Services Connect

Better services for Victorians in need

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Ministers foreword
It is with great pleasure that we introduce Services Connect our new, integrated human services model. This new model, and the vision it embodies, will make a real difference to the lives of disadvantaged Victorians and their families. Over the next few years, Services Connect will transform our processes, upend the traditional welfare model and ultimately encourage independence for the people we assist. This nancial year, Victoria will spend almost $5 billion on services for disadvantaged and vulnerable people, including housing and homelessness services, disability services, child protection and youth justice, mental health and alcohol and drug services, services to tackle family violence, and others. But despite this investment, too often we are not achieving our goal of helping people to move out of disadvantage. Increasing numbers of families with complex needs are touching all corners of our system, but unfortunately the complexity of disadvantage is matched by the complexity of our policies, services and structures. Speak to a family in crisis today and chances are they will tell you that accessing and dealing with our services feels like a full-time job in its own right. We are committed to changing that by reducing the complexity and fragmentation of our services. Services Connect looks to respond to this by forging joined-up human services that connect people with the right support, address the whole range of a persons or familys needs and goals, and help build peoples capabilities to improve their lives. We are taking a long term view with Services Connect, and while we expect change to take time, we have taken the rst important steps and are steadily building on this work. After developing and testing elements of the Services Connect client support model in three lead sites for a year, we are beginning to test new elements and extend this new way of working to service more people. We are also expanding the model to new sites across the state. This document provides an update on our progress, provides insights and experiences from those on the ground and outlines our plans for the future. Our vision for integrated human services can only become reality through the hard work of the dedicated and committed workforce in the department, across government and in the non-government sector. While change is difcult and complex, we are embarking on these reforms having done the research and testing and in the full knowledge that renements will be needed over time. It is leading edge transformation and provides the foundation for a fundamentally improved relationship between government, the community sector and vulnerable families. The Coalition Government believes that all individuals, with the right supports, can address their difcult circumstances and build a better life for themselves and their family. No matter how successful we are in growing our economy, we can never consider ourselves truly successful if we leave our most vulnerable citizens behind.

This is an overview of the new Services Connect Delivery Model.

Services Connect Delivery Model

Other

Police

GP/Hospital

Improved information, advice and referral Self Support

A  lcohol and Drug services

A  ccommodation services

C  ourts/Prison release

C  ommonwealth/ Centrelink

L  ocal Government

S  chools/Kindergartens

M  ental Health services

C  ommunity Health

C  ommunity Service Organisations

F  amilies/Friends

Self referral

Source of contact

Access

Initial Access

Identify

Immediate Service Response Comprehensive Needs Identication Clientdirected Planning Managed Support

Statutory Response

Plan

Guided Support

Service Response

Integrated Services and Support Review Exit

The Hon. Mary Wooldridge MP Minister for Community Services, Mental Health, Disability Services and Reform

The Hon. Wendy Lovell MLC Minister for Housing, Early Childhood Development

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Introducing Services Connect

We are working to transform human services to respond to the signicant challenges we are facing today. Services Connect is the centrepiece of this transformation. Services Connect is our new, integrated model of human services. It shifts the focus of service delivery so that services are built around people and tailored to their unique needs, goals and aspirations, rather than around rigid program eligibility. It encompasses an approach to practice that takes the best of what we currently do, and makes it something that all human services do. By gaining a better understanding of the people we support, it allows human services to work more efciently, ensuring people get more of the support they need and less of what they dont need. This means a better experience for people who access services, more rewarding and collaborative work for the people who provide those services, and more success in supporting people to move out of disadvantage. At the core of Services Connect is a model of service delivery that provides: One assessment when people access human services, instead of multiple assessments that duplicate each other One client record instead of multiple records held by different services, so that people only need to tell their story once One key worker to be a single point of contact for people with complex needs, so that they dont need to navigate through a maze of services on their own One plan that considers the full range of a persons or familys needs, goals and aspirations, and covers the full range of services they receive. Services Connect looks to transcend traditional administrative boundaries to connect human services; from housing to child and family services, from disability support to community mental health and alcohol and drug treatment services. More effective pathways that are easier to navigate will lead people to the right information and direct people to the right level of support. The dedicated practitioners working in the Department of Human Services (DHS), other government departments and the community sector are crucial to the success of these reforms. Services Connect will support the human services workforce to work in the way they want working collaboratively with people and families, and with their colleagues, and focusing on helping people to improve their lives.

What is Services Connect?

Services Connect is the model for integrated human services in Victoria, designed to connect people with the right support, address the whole range of a persons or familys needs, and help people build their capabilities to improve their lives.
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The case for change

The impetus for this once-in-a-generation reform was articulated in December 2011, when we outlined the major challenges facing our system in Human Services: The case for change. That document identied a range of issues, including: A fragmented, poorly coordinated system that is not as effective as it could be The system leads to practitioners and professionals, providers and programs being poorly coordinated, meaning that people have to navigate from service to service, trying to make sense of a complex system on their own. The system currently focuses on immediate problems, issues and crises in peoples lives. This prevents us from helping people to build their own capabilities and address the underlying causes of their disadvantage. been able to comprehensively tackle the fragmentation of our system. This is not a reection on the committed people inside and outside of government who have worked to make these reforms a reality, but a function of the complexity of the problems we are dealing with. Recent Victorian reform efforts in addressing violence against women and their children, community mental health, alcohol and drug treatment services, and services for vulnerable children and their families have generated consistent themes about what is needed to improve human services. To best serve vulnerable people, it is clear that human services need to be: simpler to navigate and less confusing better coordinated for families who need support from multiple services better at supporting individuals and families before they are in crisis supportive of people playing a greater role in planning their own futures more sustainable by removing inefciencies and duplication. These themes are also evident in the national and international experience. While the weaknesses of the current system are signicant, the situation also provides an opportunity. The need for transformative change means that we can take maximum advantage of new technologies and approaches to make human services in Victoria a world-leading model through one major, sustained effort. By working together across human services we can seize this opportunity through Services Connect.

