Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Contents Page
1.
Recognition
2.
Introduction
3.
2.1
Vision
2.2
Mission
2.3
Objectives
2.4
Strategies
2.5
Summary of Key Priorities
Policy Framework
3.1
Policy Overview
3.2
MHCSS Specifications
3.3
MHCSS Principles
3.4
MHCSS Planning
3.5
MHCSS Strategic Goals and Intended Outcomes
4. North Western Region of Melbourne
4.1
Inner North Catchment summaries
4.2
North Catchment summaries
4.3
North West Catchment summaries
4.4
South West Catchment summaries
5. North Western Region Catchment Based Strategic Plan 2015-2018 (Working Together: Now and the Future)
5.1
Action Planning Overview
5.2
Implementation Plan
6. Monitoring, Review and opportunities to have a say
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Working together: Now and the future
1. Recognition
cohealth acknowledges the traditional custodians of the land and their ancestors on which our offices stand and pay
respects to Elders past and present. We acknowledge the sorrow of the Stolen Generations and the impacts of
colonisation on Aboriginal and Torres Strait Islander people. We also recognise the resilience, strength and pride of
the Aboriginal and Torres Strait Islander communities.
2. Introduction
Working together: Now and the Future was prepared by cohealth in partnership with local MHCSS providers to
develop a planning tool to guide Mental Health Community Support Services (MHCSS) in the delivery of their service.
The plan was developed with consideration of local catchment need and to build readiness for future funding shifts,
including transition to the National Disability Insurance Scheme (NDIS). The overall objective of the Catchment Based
Planning function is to improve the health, social and economic outcomes for people with a mental illness and
psychiatric disability, particularly those facing significant disadvantage.
This strategic plan has been developed in response to action and feedback through 2014 and 2015. Currently a 10
year mental health plan is being developed by the Victorian Government and the transition of catchments to NDIS is
scheduled from July 2016 with MHCSS earmarked for transition in to the National Disability Insurance Scheme. As
such developing this plan has been, and will need to continue to be, an iterative process as NDIS develops.
Working together: Now and the Future is informed by the work of the local MHCSS providers namely Breakthru
Solutions, Mind Australia, NEAMI and cohealth. This work is further supported by the two centralised intake
providers: EACH providing intake services within the North catchment; and NEAMI providing intake for the Inner
North, North West and South West catchments. Additional work with the Catchment Based Planning (CBP)
Governance Group, the Consumer Representative Working Group and key local stakeholders informed the
development of the plan.
cohealth is a not-for-profit registered community health service operating across the north and western
metropolitan regions of Melbourne. It provides integrated medical, dental, allied health, mental health and
community support services, and delivers programs to promote community health and wellbeing. Over 110,000
people a year use cohealth’s services, which operate from 44 sites across 14 local government areas in the north and
west of Melbourne. cohealth prioritises those who are disadvantaged or marginalized because these groups
experience the poorest health. This includes people who are homeless or at risk of homelessness, Aboriginal and
Torres Strait Islanders, refugees and asylum seekers and people who use illicit drugs.
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
2.1
North Western Region MHCSS Catchment Based Planning Vision
Mental Health Community Support Services provide recovery oriented services that meet the needs of the local
communities and consumers across the catchments.
2.2
Mission Statement
Aligning with the state-wide MHCSS principles, guiding framework, strategic goals and intended outcomes, the North
Western Region focus is on delivering recovery oriented, client driven services. The work of the catchment based
plan is to inform service planning and delivery and in turn be adaptive to the changing nature of the service system.
The focus is on working with providers to build collaboration and focus activity on agreed priorities and actions. The
plan is expected to evolve at each reporting period to reflect learning and emerging issues or themes.
2.3
North Western Region MHCSS Catchment Based Planning Objectives
The objectives of the planning process are consistent with those developed for the MHCSS specifications developed
by the Department of Human Services, namely:
-
-
-
Gather and analyse relevant health and population data to identify and understand the distinct and diverse
needs of adults (16-64 years) with a psychiatric disability living in the service catchment, particularly those
facing significant disadvantage.
Identify service gaps, needs and pressures and monitor and analyse trends in expressed demand for MHCSS
in the catchment.
Develop cohesive strategies to improve responsiveness to community need and population diversity in
response to identified service gaps and demand pressures, taking into account available resources in the
MHCSS program and the community more broadly.
Formulate and regularly review a catchment-based strategic plan for implementation by MHCSS providers
and key stakeholders.
Engage with relevant agencies and planning structures, for example, Services Connect partnerships, Primary
Health Networks and Local Government (through health and well-being plans) and participate in discussions
and planning to:
o Identify and develop shared strategies to address systemic barriers to access by people with a
psychiatric disability, particularly primary health and community services.
o Achieve a more coordinated response to the needs of people with a psychiatric disability at the
system level across the catchment.
o Ensure the needs of people with a psychiatric disability living in the catchment are taken into
account in other local planning activity and service delivery.
