Uncovering stories, making meaning: How the Indigo
Program delivers assessment and care plan services for
Victoria’s Multiple and Complex Needs Initiative (MACNI)
September 2013
Table of Contents
Glossary ................................................................................................................................................... 3
Acknowledgements................................................................................................................................. 3
Introduction ..................................................................................................................... 4
The Indigo Program................................................................................................................................. 4
Background ...................................................................................................................... 5
Understanding multiple and complex needs .......................................................................................... 5
The Multiple and Complex Needs Initiative (MACNI) ............................................................................. 5
The Assessment and Care Plan Coordination Service Process ............................................ 8
The importance of comprehensive and holistic assessment .................................................................. 8
Conducting an assessment and constructing a care plan ................................................. 10
Investigative phase ............................................................................................................................... 10
Written information  referral and file reviews ................................................................................ 11
Interviews .......................................................................................................................................... 12
Additional clinical assessment and secondary consultation ............................................................. 12
Synthesis, analysis and formulation...................................................................................................... 12
Construction and coordination  the development of the care plan ................................................... 13
Implementing the care plan  negotiation, persuasion and intervention ........................................... 14
The outcome of the process – the key documents .............................................................................. 14
Strengths and challenges ................................................................................................ 16
The role of the Indigo assessor ............................................................................................................. 16
Managing risk and uncertainty ............................................................................................................. 16
Incorporating the individual’s perspective ........................................................................................... 17
Conclusion - contributing to systemic change .................................................................. 18
Appendices .................................................................................................................... 19
Appendix 1 – History of MACNI and the Indigo Assessment and Care Plan Development Service ..... 19
Sources and further reading ........................................................................................... 20
2
Glossary
APCD
Indigo Assessment and Care Plan Development
CERG
Central Eligibility and Review Group
CPC
Care Plan Coordination
DHS
Victorian Department of Human Services
DoH
Victorian Department of Health
DoJ
Victorian Department of Justice
WRHC Western Region Health Centre
Acknowledgements
This document draws on the work of Elaine Wilcock, former Education, Training and Development
Officer who undertook a comprehensive internal evaluation of the Indigo Assessment and Care Plan
Development service in 2010.
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Introduction
The Indigo Program
Indigo is a program of the Western Region Health Centre (WRHC) providing assessment, care plan
development and care plan coordination for clients deemed eligible for the Multiple and Complex
Needs Initiative (MACNI). The Indigo program has provided state wide care plan coordination for
MACNI since its inception in 2004, with the assessment and care plan development service added in
2007. Indigo also provides secondary consultation, mentoring and training for those working with
clients with complex support needs and/or within complex systems. The team at Indigo is currently
made up of approximately twelve multidisciplinary staff working across the state of Victoria.
While there exists an extensive literature about care plan coordination, there is little by way of
formal documentation describing the practice of assessment and care plan development for
individuals with complex needs. Hence, the unique aspects of this work may not be well understood
outside the Indigo program.
Indigo assessors begin their work in what can be difficult circumstances. Given the complexity of the
clients they are supporting, care teams (where they exist) may be experiencing conflict, chaos and
discord. Practitioners may disagree on diagnoses or suitable interventions; they may simply feel
stuck and that all available options have been exhausted.
As a newcomer to the situation, the Indigo assessor brings ‘fresh eyes’ and a depth of understanding
of the service system. Indigo assessors are in a unique position to gather extensive client information
and, more importantly have the time to reflect on what it might mean for new models of care.
Indigo assessors operate horizontally across service silos and vertically through agency hierarchies.
These boundary-spanning practices typify the collaborative intent of MACNI and reflect Indigo’s
expertise in putting coordinated care planning into action from the outset. Maintaining a stance
independent of the client’s service provision enables the Indigo assessor to develop a metaperspective that is essential in understanding complex systems. The resulting assessment and care
plan documents exemplify this considered process and are comprehensive, holistic and rich in
context.
The aim of this paper is to disseminate Indigo’s collective wisdom from extensive experience in
assessment and care planning with clients who have complex needs. In order to place the work in
context there is a brief description MACNI - how the initiative emerged, its purpose and processes,
and clients. The document then looks more closely at the work of Indigo assessment and care plan
development. The final section explores some of the strengths, challenges and unique aspects of the
work.
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Background
Understanding multiple and complex needs
In the past fifteen years, terms to describe individuals experiencing multiple disadvantage such as
‘high complex behaviours’, ‘multi-morbidity’ and ‘multiple and complex needs’, have become
commonplace in human services work. These terms are sometimes used with little elaboration or a
clear understanding of what they mean.
From Indigo’s perspective, the term ‘multiple and complex needs’ describes a person’s multiple,
interlocking health and social needs. The interplay of each individual’s needs is unique and therefore
requires individual assessment and often a tailored service response. This conceptualisation of
multiple and complex needs recognises the inherent complexity of the service system, as well as the
multiple disadvantages often experienced by the individual.