Responding to your feedback

Our response to these challenges is driven by feedback from human services professionals and from people who use our services.

The people we work with have told us

Our sector partners have told us

A narrow focus on immediate problems

I had to change workers four times I had to get used to someone else and I dont know why it was hard

Its hard to build strong working relationships when workers involved with a client keep changing

An inexible system that cannot target effort to where it is most needed A focus on programs means that people must t into whatever services are available. Services can rarely respond to the specic goals people have for themselves or be tailored to their needs. This wastes resources and threatens the sustainability of the system.

thought they could provide I me with ideas, instead I was

left with no idea of how to combat or rectify the problems. It made me feel guilty

need to alter the focus We  from a disjointed safety net and crisis response to a long term approach that supports people to fully engage in society

There are many examples of great practice across our system, but these are most often thanks to committed efforts by individuals and teams acting on their own initiative. Most innovation has happened despite the structures of the system, rather than because of them. It is not surprising that many human services practitioners and professionals have been frustrated by the inability to turn successful, collaborative and coordinated trials and pilots into mainstream practice. Victoria is proud of its leadership in human services on a number of fronts, including our early intervention with vulnerable families, recent innovation in homelessness services and individual funding for people using disability services. But none of these innovations have

you just Sometimes  want a simple answer to a simple question just wish theyd all have I the same information. So many times you get told different things

need to be involved Clients  in setting their own outcomes and the mix of services that can best assist them to achieve their goals

They dont write down everything you talk about, so the next one knows very little about you as a person

services focus on the Most  presenting issue, not holistic

needs, yet the evidence tells us that setting outcomes around social inclusion can have a signicant positive impact in peoples lives. Setting social inclusion outcomes needs to be an important part of the way we provide services

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The broader context for reform

Services Connect is occurring during a period of widespread transformation across the human services system. It is not happening in isolation and it is building on more than 150 years of hard work and innovation in the human services sector. Major reforms have been completed or are underway in disability services, child protection, housing, homelessness, family violence, community mental health and alcohol and drug treatment services. Each is seeking to improve a part of the system, integrating with other human services programs and improving outcomes in peoples lives. Services Connect complements and enhances these reforms by targeting the whole system and establishing a comprehensive model for integrated human services. The reform efforts occurring across the human services system support and underpin the development of Services Connect. They will provide an early test of how more integrated, person-centred and outcomes focused approaches can and should operate in practice. These early lessons will help rene Services Connect as it expands, particularly as we connect with services outside of government. Importantly, the Service Sector Reform project, which is led independently of government by Professor Peter Shergold AC, will be a key inuence on the development of Services Connect. The project, which is being delivered in a partnership between the Victorian Council of Social Service and government, will help us consider how government and the sector can partner to give full effect to the Services Connect model.

Some of Victorias major reform themes

Victorian Homelessness Action Plan Victorias Action Plan to Address Violence Against Women and Children New Directions for Alcohol and Drug Treatment Services A Roadmap
A joined up pathway through the treatment system Takes into account the whole family, particularly children Helps people reconnect with their families and reintegrate into their communities

Community Mental Health - Psychiatric Disability Rehabilitation and Support Service Reform
Flexible, personcentred, family focused support A sharper focus on outcomes Joined up support through improved planning and collaboration across services

Victorian Victorias State Disability Vulnerable Plan 2013 - 2016 & Children Strategy National Disability Insurance Scheme

Providing support early to prevent people from becoming homeless Better integration of homelessness services with other parts of the service system Flexible service provision centred on individual needs

Engages a range of government areas and community sector organisations to work together to address violence Has prevention at its core Early intervention approach for women and children at risk

People with disability should be supported to participate in and contribute to social and economic life to the full extent of their ability People with disability should be enabled to exercise choice and control over the purpose, planning and delivery of their supports

A shared understanding, responsibility and accountability for vulnerable children Emphasising prevention and early intervention Collaborative governance and a focus on performance

SERVICES CONNECT

Transforming the Department of Human Services

In December 2012, we transformed the departments structure in order to put clients at the centre of everything we do. The new structure removes program silos and duplication, and further supports local communities with 17 local area ofces. This new structure will help us realise our emphasis on moving towards more place-based approaches. Building connectivity and strong engagement across levels of government and with the sector in a local area will facilitate the delivery of person-centred and community based services aligned to local needs and circumstances. Every persons job in our department is now geared towards making integrated, person-centred services a reality. Individual and Family Support Units have been established in all 17 of the new local area ofces; these units will bring together case management services across all our programs. Also, new Local Connections Units will build strong local relationships with community services organisations. This will ensure better coordination of services.
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As we keep developing and testing Services Connect, the new structure will ensure all areas can work with clients in a more integrated way. This will set the foundation we need to expand Services Connect in the coming years.

