tenancy problems, but only one tenant felt

that her tenancy was contingent on agreeing to being involved, and that there would be negative consequences if she

did not participate.

There were a significant portion of tenants who appeared to be unaware that they had even been part of a project.

Some of these tenants did articulate how support had increased while they were in the project, even if they were

unaware of why and others were aware that they were receiving support from Footprints or the mental health workers.

Interviews with tenants reflected the challenging nature of informed consent and voluntary participation in a project that

involves a vital necessity to living – housing, with participants with complex mental health and other issues, as

described in Section 5.2.



8.1.5 Hoarding and Squalor

Qualitatively, from both tenant and stakeholder interviews, hoarding and squalor was a significant issue affecting

people’s tenancies that was chronic and enduring in nature. The majority of hoarding and squalor referrals were in the

crisis risk stage of their tenancy and people who had hoarding and squalor often had multiple referral reasons. A large

portion of the brokerage funds was directed to skip bin hire and cleaning to address property condition concerns

caused by hoarding and squalor issues, but it was recognised by stakeholders as only being a first step and not a

solution to the problem. Several stakeholders, both DHPW and non-DHPW, commented that the project’s timeframe

was insufficient in length to effectively work with clients with poor insight into their hoarding/squalor issues.

The significant difficulties of addressing hoarding and squalor issues became apparent in the qualitative interviews

with tenants. For example, one family lived in a condition of squalor and were at crisis point when they signed up to the

project. The instability and challenges of life made the family a priority case for the MHDP, but those same challenges

also made them unreliable participants. The tenant would often cancel appointments, albeit for what she saw as

legitimate reasons, prompting warnings that the support services would cease if she cancelled again. For another

tenant, she could not accept that she has a hoarding problem; rather, she complained that her unit is too small, dark

and unhealthy. She described how she had been subjected to a team of support workers whose goal was to ‘force’ her

to part with her belongings and who were ‘not interested’ in allowing her to move.

It was highlighted by stakeholders within and external to the DHPW that the issue of hoarding and squalor may be

reflected in the time taken to work with tenants or the tenancy outcomes. However, the reported difficulties were not

reflected in the number of housing codes tenants received either before or after participating in the project, when

compared to other referral reasons, or the duration of support they received. The duration of support was equivalent

for participants referred in for hoarding and squalor and for other reasons, with the exception of “personal issues”.

Participants who were referred into the project for “personal issues” had the shortest duration in the project, receiving

support for an average of approximately five months. However, all other referral reasons were equivalent and received

an average of 6-7 months of support.

It was also highlighted by stakeholders that the project would benefit from having a specialised process to manage

tenants with hoarding and squalor issues. As one stakeholder mentioned:

The hoarding and squalor was a significant issue that we had to deal with. It was lucky that Footprints had

training with hoarding and squalor as it meant they had a lot of the necessary resources and knowledge. If the project

was to be rolled out, there needs to be clear ideas in place with how to manage hoarding and squalor, including a

specialised process, guidelines, and trained organisations. (non-DHPW Stakeholder)

8.1.6 Risk Stages of tenancy

The distinction between crisis and early intervention did not seem to have any practical or meaningful implications.

There was no indication that the tenancy risk status determines the nature or duration of support provided. However,

for a number of people in the crisis category, the referral was considered too little too late. The project initially ran as a

crisis reactive response, rather than a planned preventative approach. However, number of tenants that were

preventative increased as the project progressed.

Only ten participants in the prevention stream had data from the 6 months before entering the project, and had

relatively few housing codes, meaning it is not possible to measure meaningful change in their housing outcomes



using data available from the DHPW. However, the majority of tenants in the prevention category did not have tenancy

problems, as evidenced by complaints, warnings, or arrears, despite being flagged as at risk. More telling, is the

qualitative interviews demonstrating the impact the MHDP had for people who were referred in for prevention reasons.

These tenants reported that the project helped them feel more secure and confident in their housing, and improved

their mental health.

8.1.7 Ongoing Housing and Neighbourhood Issues

An interesting point to arise from discussion with stakeholders, qualitative interviews with tenants, and referral

information from DHPW data was the importance of housing location and neighbourhood issues as a contributing to

factor to a person’s mental health and how their mental health or other complex needs can impact those around them.