Individuals with multiple and complex needs are often referred to as ‘falling through the gaps’ in the
service system. Some would argue that services are structured and delivered in a way that can
preclude the most vulnerable in society. The health and welfare system is intricate and services have
historically been designed to meet single, specific needs. This can lead to a situation where a person
is excluded from a service on the grounds of being ‘too complex’. Individuals with multiple
diagnoses, particularly those with cognitive issues may find it difficult to navigate the service system.
Those with behavioural issues are sometimes excluded from the services they require. This can lead
to a vicious cycle where the individual is receiving inadequate or no services; their health and
wellbeing deteriorates, and their presentation worsens – creating further barriers to access.
The Multiple and Complex Needs Initiative (MACNI)
In early 2002, the Victorian Department of Human Services (DHS) responded to concerns raised
across the service system about the poor outcomes experienced by a small, but significant group of
people identified as having multiple needs and complex presentations. These individuals were often
experiencing multiple uncoordinated and crisis-driven service responses that failed to meet their
overall needs, while drawing heavily on the resources of agencies (particularly the justice system and
emergency services). Typically the service system around the person may be struggling or unable to
fully meet their needs. These individuals at times pose a risk to themselves and to the community.
The resulting statewide Multiple and Complex Needs Initiative (MACNI) aimed to develop more
sustainable and effective individual interventions, and to build the capacity of services to work more
effectively with people with complex needs. MACNI is a partnership of the Victorian Department of
Human Services (DHS), the Victorian Department of Health (DH) and the Victorian Department of
Justice (DoJ) - a structure that demonstrates the partnership ethos of the initiative.
MACNI is a time-limited intervention (three years) established under the Human Services (Complex
Needs) Act 2009. A legislative mandate was considered fundamental to supporting a model reliant
on effective cross-sector collaboration. Under the Act, an eligible person is one who is:




16 years or older; and
appears to satisfy two or more of the following criteria: has mental disorder, has an acquired
brain injury, has an intellectual impairment, is alcoholic or drug- dependent; and
has exhibited violent of dangerous behaviours towards themselves of others, or is
reasonably likely to place themselves or others at risk of serious harm; and
in need of intensive support and supervision and would derive benefit from coordinated
services.
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Participation in MACNI is voluntary. Although there is no requirement for informed client consent in
the Act, client consent is still actively sought. The Act instead stipulates a client can refuse to
participate in MACNI. This ‘opt-out’ provision reflects the experience of individuals considered for
the initiative; people who may have little confidence in services or trust in professionals, and as a
consequence avoid support rather than seek it out.
Entry into MACNI is managed in each DHS division by Divisional coordinators who act as a gateway
to the initiative. Referrals can come from any source including from the individual. A MACNI referral
involves detailed documentation of the individual’s existing supports and services, what has been
tried in the past (and to what effect) and a clear rationale for why referral to MACNI may benefit the
individual at this point. The threshold for access to MACNI is purposely high as it is intended as an
option of last resort.
Once complete, a MACNI referral is considered at the local level by a divisional regional panel. These
panels are typically made up of senior staff from DHS, DH, DOJ, senior representatives of local
services and independent expert advisors. Once approved at the divisional level, the referral is then
considered by the Central Eligibility and Review Group (CERG), a group comprising senior staff from
across the three departments and independent expert advisors. If the person is determined eligible
the division arranges for the development of a care plan. Indigo currently develops 99% of MACNI
assessments and care plans.
A brief history of the MACNI is set out in Appendix 1. More information about MACNI can
be found at:
http://www.dhs.vic.gov.au/about-thedepartment/plans,-programs-andprojects/projects-and-initiatives/crossdepartmental-projects-andinitiatives/multiple-and-complexneeds-initiativeWho are MACNI
clients?
Individuals who are determined eligible
for MACNI are a small but
heterogeneous group; it is difficult to
describe a typical client.
Box 1. A snapshot of MACNI clients
Data gathered by DHS since the inception of MACNI indicates
that of the clients referred:

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




74% are aged between 16 and 34 years
Two thirds are male
94% present with the appearance of a mental disorder
Around 40% experience housing instability and/or poor
general health
22% are incarcerated at the point of referral
36% present with the appearance of both a mental
disorder and intellectual impairment
40% present with the appearance of both a mental
disorder and problematic substance use.
However, the demographics shown in
Half of all referrals describe the person as meeting three of
the box highlight the multiplicity of
the diagnostic criteria (mental disorder, acquired brain
disadvantage and difficulties faced by
injury, intellectual impairment, problematic substance use).
many of the individuals referred. What
is not so well represented is the
Source: Kraner & Fisher, 2012
severity of need experienced by some
individuals. For example, an individual with treatment-resistant schizophrenia who is experiencing
frequent distressing positive symptoms, has high levels of substance use in order to manage their
psychiatric symptoms; their presentation is also compounded by chronic homelessness. This severity
of need, particularly when conventional treatment has failed, can overwhelm service providers as
much as the individual and their family.