The Service Sector Reform Project

Transformation of human services must consider the way that government and the community services sector work together and the opportunities for a more vibrant, effective, sustainable and efcient community services sector. As the demand for human services has grown over the years, the community services sector has become increasingly large and complex. Today, more than 1,000 organisations are funded by the department to provide hundreds of different services. Inevitably, some characteristics of the sector some created by government and others not restrict its ability to help people achieve the best possible outcomes.

Professor Peter Shergold released a discussion paper Towards a more effective and sustainable community services system in February 2013, which has been the basis for consultation with organisations that deliver community services. The reform project will focus on how together we can achieve better outcomes for people, be more innovative, exible and efcient in service delivery, and ensure services are nancially sustainable over the long term.

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Services Connect and the Victorian trial of the National Disability Insurance Scheme (NDIS)
The Barwon area is a launch site for the NDIS, and is also hosting a Services Connect lead site in Geelong. From 1 July 2013, and over the course of the three-year NDIS launch period, around 5,000 people with signicant and profound disabilities, together with their families and carers, will have their needs assessed and will start receiving individual care and support packages under an NDIS model. Testing of the Services Connect model at the Barwon lead site in Geelong will continue alongside the NDIS launch, providing an opportunity to test how the Services Connect and NDIS platforms can best work together in practice. Once fully developed, Services Connect can provide a pathway into NDIS support for those who are eligible, and should also assist those who are not eligible for the NDIS to nd supports that meet their needs within human services and more broadly.

Services Connect and reforms to community mental health and alcohol and drug treatment services
Community mental health support services and alcohol and drug treatment services are important specialist partners in Services Connect, reecting our holistic focus on client outcomes. Community mental health support services and alcohol and drug treatment services, largely delivered by non-government organisations, will provide important points of connection with Services Connect. Services Connect will provide signicant advantages for the many mental health and alcohol and drug treatment clients who would benet from additional support, including that provided by DHS funded services, to address other issues in their lives in a more streamlined way. In many other cases, community services will benet from being able to refer people to community mental health support services and alcohol and drug treatment services while retaining overarching responsibility for coordinating their support. The Department of Health has been leading signicant reforms of the way that community mental health and alcohol and drug treatment services are delivered to Victorians, with new service models and responsibilities due to commence in mid 2014. We will create links between this work and Services Connect, as part of the effort to build stronger connections between health and community services.

Community mental health and alcohol and drug services have been involved in testing of elements of the Services Connect model in our lead sites, and stronger connections are now being built at the local level as a result. In particular, we are trialling a standardised screening and assessment tool that is being developed as part of the drug treatment sector reforms. The tool is being developed to complement existing tools developed specically for Services Connect, and can be used to improve Services Connect clients access to specialist alcohol and drug services where they could benet from this kind of support.

Services Connect and the child protection operating model

The Services Connect model complements the departments child protection operating model. It aims to ensure that people were working with, particularly families with multiple and complex needs, can access more intensive support when they need it. Services Connect practitioners are working closely with child protection practitioners to ensure that a holistic approach to intervention, planning and support is in place for the whole family. By working together we can better address the multifaceted issues in the lives of some of the most vulnerable families. Some families who are in the early stages of child protection involvement, and could benet from Services Connect, are being referred to guided and managed support. Through the Services Connect model we can work with families in an integrated way to build their resilience and condence, with the aim of preventing more involvement by child protection in the future. Early feedback is very positive. People have embraced the person-centred, strengths based Services Connect approach and have responded well to the key worker, who works in partnership with child protection practitioners. Some clients who have been challenging to engage in the past have responded very well to this model.

Services Connect and the Victorian Homelessness Action Plan

The Victorian Homelessness Action Plan is built on the same principles that underpin Services Connect: a stronger focus on peoples needs, goals and aspirations, addressing the underlying causes of homelessness, providing early support so people dont become homeless, better integrating services and providing more exible support. Improving connections between homelessness providers and increasing the focus on lasting outcomes for people experiencing homelessness will provide a solid foundation for strengthening connections to other services through Services Connect.

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Services Connect a new approach to human services

Services Connect will change how individuals and families experience human services. This will include: Creating positive engagement and lasting change with people and families We are moving from a traditional welfare approach where people receive tightly dened services, to a client-centred approach that engages people to plan their personal, social and economic goals, build their strengths and capabilities, develop independence and ultimately achieve their potential. People access services, information and support from many different sources. Services Connect will improve the quality and consistency of information by establishing streamlined contact points and information systems to provide one client record that both clients and practitioners can easily update, making the whole experience more convenient for people. One key worker to coordinate multiple services One key worker will be the main point of contact for individuals or families needing more intensive and specialised levels of support. The key worker will engage people to plan their support and will help manage and coordinate the other services involved in their lives.

