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Trial of the NT Housing Accommodation Support Initiative (NT HASI) Service Model and Program Guidelines25 September 2017

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DEPARTMENT OF HEALTH

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Document detailsDocument title Trial of the NT Housing Accommodation Support Initiative (NT HASI)

Service Model and Program GuidelinesContact detailsDate and version 25 September 2017

Version 1Approved by Dr Denise Riordan Chief Psychiatrist, Northern Territory Department of

Health (NT DOH)Date approvedDocument review(for example, annually)

Change history

Version Date Author Change details1 25 September 2017 Melissa Heywood Initial version

Definitions and acronyms The following acronyms and definitions are used in this documentAcronyms Full form

AOD Alcohol and Other Drugs

CALD Culturally and Linguistically Diverse

Case management A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality, cost effective outcomes. The case manager often takes the lead role in care coordination or it can be a function of the non-government organisation.

Carer The Northern Territory Carers Recognition Act specifically recognises carers of people with mental illness.

Care coordination Care coordination is the deliberate organisation of care between two or more parties and the person with a mental illness so that appropriate and relevant care is delivered by the right person and at the right time ensuring that all parties including services providers are aware of what care is being provided at what times.

Cultural responsiveness Describes the capacity of a health professional, health service and health system to respond to the health care issues of individuals and provide person-centred care (taking into account cultural, linguistic, spiritual and socio-economic background).

Cultural safety Identifies that health consumers are safest when health professionals have considered power relations, cultural differences and patients’ rights. Part of this process requires health professionals to examine their own realities, beliefs and attitudes. Cultural safety is not defined by the health

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professional, but is defined by the individual’s experience of care they are given, and the ability to access services and the confidence to raise concerns.

Cultural security Fundamental to closing the gap in health outcomes for Aborignal Territorains. Cultural security is a commitment to the principle that the construction and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people. Cultural security refers to the embedded structures, policies, workforce attributes and other elements enabling participants to experience cultural security.

Cultural incident Critical Incident (also known as a reportable incident) includes any adverse event that causes mild to moderate harm to any person related to the NT HASI program and has occurred during an aspect of the programs delivery. It differs from a sentinel event where serious harm or death occurs as a result of, or during the delivery of supports to a participant.

NT DOH Northern Territory Department of Health

NT DHCD Northern Territory Department of Housing and Community Development

TEHMS Top End Mental Health Services

NGO Non-government organisation

Forensic client Relates to a person with mental illness in the criminal justice system. In the Northern Territory, this usually is restricted to clients that are on Part IIA orders of the Criminal Code, a small cohort of complex prisoners and a small number of recidivist clients through the local court (section 77 of the Mental Health and Related Services Act).

NSW HASI New South Wales Housing and Accommodation Support Initiatives

NT HASI Northern Territory Housing Accommodation Support Initiative

IRP Individual recovery plan

Mental illness A clinically diagnosable disorder that significantly interferes with a person’s cognitive, emotional or social abilities. Examples include anxiety disorders, depression, bipolar affective disorder, eating disorders, and schizophrenia Mental Illness is a health problem that may significantly affect how a person thinks, feels thinks, feels, behaves and interacts with other people. It describes a group of illnesses that are diagnosed according to standardised criteria.

MHAT Top End Mental Health Services Mental Health Access Team.

NDIS National Disability Insurance Scheme

NDIA The agency responsible for implementing the National Disability Insurance Scheme

Psychosocial disability Psychosocial disability is an internationally recognised term


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under the United Nations Convention on the Rights of Persons with Disabilities, used to describe the experience of people with impairments and participation restrictions related to mental health conditions It is estimated at any one time 0.3% of the population has a severe mental illness that results in psychosocial disability. This cohort is targeted for the NDIS. In the Northern Territory it is estimated to be four hundred and twenty people.

Primary Health Care (PHC) Primary Health Care is the front line of Australia’s health system and is comprised of service providers from the public, private and non-government sectors. Services provided are broad and include health promotion, prevention, screening, early intervention, treatment and management. PHC providers include general practitioners, nurses, allied health professionals, pharmacists and Aboriginal health workers.

Public housing Public Housing is delivered through the NT DHCD for individuals who meet eligibility criteria.

Strengths approach A model of intervention that shifts the focus of work with clients from power-over to power-with, from deficits to capacities, from expert-focussed to the-client-as-expert (Hammond; 2010).

Relapse prevention plan A plan designed with the participant to prevent an episode of illness.

Recovery The National Framework for Recovery-Oriented Mental Health Services: Guide for Practitioners and Providers, outlines that there is no single description or definition of recovery because recovery is different for everyone. It notes that central to all recovery paradigms are hope, self-determination, self-management, empowerment and advocacy. Also key is a person’s right to full inclusion and to a meaningful life of their own choosing free of stigma and discrimination.

Social and emotional wellbeing

Refers to the Aboriginal and Torres Strait Islander view of health. This view is holistic and includes mental health and other factors such as the social, spiritual and cultural wellbeing of people and the broader community.

Stigma (mental illness) People with mental illness face stigma at all levels of society. Stigma occurs whenever there are negative views and stereotypes about someone with a mental illness. These negative views result in the participant being excluded, de-valued and disrespected and have a negative impact on the person’s health and wellbeing.

Social inclusion Is the opportunity for people to participate in society through employment and access to services; connect with family, friends, personal interests and the local community; deal with personal crises; and have their voices heard.

Tenancy support services Tenancy Support Services (TSS) funded by DHCD provides services to individuals and families living in public housing or on the public housing waitlist who need support to maintain their tenancy. The TSS provides case management and support to public housing tenants in the NT to maintain their housing and prevent homelessness.

Tenancy management Monitoring of all rental payments and managing rental arrears.


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This includes negotiating schedules of repayments and monitoring arrangements and providing the person with appropriate documentation regarding their accommodation and its management, including policies and processes for disputes and complaints. DHCD may also provide to the client rental documentation on request.