Among the tenants’ interviewed who had a negative experience, a predominant theme was a desire to transfer to a

new property or not liking where they are currently living. For example, one tenant reported that he ‘hates’ where he is

living and remains concerned about getting evicted because the neighbours are still causing him problems. A number

of tenants also reflected that their neighbours were the cause of their tenancy difficulties. For example, one tenant who

was already referred to QCAT when she entered the project, blamed her tenancy difficulties on a neighbour and was

angry that she was evicted and the neighbour had no blame.

This reflects on a broader point that as DHPW is the main supplier of social housing for individuals with complex or

support needs and low opportunity to access housing outside the social sector, the rates of mental health issues and

other complex needs amongst tenants is a wide-reaching problem. A DHPW stakeholder described one practical

barrier to the MHDP as “the high numbers of tenants with complex needs in certain (most?) complexes means that

one clients issues can be exacerbated by another tenant”.

8.2 CONCLUSIONS

The Outcomes Evaluation aimed to examine whether the MHDP has achieved a range of tenant and service system

outcomes. The section below provides a brief summary of the answers to these questions.

Have project participants sustained housing?

The majority of participants did sustain their tenancy and had improved housing outcomes. However, there

were a number of tenants whose referrals were made at a stage in their tenancy that they were not able to be

helped to retain their tenancies. We do not have data to identify whether these tenants engaged with support

at a later stage.

The majority of participants in the project received fewer codes in the 6 months after exiting the project,

compared to the 6 months prior to the project (79% received fewer total codes, 58% received fewer

complaints, 52% received fewer arrears or breaches, and 65% received fewer warnings).



project, there were no differences between the two services on number of housing codes.

Qualitatively, the majority of tenants interviewed reported that their housing situations have improved, either

as a result of simply having a tenancy which had previously felt precarious, or of being in an improved housing



situation as the result of a transfer or clean-up. The majority of tenants felt more competent and confident in

sustaining their tenancy. However, a minority of tenants felt their tenancies were at greater risk than

previously, or had been evicted.

Have project participants accessed and engaged with required clinical services?

There was an increase in mental health service usage while participants where involved with the MHDP. This

suggests that for the duration of the project, participants accessed and engaged with clinical services. We are

unable to determine, however, if the service use was necessary or required services, or if the way the clinical

support was designed to be provided necessitated the high service use. Surprisingly few participants

accessed the service in the 6 month period before they entered the MHDP, or in the 6 month period following

their exit from the MHDP.

Participants observed health and social functioning (as measured by the HoNOS) improved significantly from

the when they first started the MHDP, to when they exited the MHDP. It is unknown whether these

improvements were sustained over time.

The number of people accessing the emergency department decreased from pre to post participation in

MHDP. The number of acute care and inpatient mental health services used also decreased from pre to post

participation. This suggests there was a reduction in unplanned and acute care needs for the majority of

participants. There were a minority of participants who were accessing the services at a high frequency, even

after exiting the MHDP.

Have project participants accessed and engaged with non-clinical support services?

Qualitative interviews and survey data from tenants who participated in the project suggest that they did

access and engage with non-clinical support provided by Footprints. Non-clinic support that was accessed

included counselling; advocacy service and support in connecting up with other service providers; guidance

on general home care, such as meal preparation, budget management, cleaning, shopping and nutrition;

assistance with job-seeking; assistance in enrolling in social or recreational project and activities; and

assistance in setting up and travelling to appointments. Tenants spoke highly of the support they received

from Footprints, and the staff members involved.

Tenants also reported the significant degree of support they received from Footprints around tenancy issues,

including help to move to a new property (involving packing and unpacking their belongings, organising

removalists and assistance in procuring new furniture); as a mediator between themselves and DHPW by

advocating on their behalf or pursuing emergency property transfers when a transfer was thought necessary;

and being able to access and interact with support workers in her own home around tenancy issues than it

was to visit the impersonal and bureaucratic offices of DHPW to meet with a housing officer.

Has the MHDP identified tenants at risk of not being able to sustain their housing?

The MHDP identified a range of participants with a range of presenting issues, extending beyond mental

health issues. Data from the tenancy data recorded and stored by DHPW suggest that a large portion of

tenants referred into the MHDP did have significant tenancy issues suggesting their tenancy was at risk,

including complaints, breathes, warnings, and notices to leave.



Tenants were referred into the project for three reasons of tenancy risk, these are: early intervention,

prevention, and crisis. The reasons for referral are described by project stakeholders as important in

assessing and organising who accesses the project.