Services Connect works for people

In early 2012, we began testing a new approach to case management for people with complex needs in Dandenong, Geelong and the South West Coast. This new approach is a core component of the Services Connect model, and we have developed Services Connect from this starting point. However, Services Connect is more than just a new approach to case management. It contains multiple elements, some of which are now ready for further testing, while others require more development and trials over coming years. Services Connect will improve how government services work together, how we work with people accessing services and how we work with our service partners, including: How people access information and services How a persons range of needs is identied How we plan with people to determine the services they need

Building on existing strengths

Human services are built on a strong commitment to improving peoples lives. Victoria has a long history of community groups, religious organisations, charities and other not-for-prot organisations dedicating their efforts to tackling disadvantage. Weve learned a lot over this time and Services Connect builds on everyones effort and experience: -  Strong local presence: The departments network of local ofces will continue to provide services in each community. New Local Connections teams in local ofces will build relationships with service providers in their areas to connect people and their families with local support and services. -  Specialist services: Government will continue to fund and deliver a broad range of specialist services, such as statutory child protection and youth justice services. -  Partnerships with the community sector: Community sector organisations deliver vital services and achieve signicant outcomes for people. The sector will continue to play a critical role in service delivery. -  Innovation in service delivery: Government and the community sector will continue to develop new and innovative ways to support people, such as the successful Individual Support Packages introduced for people accessing disability services and the Work and Learning Centres in public housing areas.

A plan that considers the full range of a persons needs, goals and aspirations Rather than multiple plans that each focus on one issue, people who access multiple programs or experience multiple issues will have their goals combined into one plan that considers the full range of their needs. This will take into account their family context, rather than just focusing on the individual, and where appropriate plans will cover the entire familys needs and goals.

Improved access to information

Targeted support based on a persons or familys level of need Services Connect introduces a exible, tiered support model that can respond to a familys or individuals needs, goals and aspirations. This targeted approach allows a service response that ts much more closely to peoples unique situations, including their life circumstances, family and kinship relationships, community and cultural identity, and that can adapt as peoples situations change over time. We will establish a shared method of identifying peoples needs and determining the level of support they require, rather than going through multiple assessments and having to tell their story multiple times. Services Connect uses the concept of family in its broadest context - it includes anyone a person identies as being part of their family or social support network. While it isnt always appropriate to work with a family rather than an individual, family can play an important role in people addressing their problems and achieving their goals.

Services Connect will focus on...

How we deliver the service response needed to improve peoples lives. The service delivery model involves signicant changes at each of these four stages.

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Three levels of support

Key workers in managed and guided support help people and their families develop tailored service responses. They also help people engage with the specialist services they need, and work with people over time to review outcomes. Key workers in guided support will provide a small amount of initial assistance to some people accessing self support.
MANAGED SUPPORT
is for people with the most complex situations, who require multiple services and more intensive coordination and assistance.

Supporting four boys: their story*

Four boys with disabilities who could no longer live with their parents were moved into a special out-of-home care residential unit that was equipped to cater for their disability needs. The impact of the move was enhanced by their entry into the new Services Connect managed support service, where they were given a single key worker. The key worker quickly became the single contact for the multiple disability and child protection workers involved in the boys lives. This alone has greatly simplied communication between the department and the community services organisations involved with the boys. The key worker has had a signicant impact on the way the various service providers work together, making it easier for the boys to focus on their individual and shared goals as everyone is working to the same plan to support them in a coordinated way. By better coordinating support in the boys lives, the key worker has introduced a preventative approach to the care team, where crises can be pre-empted and there is a focus on building their independence. Today, the boys are experiencing signicantly fewer crises in their lives. The safe, encouraging and supportive environment is allowing the boys to be active in developing their own life plans. As a result, all four boys are getting so much more out of life. Theyre learning independent living skills, pursuing education and training, and enjoying more meaningful contact with their families. One of the boys, whose goal was to live independently, moved into a lead tenant arrangement about six months ago. Hes doing really well, ably supported by his care team. Another of the boys just moved into supported accommodation. The boys have made remarkable progress since they joined the managed support service.

GUIDED SUPPORT
is for people with moderate to high needs, who require some coordination and occasional assistance.

SELF SUPPORT
is for the majority of people; they can largely self manage their support and services with minimal assistance.

* With the exception of James story, the names and images featured in this case study, and those on the following pages, are not those of the people involved.
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A focus on outcomes
At the core of Services Connect is a strong focus on long term outcomes for people, improving lives and increasing independence. We want this outcomes focus to drive actions and decisions at every level of service delivery and administration from how we work with people day by day, to how we plan and fund services. For day to day work with people in guided and managed support, we are embedding a new outcomes focus via the Outcomes Star case planning tool. The tool tracks a persons development towards independence, from being stuck, to accepting help, learning skills and being able to manage on their own. With the help of their key workers, people can use this tool to assess their situation and develop meaningful plans to improve their lives. They can then use the tool to measure their progress against their agreed plans. We are testing the Outcomes Star in the Services Connect lead sites and the feedback has been very positive. Clients say that it motivates them to work on change, and our practitioners nd that it helps them focus on positive outcomes and progress. By giving people who use services and people who provide services a common point of focus towards the same goals, this tool is improving the chance that we will have a lasting impact in peoples lives. The outcomes captured in the Outcomes Star are developed collaboratively between individuals or families and their key worker. As such, they are specic to each persons or familys plan. This means plans are better tailored to individual circumstances and people are more actively engaged, but it also means that these outcomes are not necessarily comparable to those of other individuals and families. In addition to working with people in a more outcomes focused way, we want to better understand the outcomes people are achieving at a more aggregated level and how services are contributing to those outcomes. To do this, we need to develop a set of outcomes that will work at a more aggregated level. Arriving at an agreed set of outcomes, together with the indicators that measure how well services are contributing to meeting them, requires further dialogue with our stakeholders. We cannot let the complexity of that process get in the way of arriving at a set of meaningful outcomes even if they are not perfect. The following potential set of outcomes captures aspects across the personal, community and economic domains that contribute to a persons wellbeing, and is offered as an opening contribution to this wider dialogue to be led by the department during 2013-14.