National Standards for Mental Health Services

Standards that assist in the development and implementation of appropriate practices, and guide for continuous quality improvement across the broad range of mental health services including the government, non-government sector and private sectors.

Wraparound care Individualised and integrated services provided through a single coordinated process to comprehensively meet a person’s needs. One plan is developed for the individual and/or family. One person is nominated to facilitate the planning

ReferencesDocument LocationEvaluation of the Mental Health, Housing and Accommodation Support Initiative (HASI): First Report (2010)

https://www.sprc.unsw.edu.au/media/SPRCFile/20106HASI EvalReport 1 Web.pdf

HASI Model Evaluation – Final Report (NSW)

http://www.health.nsw.gov.au/mentalhealth/publications/Publications/pub-hasi-final-report.pdf

Evaluating the Independent Living Program. Phase 1: Policy Review. (2008)Western Australian Centre for Mental Health Policy Research. Department of Health. Perth

http://www.health.wa.gov.au/mhpr/docs/Evaluating_the_independent_living_program.pdf

Housing for people with Mental Illness – 10 Principles for Policy and Practice Victoria (2008)

http://www.mifellowship.org/sites/default/files/may200810housingpoints.pdf

HASP South Australia Housing Accommodation Support Partnership Government of South Australia (2009)

http://www.sahealth.sa.gov.auHASP Service Model 2010.pdf

Evaluation of the Housing and Accommodation Support Initiative (HASI), Social Policy Research Centre (Shannon McDermott 2012) (UNSW)

http://web.archive.org/web/20130511231031/http://www.sprc.unsw.edu.au/media/File/HASI_final_6_Sept_2012.pdf

Housing and associated support for people with mental illness or psychiatric disability. Robyn Edwards, Karen R. Fisher, Kathy Tannous and Sally Robinson (2009)

https://www.sprc.unsw.edu.au/media/SPRCFile/2009_Report4_09_Housing_Associated_Support.pdf

Fifth National Mental Health Plan (draft)

https://www.health.gov.au/internet/main/publishing.nsf/Content/8F54F3C4F313E0B1CA258052000ED5C5/$File/Fifth%20National%20Mental%20Health%20Plan.pdf

Flatau, P., Zaretzky, K., Wood, L. and Miscenko, D. (2016) The financing, delivery and effectiveness of programs to reduce homelessness,

http://www.ahuri.edu.au/research/final-reports/270


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AHURI Final Report No. 270, Australian Housing and Urban Research Institute Limited, Melbourne

Northern Territory Health Aboriginal Cultural Security Framework

http://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/730/8/Northern%20Territory%20Health%20Aboriginal%20Cultural%20Security%20Framework%202016-2026.pdf

Parsell, C. and Moutour, O. (2014) An evaluation of the nature and effectiveness of models of supported housing. AHURI Positioning Paper No. 158. Melbourne: Australian Housing and Urban Research Institute. Available from:

https://www.ahuri.edu.au/__data/assets/pdf_file/0014/2741/AHURI_Positioning_Paper_No158_An-evaluation-of-the-nature-and-effectiveness-of-models-of-supportive-housing.pdf

http://www.ahuri.edu.au/research/final-reports/240

Mental Health National Outcomes and Casemix Collection: Technical specification of State and Territoryreporting requirements, Version 2.0. Department of Health, Canberra, 2017.

http://www.amhocn.org/sites/default/files/publication_files/nocc_v2.0_technical_specifications_consolidated_20170717.pdf

Definition of Mental Illness http://www.health.gov.au/internet/publications/publishing.nsf/Content/mental-pubs-n-pol08-toc~mental-pubs-n-pol08-3

Nous Group Doorway Evaluation 2013 - Mental Illness Fellowship Victoria

https://media.wellways.org/inline-files/Evaluation%20of%20an%20integrated%20housing%20and%20recovery%20model%20-%20the%20Doorway%20program.pdf

Ridgway, P., & Zipple, A. M. (1990). The paradigm shift in residential services: From the linear continuum to supported

http://psycnet.apa.org/doiLanding?doi=10.1037%2Fh0099479


Table of contents

Contents1 Acknowledgements...................................................................................................................92 Executive summary...................................................................................................................93 Introduction................................................................................................................................94 Model........................................................................................................................................10

4.1 NT HASI Model of wraparound care..............................................................................11

5 Partnership and service delivery principles.........................................................................115.1 Program objectives........................................................................................................125.2 Program outputs............................................................................................................125.3 Program outcomes........................................................................................................125.4 Program philosophy and vision......................................................................................135.5 The partners..................................................................................................................13

6 Estimated Packages of Care Packages.................................................................................136.1 High/intensive support...................................................................................................136.2 Medium/flexible support.................................................................................................136.3 Low/ flexible support......................................................................................................14

7 Other services and support options......................................................................................148 Legislation and Standards.....................................................................................................149 Psychosocial supports...........................................................................................................1610 Provision of after-hours on call crisis support....................................................................1611 Non-Government NT HASI organisation (keyworker)..........................................................17

11.1 Responsibilities of key worker.......................................................................................17

12 Individual Recovery Plan........................................................................................................1713 Department of Housing and Community Development.......................................................1814 Top End Mental Health Service..............................................................................................18

14.1 Care Coordination..........................................................................................................19

15 Informed consent....................................................................................................................1916 Critical Incidents.....................................................................................................................2017 Duty of care..............................................................................................................................2118 Referral Criteria.......................................................................................................................21

18.1 Eligibility.........................................................................................................................2118.2 Non-eligibility.................................................................................................................22

19 Intake and assessment process............................................................................................2219.1 Initial eligibility screening...............................................................................................2219.2 Intake Assessment Panel..............................................................................................2219.3 NT HASI NGO functional assessment process.............................................................23

20 Safety and quality....................................................................................................................2321 Monitoring and evaluation......................................................................................................2322 Dispute resolution...................................................................................................................23

22.1 Participant disputes, complaints and feedback..............................................................2322.2 Neighbourhood disputes................................................................................................2322.3 Partner disputes.............................................................................................................2322.4 Step action.....................................................................................................................24


Table of contents

Appendix A – Psychosocial supports..........................................................................................25Appendix B – referral and intake process...................................................................................26


Trial of the NT Housing Accommodation Support Initiative (NT HASI) Service Model and Program Guidelines

1 Acknowledgements The Northern Territory (NT) Department of Health (NT DOH) would like to acknowledge the New South Wales Department of Health’s (NSW DOH) 2006 Housing and Accommodation Support Initiative (HASI) for people with mental illness, the South Australian Government Department of Health’s Housing and Accommodation Support (HASP) program and the Victorian Department of Human Services (VDHS) 1990s initiative Housing and Support Program, which have been reviewed in the formulation of this document.

