OUTCOMES, SERVICE MODELS AND INTEGRATED SERVICE DELIVERY

Paul Flatau

The University of Western Australia Centre for Social Impact

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THE FUNDING CONTEXT

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Three Steps to Contract

• What would success look like for our clients

Client Outcomes

Three Steps to Contract

Step 1: Define Your Intended Client Outcomes

Step 2 Develop Your Service Delivery Model

Step 3 Establish Your Value Proposition

Step 1: Outcomes

Inputs

Activities

Outputs

Outcomes

Impacts

The focus of the WA Government’s procurement reform

Your Planned Work Your Intended Results

1 2 3 4 5

Step 1: Outcomes

Inputs, Activities, Engagement

Outputs • Number of

participants reached, number of contacts and intensity of contact

Learning• Changes in

knowledge, skill and attitude

Actions• Changes in

behaviour and practices

Impact• Long-term

effects for the individual, community and systems

Change relative to baseline and the counterfactual

Understand the needs and histories of clients. Outcomes should be judged

relative to needs

Outputs

Outcomes

Impact

DAO Residential Rehab Service Outocmes

• Improvement in clients wellbeing (physical, mental, emotional, social, standard definition) in the:• Short term(3-6 months post treatment)• Long term (+6 months post treatment)

• Greater awareness/understanding of own drug use and factors impacting upon

• Improvement in the clients capacity to relate to family and function in the community• Short term(3-6 months post treatment)• Long term (+6 months post treatment)

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Step 2: The Service Delivery Model

• Establish HOW and WHY your service will achieve intended outcomes and impacts

• What links the activities you are undertaking to the intended short-term and medium-term outcomes and final impacts for clients and communities?

• How will your service model achieve the ends you are after?

• The THEORY OF CHANGE logic model

Step 3: The Value Proposition• Why your service represents value for money ……

Because you can demonstrate that your service delivery model produces (or has the capacity to produce) positive benefits for your clients and long-term positive impacts for the community … and you can do this at the right price

THE ROLE OF SERVICE INTEGRATION

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Focus • Findings from ongoing studies IN HOMELESSNESS on

comorbidity and homelessness and social exclusion• Comorbidity: coexisting substance use and (other) mental health

disorders• Homelessness: primary homelessness; supported

accommodation and temporary accommodation (couch surfing family or friends; hotel/motel as have nowhere else to go; boarding/rooming houses)

• Social exclusion: Income, wealth, resources, friendships, family

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MP Baseline: Mental Health• Mental Health

• Around half of all respondents indicated they had been diagnosed with a mental health disorder (excluding substance use disorders)

• Prevalence of mental health disorders • 33% with mood disorders• 34% anxiety disorders• 17% psychotic disorders• 12% personality disorders• 51% substance use disorder• Others less than 10%

• 34% Comorbidity (diagnosed substance use disorder and diagnosed other mental health disorder)

• 36% currently taking medication for a mental health condition

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MP Baseline: AOD

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  Outreach and Emergency  Short and Medium Term Accommodation 

Ever tried Past month 

Dependence 

Ever tried 

Past month 

Dependence

  n % n % n % % % n % n %Heroin 56 59.6 20 21.3 10 50.0 78 51.7 16 10.6 13 81.3

Opioids other than heroin 38 40.4 12 12.8 7 58.3 64 42.4 15 9.9 10 76.9

Alcohol 86 91.5 58 61.7 31 55.4 140 92.7 78 51.7 41 53.9

Cannabis 74 78.7 47 50.0 25 54.3 124 82.7 32 21.4 23 74.2

Amphetamines 57 60.6 20 21.3 13 65.0 89 59.3 14 9.4 7 53.8

Cocaine 48 51.1 12 12.8 9 75.0 79 52.7 6 4.0 2 40.0

Tranquillisers 39 41.5 15 16.0 8 53.3 64 42.4 10 6.6 3 30.0

Hallucinogens 44 46.8 3 3.2 0 0.0 80 53.0 3 2.0 2 100.0

Inhalants 24 25.5 2 2.1 0 0.0 41 27.2 3 3.0 1 50.0

Average 52 55.1 21 22.4 12 53.1 83 55.7 19 12.5 11 62.2

MP Baseline: Mental Health

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Combat experience

Life threatening accident

Natural disaster

Witness someone being badly injured/killed

Raped

Sexually molested

Seriously physically assaulted

Threatened with weapon or held captive

Terrorist victim

Any other stressful event

Vicarious stressful event

0 20 40 60 80100

8.1

55.7

26.8

69.8

10.1

22.1

65.8

60.4

8.8

48.3

45

Pe

r ce

nt

Lifetime exposure to different traumatic events

MP Baseline: Mental Health• High to very high levels of psychological distress & very high rates

of PTSD & psychosis • 95% had experienced one or more traumatic events eg witness

someone being badly injured/killed; serious physical assault; life threatening accident etc

• Typically early adolescence when 1st traumatic event occurred with worst exposure in early adulthood

trauma history well established by adulthood• 20% of MP clients screened with post-traumatic stress disorder

(PTSD) compared with 1% of adult male pop

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MP Baseline: Quality of Life16

Figures exclude participants who did not respond to the relevant questions.Findings on the 2000 Victorian Validation Study are reported in Australian WHOQOL Field Study Centre (2000 p.26).