The Outcomes Star helps clients to see where they are and where they want to be

Personal, economic and community outcomes

Triangle Consulting Social Enterprise, Used under license. See www.outcomesstar.org.uk

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How people experience positive outcomes

Positive outcomes mean different things for different people. Here are some of the ways people may demonstrate progress towards their personal, economic and social goals.

The Brown familys story Engaging with their planning

Neglect and safety concerns had seen all four Brown children subject to legal intervention. The parents had become very wary of child protection practitioners and were reluctant to talk to the department. This changed when our managed support key worker began to work with the family to assess their situation using the Outcomes Star. With a much deeper understanding of the familys circumstances, our key worker began working with the family on achieving lasting change. Using the Outcomes Star tool the key worker was able to raise concerns over neglect and safety as part of conversations about the broader needs of the family in a way that didnt threaten the parents. Importantly, the tool helped the parents to see that by managing uctuations in their mental health they could bring stability to their family. Both parents have openly acknowledged that Services Connect helped them feel genuinely heard and understood leading to a much more trusting relationship with their key worker. They are now accepting support when and where they need it. Their key worker is now hoping to move them to the guided support level with a view to one day achieving independence.

PERSONAL

ECONOMIC

SOCIAL/ COMMUNITY
People and families successfully manage their health and wellbeing
 consistently consider the consequences of their actions  have a positive view of their potential and act to achieve it  no longer develop relationships with people who use violence  overcome a history of alcohol and drug use or offending, develop new social networks and avoid the peer groups they shared these behaviours with

People and families have the skills and support necessary to participate in the economy to their fullest ability
 have strong living skills: managing the home, personal hygiene, social interaction  have strong nancial management skills: prioritise spending and live within means  are literate (in at least one language) and numerate  although not orally communicative, effectively use communication aids

People and families are safe and positively connected to friends, family and their local and cultural communities through healthy and supportive relationships
 have strong, positive relationships with their children, parents, carers or other important people  have an active connection to their cultural community

The Services Connect approach draws the community around people so they receive more support from important people in their lives and are more socially connected

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The Services Connect experience

Individuals and families will experience a new way of working from the moment they access our services to the point where they no longer need us in their lives. This diagram steps through how they will experience the new service delivery model. Access
Information about and access to services
Choice about how to contact us Improved service at rst contact  Information is easier to nd and understand Options for self-service  Faster and more meaningful referrals

Plan
The process of planning to meet needs
 One key worker who has responsibility for assisting and coordinating practitioners and specialists  One client or family plan with clear goals is developed with a person or family  A single case planning tool maintains a focus on the persons or familys outcomes and helps them work towards greater independence  Opportunities for economic and community participation are promoted  Plans reviewed every three months  for progress and outcomes

Service Response
The provision of services to help people achieve their goals
 The right support that is tailored to unique circumstances, kinship relationships, identity and culture  Key worker will work with individuals and their families t  o coordinate and stage supports across a range  of service types  Services will be coordinated to meet the goals i dentied in plans  Service providers will be working to one plan w  ith a shared understanding of the goals

Identify
Needs are identied and assessed
Information collected once  One record for each person that shows connection  to other family members  Initial response to assess level of support required  One of three levels of support, based on identied need

Exit

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Client Support how were working differently

The Services Connect model encourages an approach to practice that is person-centred, strengths based, holistic and family sensitive. Services Connect key workers embed these practice principles in the way they work with individuals and families, using strategies such as motivational interviewing and tools such as the Outcomes Star. These approaches are not new; rather they draw on examples of best practice that are already being applied across various services and programs. The difference with Services Connect is that we are seeking to embed this approach in the way we work with all clients and families; across all aspects of their lives; in all of our interactions with them. Person-centred practice involves tailoring support to meet a persons unique needs. This leads to more active client engagement, increased client responsibility, and greater feelings of empowerment. Strategies that key workers are adopting to support person-centred practice include: Developing a trusting relationship with the person or family and really getting to know them Actively listening to and understanding peoples goals and aspirations Providing tailored and exible responses that are sensitive to each persons values and preferences. A strengths based perspective recognises peoples unique strengths, skills and abilities rather than focusing on their problems. The fundamental premise is that individuals do better when they are helped to recognise and use strengths and resources available in themselves and their environments. Strategies that key workers are adopting to support a strengths based approach include: Recognising that all people have strengths and capabilities Acknowledging that people can change. Given the right conditions and resources, peoples capacity to learn and grow can be harnessed and mobilised Seeing that people may need help and guidance, but they are still the expert on their own situation. Holistic practice focuses on the whole range of a persons goals, aspirations and needs, as well as those of their family where appropriate. Key workers try to understand the interplay of personal, relationship and social factors that affect whats happening in the life of each person they are working with. Taking a holistic view of these interconnected factors, practitioners can draw on a referral network of professionals, services and community groups to offer a more comprehensive, and therefore more effective, response. Strategies that key workers are adopting to support a holistic approach include: Identifying and assessing the persons goals, aspirations and needs, rather than whether they are eligible for a particular service Use the Outcomes Star case planning tool to support holistic planning across all life domains Acknowledge the persons cultural and spiritual background. A family sensitive approach recognises that supporting positive relationships with the family network may signicantly help individuals recovering from major challenges. At the heart of the concept is the idea that providing care and support to vulnerable people is more effective if it recognises the needs of families, as well as the individual. Of course, involvement of a family will not be appropriate in all cases, and Services Connect recognises this. For example, consistent with a child protection approach, Services Connect will retain a strong focus on the safety, stability and wellbeing of children - recognising their heightened risk of vulnerability and the importance of early intervention in addressing issues that may hinder healthy wellbeing and development. Strategies that key workers are adopting to support a family sensitive approach include: Using the Family Star (a version of the Outcomes Star) to support case planning that focuses on parenting goals Arranging family group meetings to engage the broader family and signicant others, including professionals and kinship groups in working together to support the family Visiting members of the family in their own homes. Motivational interviewing is a person-centred, strengths based form of counselling that aims to elicit and strengthen motivation for change. It is essentially a conversation about change. This doesnt mean that the practitioner automatically agrees with the person about the nature of the problem or the changes that should be made. Instead, it means practitioners use careful listening and reective responses to show they understand the issue from the person or familys perspective. It requires the practitioner to draw out the persons thoughts and ideas so that they can discover their own reasons and determination to change. The person isnt told what to do or why they should do it.