2 Executive summary The Northern Territory Housing Accommodation Support Initiative (NT HASI) is a partnership between the Northern Territory Department of Health (NT DOH); Northern Territory Department of Housing and Community Development (DHCD); Top End Mental Health Service (TEMHS) and the non-government organisation (NGO) sector. The aim of the NT HASI program is to support people with mental illness in public housing to sustain their tenancies and avoid becoming homeless.

NT HASI will provide services that are individualised, holistic, integrated, culturally responsive, safe and flexible, to enable people with mental illness to remain living in the community. The primary target group for the service is individuals who are case managed by TEMHS adult teams who are living in public housing in Darwin, Palmerston and Casuarina. TEMHS will be in the initial primary referral source.

TEMHS will provide specialist clinical mental health care, DHCD will provide public housing and the NT HASI NGO will provide psychosocial support. All services will work with people in an integrated and recovery focused way.

NT DOH will develop a monitoring and evaluation framework to analyse outcome measures of individuals who access the services over time and to measure the service quality. The trial will be completed in December 2020. A final evaluation report will be developed by NT DOH to determine the success of the program and what type of service model should be funded in the future.

3 Introduction People living with mental illness are at significant risk of experiencing a range of adverse social and economic outcomes. Stigma relating to mental illness can create a significant barrier for people to access services. People with mental illness and psychosocial disability are more likely to experience homelessness and housing instability.

The 2012 NSW HASI evaluation provided evidence that when housing is linked to appropriate clinical and rehabilitation support, people are better able to overcome the often debilitating effects of mental illness and live more independent lives. The evaluation also found that the majority of HASI participants were successfully maintaining their tenancies (around 90%), that their mental health was improving, and that they were spending less time in hospital. In addition, people were regularly accepting support services in the community and demonstrating a high degree of independence in daily living.

According to Swadling et al. (2014) a housing project Doorway that was implemented in Victoria in 2011 with a specific focus of integrated team service delivery that specifically mitigates the risk of siloed practices, was found to have significant positive outcomes. These findings arose from an independent evaluation by Nous Group two years after implementation. The outcomes were; integrated mental health and housing support, increased discharge rates from clinical mental health services, reduced hospital admissions, increase in self-management of mental health and



physical health by participants, increased sustained housing tenure, improved social inclusion and economic outcomes.

NT HASI will focus on people living in public housing in Darwin, Casuarina and Palmerston and is based on the NSW HASI Model, the South Australian Housing and Accommodation Support (HASP) program and several successful evaluated models in Victoria.

The project is in partnership with the Northern Territory Department of Health (NT DOH) and the Northern Territory Department of Housing and Community Development (DHCD) and non-government organisation (NGO) sector.

The project is being led by a Steering Committee consisting of identified key stakeholders. The aim of the project is to provide wraparound clinical, tenancy and psychosocial (non-clinical) supports to people with identified mental illness in addition to other complex care needs. This may include people with dual diagnosis issues (substance misuse disorders) or other types of health issues.

The NT HASI model and program guidelines are intended to assist in the development of strong and effective partnerships between TEMHS, DHCD and the NT HASI NGO in supporting the recovery of people with mental illness and providing the NT HASI service.

The Service Model and Guidelines will provide all partners with clear information designed to provide consistency in the delivery of services to participants. The content of this document will be regularly reviewed by the Steering Committee and all partners to ensure its effectiveness.

NT HASI will be funded through the 2017-18, 2018-19 and 2019-20 Territory budgets in response to the election commitment announced in 2016.

NT DOH will provide tertiary (specialist clinical) mental health services through TEMHS, DHCD will provide tenancy management services to clients residing in public housing dwellings, and the NGO sector will provide the psychosocial supports including tenancy support and care coordination where appropriate or delegated by TEMHS.

4 Model NT HASI is a voluntary program. People who participate in the program are expected to be an equal partner in the service. Each person’s unique journey of recovery will be supported to the degree they are able to participate in the following:

Self-management of their mental illness or substance misuse disorder (depending on level of insight).

Partnership with their housing provider (DHCD), the NT HASI NGO and tertiary (clinical) mental health service (TEMHS).

Engagement in activities to support the individual with living, learning, social, vocational and recreational aspects of their lives.

Development of aspirations, goals and milestones.

Regular review of the service and other supports to better meet their recovery needs.

Carers and family members are encouraged and supported, where the person is in agreement, to be involved with plans for the care of their family member.



For the person receiving service from the program there are three partners in the model: the DHCD is the housing provider, the NT HASI service will provide the psychosocial support (including a key worker) and TEMHS will provide specialist tertiary mental health services. The person is in the centre of the wraparound care.

The following diagram represents the model with the primary providers and the participant in the centre of the wraparound care, other supports may be part of the model.

4.1 NT HASI Model of wraparound care

5 Partnership and service delivery principles Valuing the right of the person to negotiate their own Individual Recovery Plan.

Planned, coordinated and seamless approach to service delivery.

The acknowledgment of risk within a dignity of risk framework.

Culturally responsive and safe service delivery, with particular focus for Aboriginal Territorians as outlined in the NT Health Aboriginal Cultural Security Framework 2016-2026.