Indigo staff notice strong themes among their clients such as the prevalence of trauma,
unsatisfactory experiences within the service system, social exclusion and stigma. Interestingly, what
also emerges are positive themes of resilience, commitment and the ability to endure.
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Even before an assessment commences, it is apparent that many clients have experienced profound
developmental trauma stemming from harm, abuse and/or neglect during their earliest years. As a
consequence, many clients are or have been involved with the Child Protection system where their
initial traumatic experiences may have been compounded by systemic failures. These harmful and
invalidating experiences can lead to enduring problems, such as disorganised attachment, impaired
self-development and difficulties in regulating one’s emotional state.
Many individuals referred to MACNI have had negative experiences as service users. This can range
from not receiving an appropriate level of support, to being excluded from services. In exceptional
cases, clients have experienced abuse or harm while in the care of a service. For others, they may
have had too many services involved in their life and , experienced a highly fragmented model of
care with multiple practitioners attempting to address their various issues in isolation.
Many MACNI clients are disconnected from their family, friends and have tenuous social networks.
Experiences of loneliness, social exclusion and stigma are commonplace. Some clients have a
prominent notoriety and face community and service rejection due to their idiosyncratic or
challenging behaviours. Others are more hidden, perhaps incarcerated or in institutional care. Some
individuals deliberately isolate themselves from the community as a means of avoiding
stigmatisation.
Amongst the stories of trauma, loss and disadvantage there are extraordinary examples of an
individual’s ability to bounce back in the face of continued adversity. It might be that a person who
after years of institutional care, chronic illness and isolation has been able to find a place for
themselves in the community and start their process of recovery. There are examples of services
and/or workers who have persevered with a client, advocating for the person’s right to support,
holding on to hope and staying committed despite the many setbacks. These exceptions can provide
valuable clues to Indigo assessors about what might bring about positive change in an individual’s
life.
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The Assessment and Care Plan Coordination Service Process
The importance of comprehensive and holistic assessment
One of the guiding principles of the Human Services (Complex Needs) Act 2009 is for a care plan to
be based on a comprehensive assessment of the client’s needs.
Individuals with multiple and complex needs are at times under-assessed and as a consequence their
presentation is poorly understood and the support they receive may be unsuitable, even
detrimental. Alternatively, they may experience numerous single-discipline assessments, which can
lead to conflicting perspectives and fragmented service provision. Clear and integrated assessment is
vital as it provides the foundation for a client’s care plan to guide their ongoing treatment, support
and recovery.
The purpose of an Indigo assessment is to understand the individual in context, and apply this
understanding to develop a more effective model of care. Indigo assessments currently take four to
six months to complete; a few take longer or shorter periods. While this may be considered a
lengthy process the complexity of the work demands this level of time. A common misconception is
that much of the time is spent reviewing files, when in reality this is a relatively small part of the
work.
Box 2. Case study ‘Simon’
The role of an Indigo assessor
encompasses many tasks, such as:









Developing relationships with the
client and their service providers
Conducting interviews
Providing a hands-on case
management role (when the
client is disconnected from
services)
Observing the dynamics of the
client and their service system
Reflecting on the information
gathered, collating and sharing
provisional understandings
Seeking additional assessment or
secondary consultation (essential
to the development of the care
plan)
Identifying and implementing the
most appropriate configuration of
services
Bringing together and/or
supporting the care team
Trialling new interventions and
potential practice models
A full time Indigo worker undertaking
assessments has a case load of two
clients. This reflects the demands of the
Simon is in his a late twenties and lives in a regional area. He
has a mild intellectual impairment and his childhood was
characterised by neglect, physical abuse and the effects of
intergenerational trauma. Simon has been diagnosed with
schizophrenia and problematic alcohol use.
Simon has a history of offending related to his alcohol use
and symptoms of mental illness. He is well known to local
police and service providers. He has no housing of his own,
instead moving between the homes of various family
members or intimate partners. These houses are often
overcrowded and chaotic.
Simon has a range of services involved in his treatment and
support including mental health services, disability services,
accommodation providers and community corrections. He is
considered non-compliant with services and his treatment is
compromised during regular periods living in neighbouring
towns across the state boarder. Simon has been referred to
MACNI.
The Indigo assessor establishes the service providers have a
goal of housing stability, as they believe this would achieve
greater continuity of treatment and better outcomes for
Simon. She also discovers Simon’s family visits are fairly
consistent in their frequency and length, and are integral to
his social, cultural and spiritual wellbeing.
The Indigo assessor supported the care team and Simon to
understand their differing perspectives and find a way
forward. Simon was eventually housed in independent
accommodation. He still regularly visits family locally and
interstate. His service providers have improved their
communication with interstate services to ensure continuity
of support, and Simon is more reliable in contacting his case
manager.