People are encouraged when we acknowledge their strengths and the obstacles they have overcome along the way

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Making our systems work for people

To work effectively at scale, the Services Connect model needs two key enabling elements: a system for efciently communicating between us and our clients, and a system to manage client information. to self-manage their support, only accessing extra help when they really need it. This will also free up experienced and more highly skilled practitioners from devoting time to administrative tasks so they have more time to support people with higher needs.

Rosies story The benets of having one key worker

Family violence left Rosie with an acquired brain injury, emotional trauma and vision impairment. She also needs a wheelchair and walking aid to get around. Unfortunately her four children witnessed this; one has post-traumatic stress disorder, another is now Rosies full-time carer. Rosies situation is complex. At one stage it involved two disability service providers, a local advocacy group, Victims of Crime, a solicitor, health and allied health professionals, a public housing support worker and a nancial counsellor. Thats 10 specialist services. Through Services Connect, Rosie was assigned a single key worker who worked with the whole family to assess their needs and followed this up with an action plan that set out how they could work towards their goals. Almost straightaway her oldest child was getting carer support and her younger children were beneting from respite care and camps. In the past Rosie and her children would have had to deal with many different specialist service providers, who would have put together different action plans with different goals for the family. Now, with Services Connect, they have one key worker as their contact for support services. With a simpler, more efcient and responsive way of working like Services Connect, we can be more effective for families like Rosies.

Systems for handling communication more efciently

Under the current system, communication channels between people and most services are outdated and inefcient, relying heavily on high-cost, time intensive, face to face and paper based interactions. Services Connect will make it easier for people to get the information they need and to communicate with services. Under Services Connect, many activities that are currently undertaken in local ofces will be consolidated into centralised service centres. The types of activities to be treated more consistently and efciently will include responding to telephone enquiries; providing information; scheduling appointments; processing standard reports; and completing and assessing applications for services or supports. We will also establish new online, mobile and telephone self-service capabilities. The changes are intended to be benecial for both clients and the people working with them. The new approaches will enable people

Better information systems and information sharing

As Services Connect grows, we will keep making life easier for people accessing services and for the professionals who support them. Better information systems improve peoples experience of services because they dont need to tell their story multiple times. They also improve services by ensuring that practitioners have the information necessary to more quickly and accurately understand a persons situation and make an assessment about the right support for them. Better systems also ensure that different practitioners and organisations can collaborate with regard to people they are jointly supporting and avoid duplication or nonbenecial overlap of services. We are investigating ways for our practitioners to view all the information held about a person in one place, including their case history and family connections. This might involve adopting technology that can draw together all the existing client information held in various information systems, identify where information in different systems relates to the same person, and consolidate that information in a userfriendly way. This would mean that changes to a record would only need to be made once, reducing the possibility of inconsistency. Initially, were focusing on consolidating the information we hold within government. In future, we intend to explore the potential to extend the system to other parts of, and across, the sector. The protection of clients privacy will be a key consideration of this work.

Some people are amazed when we ask them for feedback on our services. They have never been asked before

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Putting ideas into practice: testing the model

We are currently testing the Services Connect model in three lead sites, with teams delivering managed and guided support. But these are only two elements of the full Services Connect delivery model, targeted at people with more complex needs who need more intensive support. We expect that a majority of people receiving human services will be able to self-manage their services, as long as they can easily access the right information and communicate with service providers in ways that are convenient for them. People in this situation will be part of the self support service, which we will begin testing later this year. We are also developing and testing the new contact and administration systems, communication channels and approaches to managing information that are essential for the Services Connect model to work effectively. In 2012 we began trialling an Information and Referral Service at the existing housing callcentre in Moe, Gippsland, as the rst step towards a comprehensive new client contact system. This means that calls from two large, high-volume DHS housing ofces (Preston and Dandenong) are managed by a team of trained contact ofcers. In most cases these ofcers can resolve peoples issues or answer their questions on the rst call. This means less time waiting around for return phone calls and less time repeatedly attempting to get through to workers. The housing call-centre is also testing consolidated processing of key housing transactions. This should improve the efciency and accuracy of processing, enabling front-line practitioners to focus more on providing higher value client services. A detailed evaluation is underway within the Services Connect lead sites to assess our progress and impact. The evaluation will also ensure that systems for ongoing data collection can assess the future impact of Services Connect.