Collection of data to inform evaluation, research and service development.

Effective and efficient use of evidence based practice in the provision of recovery focused, and person centred services.

Appropriate sharing of information in the context of duty of care.



Use of appropriate tools such as self-reporting documents, standardised outcome measures, qualitative tools and assessment of need measures to effectively identify good practice and access outcomes at both individual and broader levels.

5.1 Program objectives The following objectives will guide the project:

The provision of safe, secure and affordable housing with security of tenure.

The provision of psychosocial rehabilitation and support services that are flexible and responsive to an individual’s needs taking into account their unique recovery goals and aspirations.

Clinical mental health care which is individualised and recovery focused.

Support for people to improve their life skills and capacity to live as independently as possible in the community.

Improvement of the quality of life, health and well-being for people who access the service.

Avoiding or reducing hospital admissions and the need to access crisis services.

Program evaluation with a commitment to use outcome measures and quality assessment tools to assess the effectiveness of the service to determine future investment.

5.2 Program outputsThe proposed outputs include the provision of the following services for people living with and persistent mental illness in Darwin, Casuarina and Palmerston:

Safe, secure and affordable housing that provides security of tenure.

Psychosocial rehabilitation and support services that are flexible, integrated, responsive to an individual’s needs and provide complimentary and integrated wraparound care.

Clinical mental health care which is individualised and recovery focused.

Support for people to improve their skills and capacity to live as independently as possible in the community.

Improved engagement of family and carers.

Increased development of services that link housing and social support for people with mental illness.

5.3 Program outcomesThe proposed outcomes for program participants include:

Increased proportion of people with mental illness living in the target areas that are able to sustain their tenancy, remain in safe, secure and affordable housing.

Improved mental health and health outcomes. This may be indicated in part by reduced hospital visits, a reduced need to access crisis services TEMHS Mental Health Access Team and a reduction in inpatient stays for mental illness).

Improvement in the quality of life, health and well-being of participants.

Improved community and social participation.

Improved independent living skills.

Improved vocational and economic participation.



5.4 Program philosophy and vision NT HASI is a partnership program between NT DOH, NT DHCD and TEMHS delivering recovery focused wraparound care to support people living in public housing in Darwin, Palmerston and Casuarina to sustain their tenancies.

NT HASI will be delivered in a rehabilitation framework and strengths based approach.

Rehabilitation is a philosophy and a specialist service which requires a particular skill set. Rehabilitation services aim to provide individually targeted interventions to assist people to regain, build or develop skills which enable people to engage in their own personal and unique recovery process.

Rehabilitation should commence at the earliest opportunity and be holistic and connected with the community. Rehabilitation services should use evidence based interventions and an assessment and treatment planning approach which identifies and builds on a person’s strengths. Rehabilitation services promote recovery and aim to reduce the disability associated with mental illness.

The strengths approach is a model of intervention that shifts the focus of work with clients from power-over to power-with, from deficits to capacities, from expert-focused to the-client-as-expert (Hammond, 2010).

5.5 The partners NT Government Department of Health including Top End Mental Health Service

NT Government Department of Housing and Community Development

Top End Mental Health Service.

Non-government sector.

6 Estimated Packages of Care PackagesThe following provides a guide to the hours of care provided in each level support package:

6.1 High/intensive supportA high level of support will require approximately 20-30 hours weekly for people with the highest level of need. These are people with mental illnesses such as schizophrenia, bipolar disorder and schizo-affective disorder, and high levels of impairment, and who are unlikely to maintain their tenancy agreement without psychosocial support. Among this group, are people with very high and complex needs, and unpredictable and challenging behaviours are to be prioritised for the housing support project.

6.2 Medium/flexible supportA medium level of support will require between approximately 10-20 hours weekly. These are people with a diagnosed mental illness who can function at a high level most of the time but with infrequent risk behaviour. They require support in household tasks like budgeting, living skills, property care and good neighbour behaviour and accessing community activities. Support may also be provided to individuals who have difficulties living in the community due to a combination of housing problems and mental illness. Support levels may fluctuate over time and vary with individual circumstances from low daily or weekly support to moderate daily in-reach to occasional higher levels of clinical and personal support.



6.3 Low/ flexible supportA low level of support will require between approximately 5-10 hours weekly or fortnightly. They have functional impairment identified with low levels of psychosocial disability. They may have an agreed medication regime that they are able to follow independently without support or prompting, and typically have some involvement with their family and the community. They may require emotional support when experiencing an unwell period, particularly as this period may be having a negative impact on their ability to sustain their tenancy.

The following is based on a needs assessment conducted by the NT DOH from TEMHS and DHCD data estimating the amount of packages of care that are likely to be needed. The total number of hours is inclusive of all support including TEMHS support.

Number of anticipated people requiring high support (up to 20-30 hours per week).

Number of anticipated people requiring medium support (up to 10-20 hours per week).

Number of anticipated people requiring low support (up to 5-10 hours per week).

Area

Number of anticipated people requiring high support (up to 20-30 hours per week).

Number of anticipated people requiring me-dium support (up to 10-20 hours per week).

Number of anticipated people requiring low support (up to 5-10 hours per week).

Darwin 8 – 10 people 4 – 8 people 5 peopleCasuarina 8 – 10 people 4 – 8 people 5 peoplePalmerston 8 – 10 people 4 – 8 people 5 people

In the first year of the service people with the highest needs will be prioritised.

7 Other services and support optionsThe NT HASI will refer to other supports as appropriate including but not limited to the following examples:

24 hour supported accommodation options for people with mental illness.

Homelessness Support Services funded through DHCD.

Primary health care services – General Practitioners - Better Access to Mental Health Initiative.

Financial Counselling Services.

Family Counselling or Therapy.

Participants of the service receiving support through DHCD funded NGO Homelessness Support Service providers may continue to receive this support.