Physical Psychological Social relationships Environment0

10

20

30

40

50

60

70

80

90

100

56.653.5

43.345.8

64.1

56.7

47.2

59.5

80.0

72.6 72.274.8

Outreach & emergency accommodation Short & medium term accommodationVVS Community sample

Me

an

Sco

res

MP Baseline: Deprivation & Social Exclusion

• 78% couldn’t afford dental treatment if needed; 80% unable to afford prescribed medicines

• Causes of social isolation (short & medium term accommodation respondents)

• Lack of money: 81%• Lack of own transport: 71%• Absence of supportive family: 70%• Family related problems: 66%• Lack of friends to provide support: 60%• Lack of involvement in community/sport: 49%• Mental health: 37%• Physical health: 31%

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Intergenerational Homelessness Survey (HIS)

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Prevalence of Intergenerational Homelessness, by Sex

Parental Experiences of Jail, Stays in Hospital and Problematic Drug and Alcohol Use While Growing Up

Parental Experiences of Jail, Stays in Hospital and Problematic Drug and Alcohol Use While Growing Up, by Indigenous Status

IHS – Respondent Problems

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  Not at all Slight Moderate Serious TotalN % N % N % N % N %

Being bored 99 18.3 140 25.9 165 30.5 137 25.3 541 100.0Being lonely 115 21.4 133 24.8 155 28.9 134 25.0 537 100.0Drinking too much 220 40.7 86 15.9 104 19.2 131 24.2 541 100.0Taking drugs 221 40.9 97 17.9 92 17.0 131 24.2 541 100.0Feeling depressed, anxious or stressed

65 11.9 130 23.9 143 26.3 206 37.9 544 100.0

Losing temper 132 24.4 159 29.4 137 25.4 112 20.7 540 100.0Getting along with family

131 24.3 159 29.5 125 23.2 124 23.0 539 100.0

Lifetime experiences of problems among respondents (select indicators only). Feeling depressed, anxious or stressed highest rating in terms of seriousness of lifetime problems.

Proxy of Comorbidity: 20 per cent of respondents cited a serious alcohol or other drug problem (at some point in their lives) and a serious problem of feeling depressed, anxious or stressed (at some point in their lives)

IHS – Respondent A&OD and Depressed, Anxious or Stressed

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Comorbidity and Other Associations• Those respondents with (proxy of) comorbidity are much

more likely (than those without comorbidity) to • …have experienced homelessness first prior to the age of 12• …have experienced primary homelessness at some point in their

lives• …have experienced their parents argue with each other all the time• …have seen or heard their parents physically harm each other or

threaten each other with a weapon all the time• …left home more often because of violence between parents (with

a slightly greater chance of being residential and foster care)• …have run away from home more and done so more often

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Comorbidity and Other Associations• …consider they have had at some point in their lives a serious

problem with • Gambling• Keeping bad company• Being bored• Being lonely • Repeating the same mistakes • Losing their temper• Managing their money/debt• Getting on with their family• Dealing with the authorities

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What is integration?

Figure 2 : Ahgren and Axelsson’s integration continuum

Full segregation Full integration

Linkage Coordination Cooperation

in networks

Linkage: independent organisational units. Referral of patients to the right unit at the right time and good

communication between the professionals involved in order to promote continuity of care.

Coordination in networks: operates largely through existing organisational units.

Coordination of different

health services, sharing clinical information, and the management of the transition of patients

between different units.

Full integration: the resources of different organisational units are pooled in order to create a new

organisation.

Source: Ahgren and Axelsson (2005)

Motivation• Effectiveness of Service Delivery

• A fragmented human services system may:• Result in gaps in service delivery;• Pull clients in different directions;• Provide clients with conflicting advice and support and treatment

options; • Produce ineffective referral pathways; and,• Impose unnecessary transaction costs on clients as they navigate the

human services system

Motivation Cont…• Effectiveness of Service Delivery

• but potential issues …• Service integration may be costly (high setup costs and high transaction

costs for agencies), unwieldy and time-consuming• Possible loss of control/autonomy among agencies• Differing values of organisations• Difficulties in transmitting specific knowledge among partnership

members• Free rider problems• Requires leadership and good management particularly when

partnerships is ‘forced’ on to a set of agencies with different cultures and practices

• Loss of the benefits of specialisation in service delivery.

Ends and meansService Integration

Client Integration

Client Outcomes

Other factors

Other factors

Other factors

DAO Residential Outocmes• Improvement in clients wellbeing (physical, mental,

emotional, social, standard definition) in the:• Short term(3-6 months post treatment)• Long term (+6 months post treatment)

• Greater awareness/understanding of own drug use and factors impacting upon

• Improvement in the clients capacity to relate to family and function in the community• Short term(3-6 months post treatment)• Long term (+6 months post treatment)

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