James story The satisfaction of a job well done

Were also testing Services Connect outside of our lead sites and recently employed a Work and Learning Advisor on Prahrans Horace Petty Estate to connect its residents to training and jobs. After running a skills audit on the estates residents our advisor discovered 22-year-old James, who was out of work and at a loose end despite having completed an RMIT preapprenticeship and partially completed two plumbing apprenticeships. At the time the Horace Petty Estate was undergoing a redevelopment and as a condition of the contract Kane Constructions agreed to employ at least ve of the estates tenants. Our Work and Learning Advisor put James name forward and he was offered an interview. Leading up to the interview the Adviser put James through two practice interviews at the estates Youth Connect Job Club and helped him get as ready as hed ever be. Consequently James won the apprenticeship. With the redevelopment now complete James has only good things to say about his experience, particularly the satisfaction of being involved from start to nish. Importantly, James success has been an inspiration to residents and hes been a positive role model to other young people on the estate.

Work and Learning centres: participating in the economy and increasing independence
A key theme of Services Connect is a focus on economic participation to help people increase their independence and ability to manage their own lives. We have established ve Work and Learning Centres across Victoria on or near public housing estates to connect people who live in public housing or receive other department services with training and work. The centres are located in Ballarat, Carlton, Geelong, Moe and Shepparton. The Services Connect lead site at Geelong has established a strong partnership with the Work and Learning Centre so that they work together to support people whose plans include education, training and employment. We are referring people to the Work and Learning Centre and we are developing clear roles and responsibilities in the way that we work so we can help people achieve the best outcomes. We have also introduced economic participation facilitators working at each Services Connect lead site who engage with local and regional service providers, including State and Commonwealth agencies, to reduce barriers to economic participation for the people we support. The facilitators are developing local solutions to address barriers to economic participation and are identifying how we can better support people to engage in economic participation into the future. In the South West Coast, our local facilitator has started to bring together departmental staff and a local service provider in the Commonwealths Job Services Australia network to identify how clients with complex needs can access human services support to help them stabilise and improve their employment prospects. The goal of this work is to ensure that, by facilitating and encouraging conversations with all parties involved, people will be better supported and receive better employment services as a result.

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What do we know so far?

Our preliminary ndings suggest that practitioners and clients are both benetting from and enjoying the new approach. However, it is clear that working in this new way demands signicant cultural changes. These include: moving our focus from seeing the individual as the client, to seeing the whole family as the client changing our motivation from helping people to supporting people to help themselves shifting the emphasis of practice to take an interest in all areas of a familys life, rather than just one discrete eld. Our practitioners tell us that the new tools and approaches are helping them change practice, and are also valued by the people they are working with. They have reported signicant improvements in behaviours and short term outcomes for some people in more complex situations. Clients have said that they value practitioners showing interest in aspects of their lives beyond the single, presenting problem. They like that the new approach allows them to have more say in planning and reviewing their services and outcomes; it gives them greater control over their lives. They also report that practitioners are working with them in a more positive way. Importantly, some clients have seen a reduction in the number of workers involved in their lives; for example, in situations where several members of the same family have been receiving services, the Services Connect model has allowed one key worker to work with all members of the household. We are also monitoring the contact and processing trial at the housing call-centre, and are seeing issues resolved earlier with fewer people needing to call multiple times. Information gathering and evaluation will continue through the next few years as we expand the Services Connect model.

Kates story Taking control

Kate has been involved with child protection since she was a baby due to her mothers mental health problems and drug use which resulted in serious neglect. Kate managed OK at home with her mum through her childhood, but at secondary school she began to suffer serious mental health problems including self harm and suicidal thoughts. During this time, she disconnected from her school and community and soon found herself on a register of high risk young people. The new approach of Services Connect has re-energised both Kate and her workers who are working together to develop Kates goals and tasks. Importantly, Kate is in control of this process, reviewing and varying tasks as needed and delighting in ticking them off when theyve been completed. Kates key worker also takes great satisfaction in the feeling shes now working with Kate rather than doing things for or to her. The administrative burden reduced by the Services Connect approach also allows her and Kate to spend more practical work time together. All this has seen Kates life change for the better. With her high risk behaviour now a thing of the past shes off the high risk register and keen to get involved in working out how Services Connect can help other young people in a similar position.