8 Legislation and StandardsThe following legislation and standards will be followed:

National Frameworks and Legislation National Standards for Mental Health Services

National Disability Strategy



National Disability Service Standards

National Disability Insurance Scheme Act

Privacy Act and Principles

Health and Community Services Complaints Act

Framework for Recovery Orientated Mental Health Services

Anti-Discrimination Act

Australian Charter of Healthcare Rights

Australian Commission on Safety and Quality in Health Care, National Safety and Quality Health Service Standard 2; Partnering with Consumers

The Code of Health & Community Rights & Responsibilities

Ombudsman Act

Sex Discrimination Act

Racial Discrimination Act

Disability Discrimination Act

Age Discrimination Act

Australian Human Rights Commission Act

Disability Services Act

Disability Discrimination Act

National Disability Insurance Scheme Act

Work Health and Safety Act.

Northern Territory Frameworks and Legislation Mental Health and Related Services Act

Medical Services Act

Disability Services Act

Domestic Violence Act

Child Protection Act

Anti-Discrimination Act

Adult Guardianship Act

Carers Recognition Act

Care and Protection of Children Act

Freedom of Information Act

Health and Community Services Complaints Act

Health and Community Services Complaints Regulations

NT Residential Tenancies Act

NT Housing Act

NT Disability Service Standards



NT Domestic and Family Violence Act

NT Care and Protection of Children Act

NT Health Aboriginal Cultural Security Framework 2016-2026

NT Carers Charter.

Any other relevant national and Northern Territory legislation and/or standards.

9 Psychosocial supports NGO’s providing psychosocial rehabilitation and support to people living with a mental illness will be funded to provide intensive ‘in-home’ and community non clinical psychosocial rehabilitation, support and coordination services.

The NT HASI NGO will provide structured, goal focused, strengths based and individually tailored non clinical rehabilitation and support services at a level of intensity and duration appropriate to the person’s needs. The hours of support in the packages of care will be flexible depending on the person’s needs. E.g. if a person becomes unwell the level of support provided may increase from a medium package to a high package as required due to the episodic nature of mental illness.

The range of psychosocial supports may be across the spectrum of:

Self-maintenance needs such as self-care, insight and management of illness, home management, and shopping, cooking, cleaning, medication management and, physical and dental health care needs, e.g. diabetes management.

Provision of support to assist with maintaining sustainable tenancies including liaising with DHCD regarding tenancy management issues.

Providing services based on the philosophy of recovery through fostering hope and supporting individual empowerment and self-determination.

Productivity needs – education, employment, meaningful occupation of time.

Leisure needs – social and recreational.

Community connection – assisting people to connect with their community. Ensure those intervention strategies connect with mainstream community services.

Meet the needs of people from CALD backgrounds, Aboriginal and Torres Strait Islander people, people with physical impairment and intellectual disability.

These services will be available up to seven days a week, within extended hours depending on the person’s needs in the program. It is expected that peoples’ needs will vary and change over time. The NT HASI NGO will work with the other partners to provide a holistic and recovery focussed program of support that is flexible depending on the person’s unique level of need.

These services will build on peoples’ strengths and ensure access to and engagement with; support and resources including financial, professional, housing and social to enhance independent living skills, social and community connectedness, mental health, general health and well-being and quality of life.

For further information on psychosocial support refer to Appendix A.

10 Provision of after-hours on call crisis support Where required, the TEMHS through the Mental Health Access Team (MHAT) will provide extended hours crisis support via the NT Mental Health Line to ensure that the person is able to access crisis intervention when required. TEMHS staff will undertake assessment of mental state



and determine the person’s risk status and arrange for follow up psychiatric assessment where required. TEMHS staff will also arrange admissions to inpatient facility as per their usual protocols if and when required.

11 Non-Government NT HASI organisation (keyworker)The NGO key worker is qualified as a psychosocial rehabilitation worker from a variety of backgrounds with a minimum qualification of Certificate IV in mental health, Cert IV in peer work or working towards this qualification.

11.1 Responsibilities of key worker Coordinating the care and support provided to an individual.

Negotiate the Individual Recovery Plan (complimentary to the mental health care plan) with the individual and TEMHS case manager, in consultation with DHCD, to identify the person’s goals and aspirations.

Monitoring changes in the person’s situation that may affect their mental health care plan, support contract or services provided by other agencies.

Keep relevant TEMHS and DHCD staff informed of any relevant tenancy issues.

Lead and participate in joint reviews of the mental health care plan with relevant service providers, the individual and/or carer or significant other, where relevant.

12 Individual Recovery Plan NT HASI participants will have an Individual Recovery Plan (IRP) that documents the service provided from each partner. The NT HASI NGO will provide a copy of the IRP to the individual TEMHS and DHCD where appropriate.

The IRP will be negotiated and developed between the individual and the NGO key worker and TEMHS, in consultation with DHCD. The IRP is also required to be reflected in the TEMHS Care Plan and contains information on the following:

Participants identified recovery goals and individual aspirations.

How to manage their mental health by identifying any triggers that may make them become unwell.

Physical health and self-care e.g. referral to primary health care.

Support with increasing independent living skills.

Social networks and support.

Increased participation in vocational or work opportunities.

Increased positive relationships.

The level and type of support to be provided through the NT HASI NGO. What, how and how often.

Details of other agencies that will provide any other services including clinical mental health services and tenancy support services.

What happens if the person’s needs decrease or increase and what strategies are in place to deal with this situation e.g. a crisis or emergency plan.

What happens if the person loses the legal ability to give consent? E.g. ensure that there is an Advanced Care Plan in place in consultation with the TEMHS case manager.



Contact information about carer, and / or guardian, and next of kin.

Addresses significant lifestyle issues e.g. Alcohol and Other Drug (AOD) issues that may need to be addressed by the person. It may also list strategies to assist the person to manage these issues e.g. attending AOD counselling.

Any specific supports which may assist the person to better manage their tenancy.

Any special needs e.g. using an interpreter.

Provision for quarterly reviews.