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role and the travel involved in statewide service provision.
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Conducting an assessment and constructing a care plan
While each assessment is as unique as the individual it concerns, the process of undertaking the
assessment and developing the care plan includes the following stages:
• Colla ng
informa on
• Transla ng the
plan into
ac on




• Deriving
meaning from
the
informa on
Inves ga on
Synthesis,
analysis &
formula on
Implementa on
Construc on &
coordina on
• Developing the
care plan
Investigation – collating information
Synthesis, analysis and formulation – deriving meaning from the information
Construction and coordination – developing the care plan
Implementation – translating the plan into action
This is not a linear process but dynamic and iterative in nature. The Indigo assessor starts at
whichever point is most relevant. For example, in one case the client had made significant
improvements since her referral to MACNI, and was being supported by a cohesive, multidisciplinary care team and the DHS Divisional coordinator. The care team had developed and were
implementing an effective model of care. In this case the Indigo assessor worked backwards through
the process – starting with documenting and assisting to refine the model of support. In another
example, the assessment commenced at a crisis point for the client, hence the Indigo assessor
initially focused on coordination - resourcing and supporting the care team to develop an immediate
intervention. Elements of the process may be conducted simultaneously, while some aspects are
ongoing such as formulation. Formulation is an integrated understanding of how this person comes
to present in this way at this time, and is revised and shaped throughout the MACNI intervention.
Investigative phase
The Human Services (Complex Needs) Act 2009 allows for the exchange of personal and health
information between agencies where this is considered in the best interests of the client.
10
Accordingly, Indigo assessors are in a unique position to seek a broad range of information across
the lifespan of the client to inform the development of a suitable model of care.
Indigo assessors typically seek information such as: hospital records, child protection files, school
records, justice files, prison health records, mental health and other agency files. In addition, the
assessor conducts interviews with past and current service providers, family members and most
importantly, the client.
Hence, the assessor’s role can be likened to a detective, looking for clues and developing hypotheses
about the client and the system around them. The search for information is not exhaustive and
unlimited, but remains focussed by the question, “What do we need to know about this client, and
the services around them, at this time?” As an assessor becomes more skilled, and with supervisory
and collegial support, they learn that it is not always necessary to know everything about an
individual to develop an effective model of care. The key is in sifting through the sometimes vast
amount of information to identify what is important to know.
By contrast, an Indigo assessor may be faced with the situation where there are large gaps in
information or where access to information is limited. This presents a different challenge to the
Indigo assessor where they must look to the gaps to draw meaning about the client. This illustrates
the skilled nature of the assessor role and the need for flexibility to deal with both situations.
Written information  referral and file reviews
The assessor usually begins with the MACNI referral form and CERG meeting notes. MACNI referrals
are detailed and include a comprehensive overview of the client’s situation including the
perspectives of the current service providers. Referrals often include significant amounts of
additional appended information such as past assessments and reports. The CERG notes can provide
insight into potential areas for exploration in the assessment or suggestions about the direction of
the care plan. This is often the assessor’s first glimpse of the client, which can be quite
overwhelming for the assessor as the content tends to be predominately negative in terms of client
diagnoses and experiences of the service system.
MACNI referrals also contain a wealth of implicit information. Many referrals convey the sense of
hopelessness felt by the services around the client where there is a sense that the client and the
system are ‘stuck’ with all options exhausted. By contrast, some referrals may hint at more hidden
positive aspects of a situation, such as an event that demonstrates the client’s resilience. Sometimes
the most interesting aspect of the referral is that which is missing - issues that are absent or glossed
over. Again, the curiosity and skill of the Indigo assessor to read between the lines and further
explore the gaps is paramount.
File reviews of past and current services are conducted for a number of reasons. Establishing what
has happened to the client is an obvious starting point for any assessment. File reviews inform the
development of a chronology that documents where the client has been, when, what services they
accessed and how, and the nature of support received; that together form a useful framework for
the assessor. Historical file information can shed light on aspects of a client’s life that are not
currently well understood such as their developmental history. Reviewing records is a practical way
of physically bringing together the client’s fragmented service history to capture past learning and
assist developing a more integrated and balanced perspective.
The decision about which files are sought is made on a case-by-case basis by the Indigo assessor in
consultation with the line manager, divisional coordinator and is guided by the MACNI referral,
although what is eventually reviewed depends on a number of factors. Although this is rare,
agencies are not compelled to share information under the Act and may refuse access. Agencies can
be hesitant to share information that may not show their service delivery in the best light.
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Sometimes files have been destroyed either accidently or in accordance with archival policies or
simply cannot be located. While reviewing files can be time consuming it is a valuable exercise as
they hold a wealth of information and professional insights.