Qualitative interviews demonstrated that for a number of participants, across all three tenancy risk stages, the

project represented an opportunity to sustain housing when they were not sure they were able to.

Is the MHDP unable to engage and successfully work with some tenants in the target group?

Engagement was lower at the Fortitude Valley HSC compared to the Chermside HSC. Tenancy risk status,

referral reason, demographics (including age, gender, and Indigeneity) did not predict who engaged with the

project. Participants from Fortitude Valley HSC had similar outcomes to Chermside HSC, suggesting the

project was equally successful for the two HSC, when participants engaged. That is, the provision of support

provided by the MHDP (e.g. Footprints, mental health clinicians, case-coordination, etc.) was effective for both

HSCs once people were engaged with the support.

The project was least successful for participants in the Early Intervention Risk stage of their tenancy – people

who were categorised as early intervention had more tenancy incidences recorded in the 6 months after

exiting the program, compared to tenants who referred in at the Crisis and Prevention stage. Although the risk

stages are on a continuum, this suggests that Early Intervention is not a useful category to assess and

organise who and how a person accesses the project.

The reflections by stakeholders and tenants themselves, suggest that a willingness and insight into the issues

affecting a tenant’s tenancy is a key factor in engaging with and benefitting from the MHDP.

Is the MHDP a successful approach to achieving collaboration across government and community

organisations for the purposes of supporting tenants to sustain housing?

Collaboration between the three main organisations were achieved, this was helped along by meetings,

increased shared understanding of each-others work, and practical resources such as a shared information

platform. Evidence is not apparent if this extended beyond the three core organisations.

Difficulties existed when there was not trust or full information sharing between the three organisations. It was

considered to be important that the three core organisations were working alongside each-other and seen as

equal and respected.

Only two tenants from the community housing sector were referred into the MHDP. There are at least

three reasons to explain a lack of participation from the community sector: the community housing sector

have few eligible tenants; the community housing sector are resourced to provide more intense and

supportive tenancy management, thus reducing the need for the project; and tenants residing in

transitional housing are not eligible (outlined in detail in the Interim Report).

Has the MHDP demonstrably enhanced the capability of the housing, health and community organisations to

support tenants to sustain housing?



Tenants who were involved in the MHDP showed improvements in their tenancy management, mental health,

and less emergency department admissions, and acute mental health care needs. This suggests that the

housing, health and community organisations involved with the MHDP had the capability to support tenants

while they were in the project, and this had beneficial outcomes in the 6 months after exiting the project.

It appears too soon to know whether broader capability enhancement within and across housing, health and

community organisations to support all tenants, and not just those known to be in the project, has been

achieved to the level required.

Do the housing, health and community organisations have a shared understanding of the MHDP approach

and objectives?

There does appear to be a shared understanding of the MHDP approach and objectives amongst the key

stakeholders involved in the project. Stakeholders who responded to the open-ended questions reflected that

understanding of the MHDP and the roles of each organisation continued to develop and solidify over the

course of the project duration.

Is the MHDP successful in delivering a planned preventative approach, rather than a crisis reactive approach?

The distinction between crisis and early intervention did not seem to have any practical or meaningful

implications. There was no indication that the tenancy risk status determines the nature or duration of support

provided. However, for a number of people in the crisis category, the referral was considered too little too late.

The project initially ran as a crisis reactive response, rather than a planned preventative approach. However,

number of referrals that were preventative increased as the project progressed.

Only ten participants in the prevention stream had data from the 6 months before entering the project, and

had relatively few housing codes, meaning it is not possible to measure meaningful change in their housing

outcomes using data available from the DHPW. However, the majority of tenants in the prevention category

did not have tenancy problems, as evidenced by complaints, warnings, or arrears, despite being flagged as at

risk. More telling, is the qualitative interviews demonstrating the impact the MHDP had for people who were

referred in for prevention reasons. These tenants reported that the project helped them feel more secure and

confident in their housing, and improved their mental health.

Have people from government and non-government agencies successfully engaged with the Learning

Management System e-module training?

Respondents were housing officers or senior housing officers, support workers, medical professionals,

allied health professionals, managers, and administrative staff. All respondents were from Queensland,

with the majority from South-East Queensland region. Other regions included North-West Queensland

(Mount Isa and Cloncurry), Central Queensland (Gladstone, Emerald, and Rockhampton) and North

Queensland (Cairns).