13 Department of Housing and Community Development The DHCD will provide tenancy management services to NT HASI participants residing in public housing dwellings.

Tenancy Management

Managing tenancy involves the following: Ensuring that NT HASI participants understand their rights and responsibilities under their

signed Tenancy Agreement. Ensuring that tenancies are maintained and repaired according to the NT Residential Tenancies Act.

Receive rental payments from the individual, monitoring of all rental payments and managing rental arrears. This includes negotiating schedules of repayments and monitoring arrangements, which may include the provision of rental documentation.

Providing the person with appropriate documentation regarding their accommodation and its management, including policies and processes for disputes and complaints.

With consent, refer any public housing tenant to the program through TEMHS who appears to have mental illness.

In undertaking these roles DHCD will engage with the individual in a sensitive and responsive way. They will also ensure the person understands what is required of them as part of their Tenancy Agreement. In the case of tenant damage to a public housing property, the DHCD will negotiate repairs and payment with the tenant according to their internal policies and in line with the provisions of the NT Residential Tenancies Act.

People may wish to move from their accommodation, either due to no longer needing the level of support provided by the NT HASI program, or because they wish to move locations. The NT HASI NGO will work with people and the other partner agencies to assist people to access secure long term housing, where possible.

It may be identified that the dwellings provided by DHCD are not sufficient to meet a person’s recovery goals. DHCD may assess and prioritise where possible, an alternative dwelling that meets their individual needs.

14 Top End Mental Health Service People who access the NT HASI in many cases will be long time patients of community mental health services, in particular the TEMHS adult teams.

Clinical services generally focus on assisting people to manage the effects of mental illness. Community mental health services are usually multi-disciplinary in nature and include registered nurses, occupational therapists, social workers, psychologists and psychiatrists. The Community mental health service is the central and coordinating service on the mental health services continuum.



Clinical services provide a case manager for each person accessing the adult team who is responsible for coordinating care which includes after hours support. TEMHS staff also work in partnership with GPs, non-government organisations and other government providers as well as the individual, carers and their families.

14.1 Care Coordination The mental health case manager is the designated person from the community mental health service (TEMHS) who is responsible for coordinating and providing mental health care to the individual.

The mental health key worker (NT HASI NGO provider) is responsible for working closely with the individual, carers and other NT HASI Program partners to enable the person to reach the recovery goals identified in the mental health care plan and/or Individual Recovery Plan (IRP).

This process will include Responding to any new developments or changes in the individual’s situation and amending

the care plan where necessary.

Regularly reviewing the rehabilitation process with the individual and other parties.

Working closely with Program partners to ensure services provided are integrated and targeted.

Monitor mental state and medication management and compliance.

The allocated mental health care coordinator (TEMHS Case Manager or NGO Keyworker) needs to work flexibly with all partners of the NT HASI program. Should the person be admitted to an inpatient facility (whether acute, sub-acute or rehabilitation), the mental health care coordinator will remain in contact with the individual.

Each person will have a mental health care plan (Care Plan) provided by TEMHS which is the document that underpins the person’s mental health care. The development of the Care Plan is a collaborative and joint process between the person, carer (where appropriate), case manager from TEMHS, DHCD (where appropriate) and the NT HASI NGO. A Care Plan has three broad sections – the person’s Plan, Carer’s Plan and Service Plan – and incorporates the information previously contained in crisis intervention plans and relapse prevention plans.

A mental health care plan contains information about: demographics, socio-cultural considerations, legal considerations, advance care directives, wellbeing matrix, recovery plan, collaborative therapy, physical wellness and wellbeing, medication, carer’s/family plan, service plan and shared care agreements. The individual may also have a service plan or IRP that should be reflected in the person’s TEMHS Care Plan which includes the dates and proposed times that the NT HASI NGO service will provide services and what type of service. The NT HASI NGO will support each individual in the service to develop and Individual Recovery Plan (IRP).

15 Informed consent All individuals referred to the service will have signed a NT HASI consent form. The consent form will include communication between all NT HASI partners about the individual (TEMHS, NT HASI NGO, DHCD, and DOH).

It is important that individuals who wish to participate in the NT HASI initiative have a clear understanding of their right and those of their carers to:

receive and understand information about how their information is being shared

make informed consent, including withdrawing consent at any time



have their decisions respected.

Informed consent is the two way communication process between the individual and the NT HASI organisation. It reflects the principle that an individual has the right to decide what is appropriate for them, taking into account their personal circumstances, beliefs and priorities.

This includes the right to accept or decline elements of their information being shared and the ability to change that decision at any time. It is a process that can occur over a single occasion, or multiple occasions if needed with a completed consent form documenting that the process has occurred and informing all impacted parties.

In order for an individual to exercise this right to decide, they require the information that is relevant to them, presented in a way that they are able to fully understand. In addition, individuals must be given the time they require to consider the information presented in order to make a decision.

Consent is considered to be the basic legal principle that reflects a person’s agreement to something.

NT HASI participants will be expected to consent to the following The individual understanding that the NT HASI NGO will need to provide information to service

providers (and all partners) to support the individual.

That the NT HASI NGO may seek information from other providers about the person in order to inform the functional assessment, and IRP.

If consent is withdrawn at any time from any partner the person will be withdrawn from the program.

The person understanding that with consent their de-identified information will be provided to the NT DOH for the purposes of monitoring and evaluation and with the aim of improving the NT HASI model. If consent is withdrawn to participate in the evaluation component of the program they can still receive the service.

(Please note that if consent is not gained from a person to provide information to inform the evaluation this will not exclude them from receiving service).

Informed consent reflects that an individual has received information relevant to them to make an informed decision and they have given permission to the NT HASI NGO to share it’s information as required.

Explicit or express consent involves a person clearly stating their agreement to do something or for something to happen, for instance, participate in the initiative including the option of participation in the evaluation, or that their information can be shared with others including all partners. This may be verbal or in writing. Should verbal consent be given, this should be documented and witnessed in the event that consent is contested.