Interviews
A more subjective, but perhaps richer, source of assessment data comes from interviews where
people tend to be more relaxed and candid. The opportunity to talk to the client about their
perspective is invaluable as it is often minimised in the professional documentation. Former workers
are an excellent source of information and systemic analysis. Often they have had time to reflect and
consider their involvement with the client, and with the benefit of hindsight, may have new
perspectives to share. While some former workers are reluctant to talk, most are willing (even
relieved) to share their insights and contribute to a process that aims to improve the client’s
supports. All agencies currently working with the client are also interviewed for their perspective.
In the course of an assessment, the Indigo assessor may talk to a range of other people, such as
family members, partners, carers, friends and neighbours. Similar to the client’s voice, these
accounts may not be well represented in professional records and can add unique perspectives to
the assessor’s understanding of the client. For example, an Indigo assessor conducted a 45-minute
phone conversation with a client’s estranged aunt in the latter stages of the assessment. While the
information she provided was subjective (some of it pejorative), it provided helpful insights into the
client’s family history and family’s perspective of the involvement of Child Protection services.
Additional clinical assessment and secondary consultation
One of the purposes of a MACNI assessment is to address gaps in the understanding of the client.
The Indigo assessor will seek input from a range of practitioners who may assist in clarifying aspects
of a client’s presentation. This can include: neuropsychologists, occupational therapists, forensic
specialists and psychiatrists.
If a client is willing, additional assessments are undertaken to clarify aspects such as mental health
diagnoses, their risk of reoffending, cognitive function or living skills. This can be particularly helpful
for clients living in regional areas who may not have had access to specialist services in the past.
Indigo staff frequently access practitioners for secondary consultation. This additional input is used
in a variety of ways: to discuss formulation, review past assessments and provide an opinion, or to
work with a care team. The use of additional assessment and secondary consultation will vary
depending on the circumstances of the client, their care team and the assessor.
Synthesis, analysis and formulation
Deriving meaning from the information gathered is at the heart of the assessment process. The first
step involves synthesis where the separate elements are built into a connected whole. The assessor
collates information under the five broad domains of: health and well being, stable accommodation,
social connection, safety and service system responsiveness. This process enables the assessor to
draw together disparate information to create a deeper understanding of the person’s experience
and presentation.
Analysis is the examination of the collated information for themes, patterns, gaps and exceptions.
For example looking across a person’s history from the different domains of early childhood,
education and accommodation can enable the assessor to see whether patterns of offending
behaviour are linked to periods of instability. Alternatively, the synthesis and analysis can highlight
12
times when things were going well for the client. Such findings often inform interventions trialled as
part of the care planning process.
Formulation is about drawing this understanding together into a comprehensive conceptualisation,
with reference to relevant theories, research evidence and literature. Developing a comprehensive
and concise formulation is one of the most challenging aspects of Indigo assessment. A formulation
seeks to understand the person in context, and is more than a diagnosis. The formulations
developed by Indigo are multidisciplinary and are informed by a range of theories and disciplinary
perspectives. Ideally a MACNI formulation ‘…provides a map of how things are, how they came to be
that way, to what extent they are changeable, and how such change can be achieved’ (DHS, 2012: 5).
The resulting formulation is not static, but is interrogated, shaped and refined throughout the
MACNI process.
Construction and coordination  the development of the care plan
The Indigo assessor develops the care plan in consultation with the client and their current service
providers. The care plan should reflect the person’s current assessed needs while also laying a
foundation for their future support throughout MACNI and beyond. The assessor does not start with
a ‘blank canvas’ as there are always elements of the client’s existing support that can be retained
and/or remodelled.
Care plan development is a cooperative endeavour requiring the input and support of a care team.
The care team usually comprises Indigo, the services working with client (either directly or
indirectly), secondary consultants, the DHS regional coordinator, and the client (directly or
indirectly). Establishing an effective care team is an important task of the Indigo assessor during the
assessment, as this structure forms the basis of the coordination phase of MACNI.
Increasingly the care team is established and functioning prior to the assessment commencing, as
coordinated approaches are becoming more widely used in the complex needs sector. If there is no
care team operating, the Indigo assessor convenes an initial meeting of services. Bringing a group of
service providers together for the first time is not always an easy task. Equally challenging, the
assessor may be working with an existing care team that may not be functioning as well as it could.
Establishing and coordinating a care team requires significant strategic skill, and an ability to
maintain a meta-perspective, which is the ability to scope the multiple (sometimes conflicting)
perspectives present in a complex system. This may involve recruiting new services, introducing
specially brokered services/practitioners, enticing disengaged services ‘back into the fold’ or exiting
services that no longer meet the client’s needs. There may be tenuous relationships or differences of
opinion between practitioners or agencies, stemming from personality clashes, historically poor
working relationships or conflicting views about treatment approaches or diagnoses. These early
care team meetings can be challenging and require the Indigo assessor to exercise strong leadership,
excellent communication skills (especially listening skills), authority and the ability to manage group
dynamics.