Approximately 60 – 80% of respondents who began completing the Learning Management System e-

module finished the modules. There were no statistical differences in who started the Modules and who

completed the modules. There was a systematic decline in the number of people beginning the modules (that



is more people began and completed the first module compared to the second, more people began the

second module compared to the third module) for both the Mental Health modules, and the Housing modules.

For those who completed the modules, the majority reported improvements in understanding in the specific

areas targeted by the module.

To what extent is participating in the Learning Management System e-modules associated with reported

improvements in participant’s awareness and understanding of the information targeted in the modules?

The Learning Management System e-module component of the MHDP enhanced completers of the modules

perceptions of their competency and confidence in the areas targeted by the modules. That is, participating in

the mental health, suicide and alcohol and other drugs training was associated with reported improvements in

participant’s awareness and understanding of mental health, suicide, and alcohol and other drugs.

Similarly, participating in the Housing modules was associated with reported improvements in understanding

the DHPW. The biggest factor that impacted respondents’ confidence and commitment in applying what they

learned was having the necessary resources and time.

How could the MHDP be improved?

Ensure there is clearly defined role, responsibilities, service parameters, and expectations

Target engagement at the initial point of first contact, and obtaining informed and voluntary consent

Extend the duration of support to reflect the longer needs of more complex tenants or tenant with complex

and chronic mental health or other complex needs. Additionally, it appeared important to allow the time and

opportunity for tenants to develop an ongoing relationship with their support team and not have an intensive

and high number of support people over a short period of time.

The case coordination model should seek to avoid duplication and to use available resources effectively.

Having an understanding of the differences in case work approaches when partners come from different

professional disciplines and practice frameworks, so that the differences are not a barrier to effective case

coordination.

Embedding professionals with social work, psychological, or other mental health expertise and case

coordination expertise within Housing Service Centres may represent an efficient means of reducing tenancy

problems by improving the practice systems, capability, and capacity of the DHPW.

Embedding a person who is able to engage in service coordination with housing capacities within Queensland

Health, may also represent a successful means to meet the needs of social housing tenants with both health

and support requirements.

How does the MHDP sit within the existing service system (complementary, crowding, filling a vital gap)?

The MHDP was established to address service provision and systems gaps evident in meeting the needs of

social housing tenants with mental illness or complex problems. The service and system gaps were identified

in a report funded by the Queensland Mental Health Commission (QMHC) which examined the impact of the

former Anti-Social Behaviour (ASB) Management Policy on social housing tenants living with mental illness,

mental health difficulties and problems with substance use (collectively referred to as ‘complex needs’).



Overall, integrating the findings of the outcomes evaluation suggests that the MHDP provides a needed

service and the provision of support contributed to improving tenants’ lives. There is a need within the

existing service system to provide support for individuals with complex issues, and the types of issues faced

by tenants are complex and multi-faceted.

What lesson does the MHDP provide for housing, health, and community service delivery and tenancy

sustainment outside of the trial area?

The MHDP meets an urgent need, the initiative helps establish the DHPW as a human service organisation,

and the model moreover is a useful mechanism to achieve inter-department and interdisciplinary

collaboration.

The project developed and evolved across the duration of the project, adapting to the needs and practical

considerations of delivery the program. The project embodies the features of a trial and demonstration

initiative.

The scope of the project has been established, in practice, in broad ways to encompass the variety of issues

that can impact housing tenancies, rather than a project specific to people with mental health or what are

generally considered complex needs.

Service integration and having resources to provide both clinical and non-clinical support in a complementary

fashion was a key contributor to success.

Having clearly defined role, responsibilities, service parameters, and expectations is important to develop at

the onset of integrated service delivery.

Brokerage assumes a complex role. Having brokerage funds was perceived by stakeholders to be an

important element to be able to provide flexible and individualised support. However, only a portion of the

brokerage budget was used.

Having a case coordination and case management approach, as facilitated via CAIRT meetings and the HSIC

role, was an integral component of service delivery. There was less clear evidence that integrated Housing

Support Plans was a useful tool for facilitating service delivery and tenancy sustainment.

A barrier to providing integrated support identified by stakeholders was difficulties in coordinating support with

funded services and government agencies outside the three core agencies of the MHDP that a tenant may

have been involved with, such as child safety, disability services, and public guardians. One of the central

benefits of the project was the funding source and project design that ensured the commitment and

contribution from the three partners.

Hoarding and squalor was a significant and chronic issue, and as such having a specialised process to assist

tenants with hoarding and squalor issues may be helpful to enhance capability and capacity for DHPW staff

working with tenants with hoarding and squalor issues.

