Koorie Coordinated Care “An Aboriginal Partnership Model” 7/11/2018 Koorie Coordinated Care Model

We acknowledge the Wurundjeri people of the Kulin Nation The Traditional Owners of the land on which this partnership is based We pay respect our Elders past and present and highly value their contributions to this model 7/11/2018 Koorie Coordinated Care Model

A Closing the Health Gap initiative This Model was developed by the North and Western Metropolitan Closing the Health Gap Advisory Committee. Inspired by a vision to work collaboratively to support client intake/assesment, referral and follow up The major project partners are: Victorian Aboriginal Health Service (VAHS) Aborigines Advancement League (AAL) Aboriginal Community Elders Services (ACES) Victorian Aboriginal Community Services Association Ltd (VACSAL) Victorian Aboriginal Child Care Agency (VACCA) Victorian Department of Health With an invitation extension to Model idea was born from listening to people over many years Great opportunity here in Melbourne – strong resilient organisations Large workforce of people across 5 agencies. VAHS – 160 staff - Programs AAL- 28 staff ACES- 45 staff 3 program areas – PAG and CAPS (including the nursing home and hostel) VACSAL- VACCA – 240 staff 7/11/2018 Koorie Coordinated Care Model

Koorie Coordinated Care Model Victorian Aboriginal Legal Service. Ngwala Willumbong Wadamba Wilam 7/11/2018 Koorie Coordinated Care Model

Koorie Coordinated Care Model Major goal Improved health and wellbeing of vulnerable Aboriginal people and families through stronger connections to family, services, culture and Community. This model is about connecting community Navigating the health and social service system.– Melbourne is a transient city – people come and go. how do you navigate the system If you don’t have faith in certain org for various reasons – how do you navigate the system to get you needs met. We are trying to building a system that supports everyone. CHANGE MANAGEMENT 7/11/2018 Koorie Coordinated Care Model

Four core principles informing the Model Aboriginal cultural wellbeing is fundamental to health Aboriginal health and wellbeing is everyone’s responsibility A holistic family-centred approach will deliver better health outcomes Families and individuals in crisis need to be empowered to improve their health and wellbeing 7/11/2018 Koorie Coordinated Care Model

What is coordinated care? 7/11/2018 Koorie Coordinated Care Model

Care or case planning and exit. The Victorian Department of Health represents coordinated care as being the outcome of a multi-step repeating process. Steps being Initial contact Needs identification, Assessment and Care or case planning and exit. The Koorie Coordinated Care Model is based on these principles with a focus on a Change Management across 5 Organisations Refining our intake and strengthening our referral pathways and processes and strengthening our networking through the coming together of organisations to case conference supports where required Aboriginal organisation are often the gathering point in many communities. mostly the first point of call for any one coming into a community to touch basis We rely on them for support but also for employment. Our kinship structures are strongly embedded in our organisations. This model recognises the strength our or kinship structure we wamt to build on that strengt to ensure all our community are supported no matter where they come from. Source: Good Practice Guide: A Resource of the Victorian Service Coordination Practice Manual. Victorian Department of Health Primary Care Partnership Executive, June 2012 7/11/2018 Koorie Coordinated Care Model

KCC Core service priorities Culturally appropriate client-focused agency responses Client empowerment Collaborative interagency partnerships involving clients Better outcomes for clients with complex needs 7/11/2018 Koorie Coordinated Care Model

The key KCCM steps 1. Client contacts a service 2. Client needs identified and support provided 3. Care planning 4. Monitoring 5. Care plan Review 6. Revise care plan or exit client Everybody’s needs change over time Support plans need to be reviewed and changed as necessary. A client seeks support or is referred by another organisation. When client needs are identified support needs become clearer. Support can be: In–house support AND/OR Client referred to another org AND/OR Client identified for care planning. Is the support package meeting priority needs? Client consents to share information The client needs to be an active part of the care planning process The client can coordinate their own the care plan and monitor the support given by partner orgs Care planning is appropriate for people with complex or multiple needs which cannot be met by one org or one service in an org. The need for brokerage support linked to care plan outcomes is considered at this point 7/11/2018 Koorie Coordinated Care Model

Koorie Coordinated Care Model Training An accredited Coordinated Care training package aimed to up skill staff across the 5 agencies in coordinated support. Accredited VACSAL Training S2S Online e-referral system training Work place based support from a case coordination specialist for 12 months Competitive tender process between Koorie agencies for the training contract VACSAL – (Victorian Aboriginal Community Services Associated Limited) were engaged to develop the training package. VACSAL are an accredited training provider. Was initially developed with health worker level in mind but we wanted to focus on intake. Motivational interviewing. Supporting staff to capture a clients story /journey at intake and supporting the client to navigate the system. Eg. Father three chn. 2 young 8 & 10 1 in year 11 at high school Grandmother. They are not connected to any program or support network but he knows he can get a voucher from each of the agencies each months and food parcels. So he struggles from fortnight to fortnight. Not knowing there are programs that can help him with support of the kids at school. Support from ACES to provide respite care. Scholarships for young up and coming students. Supported Co-ordination. developing a care plan that he can control with interagency support. 7/11/2018 Koorie Coordinated Care Model

Koorie Coordinated Care Model VACSAL accredited training: Part 1: 1 Day forum for CEOs and Program Managers Part 2: Pilot support / workforce development delivered by VACSAL RTO Focus: contributes to Cert III Cert IV. commencing September 2014 Six in-class days spread over 5 weeks Includes work-place follow up and work-place based assessment 20 workers in the initial course VACSAL developed course coordinates development of training resources, delivery, assessment. Links to follow-up support provided in the work place by the specialist care coordinator. Specialist contributions from project partner orgs (AAL, ACES, VAHS, VACSAL, VACCA and others e-referral unit – links to S@S roll-out Workplace care coordination specialist attending Graduation December 2014 7/11/2018 Koorie Coordinated Care Model

Koorie Coordinated Care Model Where to from here? 7/11/2018 Koorie Coordinated Care Model

Implementing the model Building skills across the org’s Road testing the model across the 5 organisations - Working with families Measuring outcomes 7/11/2018 Koorie Coordinated Care Model

The Koorie Coordinated Care Model logo The net is an important traditional contributor to survival in Country. The strands of the KCCM net remind us that strong connections to family, Community and services are important to health and wellbeing. So many of our community fall through the gaps. The KCCM net has been developed to recognise the project model partnership . Closing the gaps, developing a safety net in organisations and wider Community through coordinated care. The net is an important traditional contributor to survival in Country. The strands of the KCCM net remind us that strong connections to family, Community and services are important to health and wellbeing. So many of our community fall through the gaps. The KCCM net has been developed to recognise the project model partnership . Closing the gaps, developing a safety net in organisations and wider Community through coordinated care. Artist: Gary Saunders 7/11/2018 Koorie Coordinated Care Model

Koorie Coordinated Care Model Project contacts Don Stewart Koorie Coordinated Care Model Pilot Project Worker M: 0408 605 998 E: defordon@gmail.com Joanne Atkinson  CtHG Partnership Manager  North and Western Metro Region M: 0478 818 011  E: joanne.atkinson@vahs.org.au  joanne.atkinson@health.vic.gov.au Project contacts Don Stewart Koorie Coordinated Care Model Pilot Project Worker M: 0408 605 998 E: defordon@gmail.com Joanne Atkinson  CtHG Partnership Manager  North and Western Metro Region M: 0478 818 011  E: joanne.atkinson@vahs.org.au  joanne.atkinson@health.vic.gov.au 7/11/2018 Koorie Coordinated Care Model