The Indigo assessor leads the care team in the development of the care plan. The care plan is directly
informed by the co-occurring assessment and includes the client’s goals, rationale, and service plan
outlining tasks with responsibility assigned. To achieve this, an assessor has to have a good
understanding of the various needs and perspectives of individual care team members, and strong
negotiation skills to assist the team to reach a consensus, in order to move the planning forward.
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Implementing the care plan  negotiation, persuasion and intervention
As the formulation becomes clearer and the care plan develops, the focus of the Indigo assessor
shifts to engaging services to work on implementing the proposed plan. Essentially this is about
managing a change process; as the assessment introduces alternative ways of thinking about the
client’s situation, the care team brings a more integrated and inter-disciplinary way of working and
the care plan introduces a different model of support. The degree of change the process brings will
vary but in all cases it requires active management and support, which is coordinated by the Indigo
assessor.
MACNI care plans are needs-based and focus on what support or services the client requires, rather
than being restricted to what is provided by existing services. Client-attached brokerage funding is
available to bridge this gap. Using brokerage to develop and trial the implementation of new
interventions is intended not just to meet the needs of an individual client, but also to generate
innovation within the service system.
Typically brokerage is used to temporarily:




Augment existing service models to trial an enhances service response – for example to
increase the client/staff ratio in an existing residential program or to provide clinical support
to attendant care workers
Fund cross-service/collaborative interventions to improve service planning and
responsiveness– for example, providing reflective group supervision to a care team
Fund a client-specific model of care to trial a new service response
Purchase goods or services to assist the client’s support or service engagement
Brokerage is used judiciously as it is limited to the MACNI period with the aim of achieving
sustainable options within the funded service system. Constructing a model of care that includes
non-government funded agencies, public and private providers involves significant negotiation with
senior management to discuss and finalise the tasks assigned to them within the plan; and, if
brokerage is being used, the fee structure and accountability mechanisms.
The outcome of the process – the key documents
Three interconnected documents are produced at the completion of the process: an assessment
report, a care plan and a service plan. The documents set out the individual’s history, needs and
systemic issues under five platforms:





Stable accommodation,
Health and wellbeing,
Social connectedness,
Safety (including a risk and vulnerabilities analysis), and
Service system responsiveness
The assessment is the most detailed of the documents. It paints a comprehensive picture of the
relevant aspects of the individual’s experience, life history and influences that have contributed to
their current complex presentation. Indigo’s comprehensive assessments have been identified as a
critical success factor in MACNI (DHS, 2008; DHS, 2012). The depth and breadth of Indigo
assessments are highly valued by external stakeholders who expect a thorough analysis of the
individual’s situation in context alongside a clearly articulated formulation and rationale for the
proposed model of care. A comprehensive assessment is fundamental for service providers to
enhance their understanding of the individual to inform their consequent decision making.
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The care plan is addressed directly to the client and offers a succinct summary of their goals and
wishes, their assessed needs, the main service system gaps and model of care to be offered. This is
often in the form of a letter as this format is direct and personal, and easily adapted to suit differing
communication styles.
The service plan includes a clear rationale directly informed by the assessment, and sets out the
roles, responsibilities and expectations of all services involved. Executive managers of key services
involved in the care plan complete a sign-off form to affirm their commitment to the care and
service plans.
The written documents are used in a number of ways: to inform the client about their care plan, to
inform and influence decision makers (primarily the divisional panels) and to guide the care plan
coordinator and care team. In order to suit these varied audiences the documents are clear, concise
and demonstrate the assessor’s competence and depth of understanding of the client and the
service system, as well as being balanced and objective.
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Strengths and challenges
Indigo has significant experience and strengths in working with complex clients within complex
systems. Such work is both challenging and rewarding as discussed below.
The role of the Indigo assessor
As highlighted in the previous section, the work of the Indigo assessor is ‘demonstrably complex,
requiring high levels of conceptual ability, knowledge and skill’ (Absler & McDermott, 2009: 4).
Indigo staff require a broad range of skills including: communication (written and verbal),
negotiation, team building, leadership, conflict resolution, diplomacy and the ability to work
autonomously. They also need experience of working with complex clients, knowledge of the service
system (including in regional areas), the political and policy context, as well as an understanding of
current theory and practice evidence. The values that underpin the program are a client centred
approach, with a strong commitment to achieve better outcomes for people with complex needs.
Indigo staff describe the work as challenging, dynamic and stimulating despite the steep learning
curve involved. An assessment worker may be one day sitting in a park in small country town,
talking with client about their life; the next, meeting with a group of senior practitioners to discuss
risk management and negotiate intensive support options. Trying to make sense of a person’s life,
unravel the complexities of the service system, plan a way forward and bring services together is no
easy task.