Gaps still exist within the service system and this is reflective of the organisational and policy frameworks.

Embedding professionals with social work, psychological, and case coordination expertise within Housing

Service Centres and professionals that could provide expertise working with Housing tenants within

Queensland Health service coordinator role may represent an efficient means of reducing tenancy problems

by improving the practice systems, capability, and capacity of the DHPW.



REFERENCES

Bruce, J., McDermott, S., Ramia, I., Bullen, J., & Fisher, K. (2012). Evaluation of the housing and

accommodation support initiative (HASI), Final Report. Social Policy Research Centre, Sydney.

Department of Housing and Public Works (n.d.). Mental Health Demonstration Project: Service Delivery Model and

Guidelines. Queensland Government.

Department of Housing and Public Works (2016). Contract Details: Mental Health Demonstration Project Evaluation.

Queensland Government.

Jones, A., Phillips, R., Parsell, C., Dingle, G. A. (2014). Review of systemic issues for social housing clients with

complex needs. Prepared for Queensland Mental Health Commission. Brisbane, QLD, Australia: The

University of Queensland Institute for Social Science Research.

Moseley, A. and Oliver, J. (2008). Central State Steering of Local Collaboration: Assessing the Impact of Tools of

Meta-governance in Homelessness Services in England. Public Organization Review, 8(2): 117-136.

Parsell, C., Petersen, M., Moutou, O., Culhane, D., Lucio, E. & Dick, A. (2016). Brisbane Common Ground

Initiative Evaluation. Final Report. Brisbane: Queensland Government, Department of Housing and

Public Works.

Parsell, C., Walter, Z. C., Phillips, R., & Cheshire, L. A. (2016). Mental health demonstration project evaluation:

Interim report. Prepared for Queensland Government, Department of Housing and Public Works.

Brisbane, QLD, Australia: The University of Queensland Institute for Social Science Research.

Williams, G. C., & Deci, E. L. (2001). Activating patients for smoking cessation through physician autonomy

support. Medical Care, 39, 813-823.

Williams, G. C., Freedman, Z.R., & Deci, E. L. (1998). Supporting autonomy to motivate glucose control in patients

with diabetes. Diabetes Care, 21, 1644-1651.

Wing, J.K., Beevor, A.S., Curtis, R.H., Park, S.B.G., Hadden, S. & Burns, A. (1998). Health of the Nation Outcome

Scales (HoNOS): Research and development. British Journal of Psychiatry, 172, 11-18.



APPENDIX

MEASURE – MHDP AUTONOMY SUPPORT CLIMATE QUESTIONNAIRE

This set of questions are related to your participation with the Tenancy Support Project and how you got on with your

support worker(s). Support workers may have different styles in how they work with people, and we would like to know

more about your experiences with support workers in the Project. Your feedback is confidential, so you can say what

you really think. We value your opinion and appreciate your honesty and openness.

How much do you agree or disagree with

the following statement?

Strongly

Disagree

Disagree Slightly

Disagree

Neutral Slightly

Agree

Agree Strongly

Agree

I feel that I have been provided with choices

and options in my action plan 1 2 3 4 5 6 7

I feel understood by my support workers 1 2 3 4 5 6 7

My support workers express confidence in

my ability to make change 1 2 3 4 5 6 7

My support workers encourage me to ask

questions 1 2 3 4 5 6 7

My support workers listen to how I would

like to do things 1 2 3 4 5 6 7

My support workers try to understand how I

see things before suggesting a new way to

do things

1 2 3 4 5 6 7

MEASURE FOR PERCEIVED COMPETENCY FOR MAINTAINING HOUSING TENANCY

This set of questions are related to your housing tenancy. Please respond to each of the following items in terms of

how true it is for you regarding your housing tenancy. Your responses are confidential and we are interested in what

you really think. We value your opinion and appreciate your honesty and openness.

How true are the following statements

for you?

Not at

all true

Somewhat

True

Completely

True

I feel confident in my ability to maintain my

tenancy 1 2 3 4 5 6 7

I am capable of handling my tenancy 1 2 3 4 5 6 7

I am able to achieve my goals for

maintaining my tenancy over the long term. 1 2 3 4 5 6 7

I feel able to meet the challenges of

maintaining my tenancy 1 2 3 4 5 6 7

evidence for the mental health demonstration project: a ......the outcomes evaluation of the mental...

Documents