16 Critical Incidents The NGO must immediately notify by phone call to the Mental Health Directorate, or their nominated representative of any critical incidents. These include, but are not limited to; deaths or serious injury on the premises, criminal behaviour in or associated with the service, serious inappropriate behaviour, environmental or building hazards at the site and/or any other matter that might affect the safe and efficient delivery of this service or generate significant public or media concern.

Within 24 hours of a critical incident, the NGO must provide a written report of the critical incident to NT DOH via the Mental Health Directorate.



17 Duty of care There are some circumstances where professional judgement by the NT HASI staff members will be required and there may be a requirement to share some information with other parties even without consent. These circumstances could include:

when the person is in danger of harming themselves or others

when the person may be at risk of harm

when information about illegal activity has been disclosed.

The person should be made aware that their information may be required to be shared with others, such as emergency services (police or ambulance), depending on the circumstances and nature of the information.

Where informed consent from a person is not possible, it is good practice to explain and involve the person as much as possible in decisions that affect them, using language or other means appropriate to their needs and level of understanding. A careful assessment of the person’s capacity should be undertaken by TEMHS to confirm they do not have the capacity to consent.

Capacity is generally defined as the person being capable of understanding the nature and effect of decisions about a matter

freely and voluntarily making decisions about a matter

communicating the decisions in some way.

Where informed consent from an individual is not possible, consent should be sought from a person 'responsible' for an individual who could be defined as per National Privacy Principle 2.5.

The following people may be defined as ‘responsible’ for an individual parent of the individual

child or sibling of the individual and at least 18 years old

spouse or de facto spouse of the individual

relative of the individual, at least 18 years old and a member of the individual's household

public Guardian of the individual

exercising an enduring power of attorney granted by the individual that is exercisable in relation to decisions about the individual's health

person who has an intimate personal relationship with the individual

person nominated by the individual to be contacted in case of emergency.

18 Referral Criteria

18.1 Eligibility participant voluntarily consents to be referred to the program

currently case managed by TEMHS

has a primary diagnosis of mental illness which may include a secondary substance misuse disorder

currently is a public housing tenant living in Darwin, Casuarina or Palmerston and must be listed on the public housing tenancy agreement



aged between 18-64 years

is at risk of losing tenancy and requires coordination of services and wraparound care

TEMHS forensic clients will be accepted

parents with a mental illness with dependent children in their care will be accepted.

People in receipt of a Homelessness Support Service funded by DHCD or other appropriate supports may still be eligible to be referred to the service.

18.2 Non-eligibilityThe service is not designed to meet the needs of the following groups of people:

people over the age of 64 years

people less than 18 years of age (this criteria will be flexible if a person is determined to need the service)

a person who does not consent to participate

people who are not living in public housing in Darwin, Casuarina or Palmerston

persons whose primary diagnosis is not mental illness, and who have a medium to high functioning capacity.

19 Intake and assessment process In determining eligibility TEMHS, DHCD and the NT HASI NGO should keep in mind that NT HASI is a highly targeted program aiming to assist a relatively small subgroup of people with mental illness whose tenancies are at risk. A person who is already in receipt of NGO support for tenancy issues through a DHCD Homelessness Support Services program will still be eligible for the program which will be negotiated at the NT HASI NGO functional assessment stage.

19.1 Initial eligibility screening All referrals are to be provided via the NT HASI referral form. The initial screening of referrals will be actioned by the TEMHS housing project officer.

There will be one of the following outcomes though the TEMHS housing project officer:

The referral is accepted and forwarded to the NT HASI review panel for approval. Once approved it is then forwarded to the NT HASI NGO for the individual to progress to the functional assessment stage.

The person is accepted however is not referred to the NT HASI NGO due to there being no places available and is put on a waitlist.

The person is determined not to meet criteria. The referrer is advised and is offered to be referred to a more appropriate service.

The TEMHS housing project officer records all data relating to intake for the purposes of monitoring and evaluation.

19.2 Intake Assessment PanelAll referrals deemed to fit the intake criteria will progress to the intake and assessment panel to prioritise and approve entry to the service. The panel will consist of a TEMHS housing project



officer, TEMHS consumer consultant, a DHCD service delivery representative and a NT HASI NGO representative.

19.3 NT HASI NGO functional assessment processThe functional assessment process is the initial meeting with the referred individual during which the NT HASI NGO staff member gathers information to address the person's immediate needs to encourage their engagement in service. All staff engaging in this process from the NT HASI NGO must be suitably qualitied or trained to work within the program and have training in providing culturally safe and secure services to Aboriginal people.

To view the referral pathway flowchart please refer to Appendix B.

20 Safety and quality Risks and issues will be managed by the steering committee, the NT HASI NGO, TEMHS and DHCD. The successful NT HASI NGO will be able to demonstrate that they are an appropriately accredited organisation or are working towards an appropriate accreditation framework and how they will report serious risks to the Chair of the Steering Committee (NT DOH Director Mental Health) within two working days.

Comprehensive assessment including risk assessment planning and regular three monthly reviews including the development and review of crisis and/or relapse prevention plans for all participants is to occur.

21 Monitoring and evaluation Monitoring and evaluation is an essential part of the NT HASI program, to provide assurance of the effectiveness of the program. Monitoring and evaluation will be undertaken by NT DOH.

22 Dispute resolution

22.1 Participant disputes, complaints and feedbackSometimes a person will disagree with their treatment or support. The NT HASI NGO, DHCD and/ or TEMHS, will use their existing compliments and complaints mechanisms for resolving this type of dispute, including talking through the issue with the person, involving the NT HASI NGO manager, TEMHS team leader or senior clinician, trialling a modification to treatment or support, formally reviewing treatment or support, and reviewing participation in the program. DHCD will be notified of any issues with NT HASI participants and any strategies that are put in place to support the person in their tenancy.