There are high expectations (at times conflicting or unattainable) placed upon Indigo, and the
ongoing challenge for Indigo workers to balance the competing needs of stakeholders, while
remaining client-focused. Indigo like any service, does not always get this balance right. The strong
culture of reflective practice within the program assists the team to learn from mistakes or
unexpected outcomes, in way that strengthens rather than diminishes their practice.
The work of the Indigo program is also subject to an extraordinary degree of scrutiny. This can be as
quite an adjustment for new workers and a potential source of stress. However, staff acknowledge
the need for strong accountability measures given the expenditure of public funds, hence scrutiny is
recognised as a vital and justifiable aspect of the role.
A particular challenge for Indigo staff conducting an assessment is how to navigate and make sense
of the information gathered. Assessment workers have spoken about feeling initially overwhelmed
by the size and scope of the task, as well as the risk of getting lost in data and ‘bogged down’ in the
detail. Regular supervision is essential to assist the assessor to maintain perspective.
In addition, the material reviewed can at times be confronting and cause distress. For example, an
assessor may struggle to maintain empathy for a client who has perpetrated sexual violence, or is
hostile or aggressive towards others. These challenges are contrasted with strong feelings of pride
and job satisfaction following the completion of an assessment and care plan, when a previously
hopeless situation is rendered hopeful.
Managing risk and uncertainty
Considerations of safety and risk are part of every Indigo assessment process. When assessing issues
of risk, Indigo assessors explore the differing expectations and wishes of the client, the family,
advocates, service providers, the CERG and divisional panel, as well as considering practice
evidence, expert opinion and community expectations. Indigo staff have learnt that effective care
planning is achieved by balancing all the domains of the client’s life, not by a singular focus on
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safety. These are complex situations that involve human rights, self-determination, personal safety
and community protection – significant issues that can at times be hard to reconcile. Ideally,
considerations of risk should inform decision-making, rather than drive it, to ensure a balanced
perspective.
While managing risk and potential harm is a central part of the work, it can also be contentious. How
risk is defined and understood is not consistent throughout the service system. A rational and
technical view of risk perceives it as something that can be measured, mitigated and at best
eliminated. Such a view is often concerned with the potential of institutional risks such as
negligence, loss of reputation and professional error (Green, 2007). The divisional panels have varied
approaches to risk. In contrast, Indigo’s practice emerges from a community-based setting where
‘…the relationship between risk and practice is truly complex, unpredictable and contingent’ (Green,
2007 p.397). This requires Indigo assessors to clearly explain the client risk assessment and provide a
rationale for the recommended management strategies, particularly when the approach suggested
is unusual or novel.
When working with clients with complex needs sometimes rational risk management practices fail.
One example is where a client with a history of serious violent offending was placed in a stand-alone
residential setting with two staff, 24 hours a day. While this model may have mitigated the
institutional and community risks, in practice it exacerbated the client’s negative behaviours and
distress, and increased the risk to direct care staff. The placement rapidly broke down and the client
was incarcerated. Upon their release a much less intensive outreach model was implemented, with
greater success.
By definition MACNI clients are exceptional and do not fit easily into existing service models,
including standardised risk assessment frameworks. It may not always be possible to fully
understand a client’s presentation, and therefore to fully assess their risk. It is also pertinent to
consider risk is not wholly negative but can be part of learning and growth. The challenge is to
ensure that divergent perspectives of risk are discussed openly, as failing to do so can lead to
misunderstandings and unmet expectations that undermine collaborative practice. The experience
of Indigo is that ‘high risk’ situations are best managed with an approach of collective accountability,
where all service providers (including decision makers) share the risk.
Incorporating the individual’s perspective
By the time an individual is referred to MACNI, the professional narrative tends to focus on their
diagnoses or the problems of services involved, rather than the individual’s experience, needs and
wishes. Given this context, accurately representing a holistic view of the client’s life is of primary
concern to Indigo assessors. The client’s input into their care plan and inclusion of their perspective
is essential. The preference of Indigo assessors is to meet with the client, although this may not
always be possible due to their physical, cognitive or mental wellbeing; or if the client does not wish
to engage with another service. In these cases, the assessor encourages input and reflection from
direct workers or significant others as appropriate.
External stakeholders have noted that Indigo assessments describe the client’s needs and story in a
way that humanises, demystifies and de-stigmatises them. Indigo assessments ideally place a person
in context, broadening the narrative to highlight the social and structural factors that lead an
individual to where they are today.
Indigo has continually focused on increasing client involvement and ways of representing the client’s
perspective. In 2011, the program recruited a senior mental health consumer consultant to improve
the quality of Indigo’s services to consumers, the vast majority whom have mental health issues. The
assessment and service plan documents were also modified to increase the client’s perspective and
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ensure client goals are prominent. Most importantly the care plan now directly addresses the
individual, rather than service providers, and clearly reflects their goals as well as acknowledging
divergent professional opinion.