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New ways of working: reections of our key workers

Staff in our lead sites have given us feedback about how Services Connect is working for them.
Joanne key worker, Client Support Team, Geelong
Whats different for you? My time with Services Connect has completely changed my experience with the department. I feel energised by this way of working and the difference its making for people I work with. A woman I am working with has been in a violent relationship for 15 years; her former partner is in jail for assaulting her. We used the Outcomes Star to identify what she wanted from her life and how she could be safe from the violence that has dominated her past. When her former partner sent abusive letters from prison, for the rst time she took the letters to the police and they acted on his breach of the intervention order. This was a big step in a new direction; she was so pleased to have drawn the line and taken charge of her life. Im also working with a woman who has had signicant drug and alcohol issues in the past. She has made so much progress that she is ready to move from managed support, where the amount of support received is relatively high, to guided support, reecting the fact that her need for support has diminished and she is coping much better with the challenges of her life. She is enrolled in a course now. We had never been able to talk about this before but now that she has dealt with the immediate issues shes facing, she can think about her hopes and dreams. We will stay in contact but we wont need to work as intensively together. Our approach is to bring people to a stronger point in their lives, and the motivational interviewing sets the foundation for a good, honest relationship. Theres no limit to how good someones life can be.

Nadia key worker, Client Support Team, Dandenong

Whats different for you? This approach is really what Im about as a social worker. Ive been able to demonstrate the passion I have for people and providing great services. In my previous role in disability services, we worked in a person-centred way, but the way Im working with individuals and families as a key worker takes it to another level. Our leaders in client support are encouraging us to really listen to what the individual or family wants and people are responding so well to this. People have told us that they feel they are being listened to and as a result, theyre more motivated to do what they need to do and take control of their life. In the Services Connect model clients are doing more of the talking and providing their point of view about where they are at in different areas of their life. I visited a woman who is in prison and we worked through the Outcomes Star. For the rst time we talked about her offending behaviour and why she feels she is caught in the cycle of drugs, offending and prison. She said this was the rst time she had ever talked about the reasons behind her behaviour. Whats working well? Another man I am working with told me that this is the rst time anyone has listened and asked him what he wants. There is also a difference in how I receive supervision. I enjoy my supervision as it is more focused on how people are going and their progress, rather than identifying tasks I need to complete.

Lisa key worker, Client Support Team, Geelong

Whats different for you? In our traditional approach we dont often get to celebrate the small steps someone takes. Until now, weve focused on averting the crisis in peoples lives, which needs to be done, but thats often about as far as we can go. Before we start working with anyone, we bring together the different plans that have been developed by services and we build a picture of the family history. That way, people dont have to start right at the beginning and answer the same questions theyve been asked so many times before. I have been working with a woman who was living on her own with mental health issues. She was very unwell and struggling to take care of herself. She took her medication irregularly and neglected her dog and home. We worked with her to secure a place in supported accommodation; that means she has support around her to take her medication regularly and eat regular meals. Now she has started a course at the local TAFE, which is a great achievement. We would never have contemplated this as an eventual outcome but it shows what we can do with this approach over time. And actually, everyone Ive worked with in this way has achieved a great outcome.

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Tysons story Connecting with community

Tyson had been involved with disability support services for several years. He seemed difcult to engage and often missed appointments with services he was referred to. Practitioners involved with Tyson struggled to keep up consistent contact and keep him connected to support. Tysons situation began to decline; he moved out of supported accommodation into a rooming house, was hospitalised for self harm and charged with breaching a Community Based Order. In 2012, Tyson was referred to the Services Connect managed support service and his key worker began building a relationship with Tyson based on his needs and aspirations. Tyson and his key worker completed the Outcomes Star, and in this discussion Tyson explained that the reason he skipped appointments was that he was scared to meet new people. But the Outcomes Star and the key workers approach were a breakthrough. Through his regular appointments with his key worker, Tyson has made the important connection between his depression and being bored and the need for social connection. Tyson felt motivated to start looking for work and he secured two job interviews without support. He also chose to

Services Connect next steps

We intend to keep working to expand the Services Connect model from these rst steps. Over the next year, we will introduce the full model encompassing managed, guided and self support in our lead sites, and in new sites across the state. We will also continue to develop the client contact system and the information technology, tools, processes and business systems needed to support the model. There is still a lot of preparation and development to do before we can start expanding the model widely. This includes training our people, getting our information systems right, and developing the access and intake processes for the model. We are clear about the goal we are working towards but we cant get there alone. Consultation with people accessing our services, as well as human services professionals both within government and in the community sector, has been a driving force behind the design of Services Connect. As we progress with expanded testing and development of the models components, we will continue to be guided by the views, knowledge and experience of people who work in and with human services. By working together we can achieve our shared goal of improving the lives of our states most vulnerable people.

Its about taking small steps. We cant solve everything for someone overnight but people can see were trying to help so they work with us

change his employment agency, which has led him to a three month part-time work trial. Tyson has also re-established contact with his mother, and they have moved in to a new at together. This has greatly improved Tysons mental and physical health. He is keeping his weekly appointments and looking forward to checking his progress each three months on his Outcomes Star. In the not too distant future, Tyson will be ready to reduce his appointments from weekly to fortnightly.

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If you would like to receive this document in another format, please phone the Policy and Strategy Group on 1300 650 172, using the National Relay Service 13 36 77 if required,or email servicesconnect@dhs.vic.gov.au This document may also be downloaded from the Department of Human Services website at www.dhs.vic.gov.au Published by the Victorian Government Department of Human Services Melbourne, Victoria Copyright State of Victoria, Department of Human Services 2013 This publication is copyright, no part may be reproduced by any process except in accordance with the provisions of the Copyright Act 1968. Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne Print Management by Finsbury Green.

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www.dhs.vic.gov.au