22.2 Neighbourhood disputes On occasion disputes will arise between the NT HASI participant and their neighbours. In these instances DHCD will use their usual mechanisms for resolving neighbourhood disputes, including talking to both parties, negotiating agreed behaviour or actions between the parties, mediating a meeting between parties and more formal processes, including local council, Public Housing Safety Officer (PHSO) or police involvement or a review of their tenancy and conditions; and/or the issue of demerit points under the Red Card policy.



22.3 Partner disputes In circumstances where a difference of opinion or dispute arises between the NT HASI NGO, DHCD and/or TEMHS it is expected that the parties adopt a staged approach to resolving the dispute amicably and professionally.

There will be occasions where decisions may not be able to be resolved. In this situation the following actions are to be taken:



22.4 Step action

Step Action

1 The individuals directly involved in the care and support of the person, usually the case manager and the key worker, will meet to work through the issues and negotiate a solution as a part of the ongoing working partnership. Additional input may be sought from each party’s supervisor/team leader and/or manager, who may assist with meetings, negotiations and solutions. A record of actions/outcomes will be kept by the NGO provider and reported to the steering committee through progress reporting.

2 If a dispute is not resolved in Step one, either party can refer the issue to the Steering Committee, where the broader and more senior group of people from all partner organisations will formally consider the matter, including listening to the individuals involved in the dispute and requesting input from management staff from each organisation.

3 If a dispute is not resolved in Step two, the Steering Committee will refer the issue in writing to the mental health directorate.

Each participant of the program will provide feedback through each organisations complaints and feedback mechanisms. All complaints and feedback will be provided to NT DOH to inform the evaluation with the participants consent.

23



Appendix A – Psychosocial supports The following are examples of psychosocial supports.

Supporting and Promoting Self-Management, Health and Wellbeing

Mental health Working with the individual and the TEMHS team to implement strategies to increase self-management of mental health and emotional wellbeing e.g. assistance to attend specialist appointments, prompting and monitoring of management strategies, support in assuming increasing responsibility for own mental health, attendance at support groups, counselling. Work in partnership with specialist mental health services and the individual around strategies relating to managing medication.

Physical health and personal care, activities of daily living

Working with the individual to implement strategies to increase self-management of self-care including hygiene, physical health and well-being e.g. assistance or encouragement to attend medical appointments, prompting re medication, liaison with pharmacist. Developing healthy approaches to nutrition and exercise.

Drugs, alcohol and tobacco

Working with the individual to implement strategies to address drug/ tobacco and alcohol issues e.g. assistance to attend specialist appointments, prompting re management strategies, encouragement and support for persons efforts.

Developing Living Skills and capacity to take responsibility

Household management

Working with the individual to implement strategies to participate, initiate or take responsibility for household management e.g. cooking, shopping, cleaning, and gardening, support to manage tenancy such as paying rent or negotiating tenancy issues, requesting repairs to the dwelling according to the person’s capacity. NB that this may be provided through DHCD Homelessness Tenancy Support Providers.

Transport Working with the individual to develop skills and confidence to increase mobility and access in the community e.g. obtaining drivers licence, catching bus or taxi.

Financial management

Working with the individual to implement strategies to improve financial management e.g. budgeting, banking, bill paying, internet banking.

Community Engagement

Accommodation Working with the individual to develop responsibility for own tenancy. Direct dealing with the Department of Housing (landlord), rent payments, care and maintenance of home. Support and assistance if the person chooses to relocate.

Education/training Working with the individual to access educational and training opportunities e.g. assistance to attend classes, assistance in course selection, liaison with educational providers.

Employment Working with the individual to access employment opportunities e.g. assistance to get a job, keep a job, change jobs, and negotiate leave entitlements.

Income security Working with the individual to ensure income security e.g. assistance to negotiate wages and conditions, liaison with Centrelink re entitlements.

Recreation and leisure

Working with the individual to access recreation and leisure opportunities e.g. assistance to access chosen activities, introducing the person to a wider range of activities in the community.

Cultural Working with the individual to access social and emotional wellbeing issues, or cultural activities e.g. assistance to attend cultural days and activities, specialist health providers, access to interpreters. This is important for many Aboriginal Territorians and connection to culture, family, and community.

Family and Social Relationships

Parenting Parenting support, including working with the individual to implement parenting strategies e.g. prompting appropriate parenting, assistance with access arrangements, and liaison with schools.

Legal Supporting the individual to attend to statutory requirements and legal matters e.g. payment of fines, attendance at court appointments, visits to lawyer, adherence to legal orders. consideration of support to variations to licence conditions.



Appendix B – referral and intake process The following is an overview of the NT HASI referral and intake process adapted from the NSW HASI referral pathway.


NT HASI Review Panel – (accepted into service or placed on waitlist)

TEMHS Adult Teams concerned person may lose tenancy. Person

consents to referral to NT HASI

NGO Homelessness Tenancy Support Provider concerned person may lose tenancy has

a mental illness. Person consents to referral to NT

HASI

DHCD concerned a tenant may lose

their tenancy. Person consents to referral to NT

HASI

TEMHS Housing Project Officer logs outcome for data

collection and advises of other support

Screening process through the TEMHS Housing Project Officer to determine eligibility

Individual determined not eligible– TEMHS

Intake Worker informs referrer

Individual determined as

eligible

Eligibility and

screening process

Other service providers

Program entry

process

Referral and intake

process

NT HASI NGO functional

assessment and

engagement of participant

and other stakeholders

Carers/significant others

TEMHS, NT HASI NGO DHCD

Independent living – recovery - engage other

appropriate support service

National Disability Insurance Scheme

General Practice/Primary

Health Care

Individual Recovery Plan developed and

service delivery negotiated

Feedback surveys quarterly outcome

measures data collected

Care Coordination

Program exit

Primary Health Care Providers

Documents

Trial of the NT Housing Accommodation Support Initiative ... Web viewTrial of the NT Housing Accommodation Support Initiative ... Convention on the Rights of Persons with ... Housing