Indigo workers encourage clients to participate in MACNI at whatever level they choose. While still a
small minority, some clients (and their carers) regularly participate in their care team meetings. A
small number of clients have chosen to attend a panel session, although this can be a daunting
process due to their size of membership and formality. While recent reforms within DHS have
resulted in an increased focus on client perspectives, increasing client participation and the inclusion
of consumer groups remains an area of development within MACNI more broadly, particularly at the
decision making level.
Conclusion - contributing to systemic change
Since its inception, one of the aims of MACNI has been to improve responses to individuals with
multiple and complex needs across the service system in order to achieve long term structural,
legislative and cultural change. Indigo, as a service delivery arm of MACNI, plays a key role in this
task as its primary focus is working with service providers to improve client outcomes. A unique
aspect of Indigo assessment is that it considers systemic issues that have contributed to a client’s
situation, as well as discussing ways to potentially improve the service system. While it may be
relatively easy to identify how a system could be improved, achieving (and measuring the extent of)
systemic change is altogether, a more difficult process.
What the evidence shows is that services involved with MACNI experience increased confidence and
capacity in working with complex clients. This outcome is well known to Indigo staff as they work
closely with services over long periods and see the benefits emerge. Indigo assessors see services at
the start of the process where staff who work with complex clients may be feeling fatigued, burnt
out and helpless. As the assessment progresses, the support to services is bolstered, previous
knowledge of the person is uncovered and new understandings emerge.
By supporting and building the capacity of services to work in new and innovative ways with new
insights and coordinated planning, what was once a seemingly hopeless situation has more often
than not changed to a more positive one.
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Appendices
Appendix 1 – Indigo Assessment and Care Plan Development Service timeline
Date
Event
2002
The Victorian Department of Human Services responds to concerns
raised by the service system about clients with complex needs. DHS
establishes the Responding to People with Multiple and Complex Needs
Project.
2003
The Multiple and Complex Needs Initiative (MACNI) is established under
the Human Services (Complex Needs) Act 2003
2004
MACNI commences.
The Indigo program (auspiced by Western Region Health Centre)
commences providing care plan coordination for MACNI.
The multidisciplinary assessment process is provided by Care Plan
Assessment Victoria (CPAV)
2005
A comprehensive external review of MACNI conducted by external
consultants commences.
2007
Final report of review recommends devolution of decision-making to DHS
regions to improve efficiency, build capacity and provide scope for local
service innovation in the MACNI model.
The care plan assessment service is tendered to Indigo. Two teams are
developed to provide care plan coordination, and assessment and care
plan development for MACNI clients.
2008
Evaluation of Indigo care plan coordination conducted by external
consultants.
2009
A new MACNI service model commences with the Human Services
(Complex Needs) Act 2009, including several reforms:



devolution of decision-making from a statutory panel to eight
regional panels and the Central Eligibility and Review Group;
broadened role for DHS regional coordinators; and,
extension of care plans from a maximum of two years to three.
2010
The Western Region Health Centre internal evaluation of Indigo
Assessment and Care Plan Service
2011
The Indigo program recruits a senior mental health consumer consultant
to advise on improving the client’s participation.
The Indigo program completes the integration the Assessment and Care
Plan Development and Care Plan Coordination teams into one service
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Sources and further reading
Absler, D & McDermott, F (2009) Holding the system: an evaluation of care plan coordination,
Western Region Health Centre.
Department of Human Services (2003) Responding to people with multiple and complex needs. Phase
one report, Victorian Government, Melbourne.
Department of Human Services (2006) Multiple and complex needs initiative: Human Services
(Complex Needs) Act 2003 summary notes, Victorian Government, Melbourne.
Department of Human Services (2010) Care plan coordination: the multiple and complex needs
initiative, Victorian Government, Melbourne.
Department of Human Services (2012a) Multiple and complex needs initiative - client outcomes 2,
www.dhs.vic.gov.au
Department of Human Services (2012b) Balancing risk aversion and client autonomy in the multiple
and complex needs initiative, Victorian Government Department of Human Services,
Melbourne.
Department of Human Services (2012c) MACNI integrated formulations, Victorian Government
Department of Human Services, Melbourne.
Green, D (2007) ‘Risk and social work practice’, Australian Social Work, Routledge, Colchester, 60,
395-409.
Hamilton, M & Elford, K (2009) The report on the five years of the multiple and complex needs panel:
2004-2009, www.dhs.vic.gov.au
KPMG (2007) Evaluation of multiple and complex needs initiative: final report, KPMG, Australia.
Kraner, M & Fisher, V (2012) ‘The multiple and complex needs initiative: a coordinated and
integrated response’, New Paradigm: the Australian journal on psychosocial rehabilitation,
Spring/Summer 2012: 34-41.
Western Region Health Centre (2008) Multiple and complex needs initiative: Indigo assessment and
case management guidelines, Western Region Health Centre, unpublished.
Wilcock, E (2011) Indigo assessment and care plan development service evaluation, Western Region
Health Centre, unpublished.
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