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
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Ensure the views of consumers and carers inform the development and review of the catchment-based
strategic plan and are represented in other relevant planning forums.
2.4
Strategies supporting Catchment Based Planning
2.4.1. The Collective Impact approach
Collective Impact (Kania and Kramer, 2010) has gained traction in recent years. Emerging from successful
community development activities in the United States, Collective Impact identifies five key principles:
 A shared agenda
 Collection of data
 Mutually Reinforcing Activities
 Continuous communication
 A backbone organisation
The catchment based planning function operates as the backbone in this instance, bringing together key
stakeholders to inform change across agreed areas of action. The applicability of collective impact to the
catchment based planning process provides a suitable framework to identify and respond to change
initiatives at the broader plan level and to priorities within catchments. More information is provided on
collective impact at the end of the plan.
2.4.2 Data framework
The use of data is critical to the planning process and is indicated as a key component of collective impact
approaches. A range of data sources formed the basis of data presented in this plan, and in the formulation
of the development of the work. Data ranges from mapping the population at the local government area
level, coupled with demand for MHCSS services.
Data will inform ongoing reporting, as a means to evaluate the plan and service delivery and to indicate new
opportunities for improving services or identifying service pressures. This will draw upon data collected by
the providers in their reporting to the Department of Health and Human Service. Service data will be collated
and published quarterly.
The data collected comprises:
a. Population Data
b. MHCSS Data
i. Intake and Needs Register
ii. User characteristics
iii. Service data
c. Project Data
i. Data dashboards
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
2.4.3
Communication framework
Sharing data, information and learning from the catchment based planning work is vital to its effective
implementation. Multiple approaches are being utilised to inform the strategy. This ranges from
participation in mental health alliances and other local stakeholder groupings, to the development of an
approach to capture stakeholder feedback and publication of materials.
The following linkages and communication pathways are in place:
a.
Web Presence on the cohealth website
Publish all key documents including data, project materials, reports and other
information prepared in the catchment based planning process.
b.
MHCSS Steering Groups
This group comprises senior managers from the MHCSS Service Providers and Intake
providers
c.
CBP Governance Group
This group comprises MHCSS Providers, representatives from Clinical Services,
mental health consumers and other key external stakeholders.
d.
Consumer Representative Working Group
This group comprises consumer consultants or their equivalent from the four
providers and two consumer representatives from each of the providers.
e.
Carer and other community engagement
f.
Linkages with other stakeholders including participation with the mental health alliances
across the four catchments.
2.4.4
North Western Region, Catchments and LGA approach
The activity of the catchment based planning process takes place at the North Western regional level, at the
catchment level and in turn will focus on specific local government area activities. This will occur in
partnership with MHCSS providers, Catchment Based Planning Governance Groups, and other groupings
across the North West, such as mental health alliances.
The approach to developing the plan and subsequent activity includes:
a.
b.
c.
d.
Aligning strategies with existing groups, particularly Mental Health Alliances
Identifying and supporting locally focussed activities
Sharing learning across the catchments
Reviews of the plan will be informed by local projects, activities and emerging themes
Data has been collated at the local level, with detailed summaries available on the cohealth website that are
key attachments to this plan.
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
2.5
Summary of North Western Regional Priorities
Working Together: Now and into the future identifies a number of key priorities and action areas to be
undertaken through to June 2018. Underpinning these specific areas is service responsiveness to the needs
of the individual. Planning and service delivery is undertaken with a sense of the whole person. The plan
seeks to bring together partners in an integrated and joined up approach to the development and response
to the priorities outlined below.
Priority 1: Focus on consumer choice and identified service priorities.
Priority 2: Build a collaborative service approach within MHCSS in the North Western region and catchments
and across the health, mental health and community support service system.
Priority 3: Improve access for people from disadvantaged or vulnerable groups in the community.
Priority 4: Partner with consumers, community and service providers to assist with changes to the MHCSS
service landscape, including the transition to NDIS.
Priority 5: Develop and implement an effective consumer participation strategy to inform catchment based
planning and service development.
Priority 6: Extend and develop the availability of data to support planning and continuous improvement.
These priorities operate at the North Western regional levels; however, the plan has been developed to
enable a number of locally focussed actions that address specific issues or needs. Bringing together this
learning across the region enables evidence based approaches to be developed locally and shared broadly.
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
3
The Policy Framework
The provision of mental health services is informed by a range of policies at both the State and Federal level. The
development of MHCSS is part of a suite of service responses to people requiring support towards their journey and
associated goals. It is within this context that the catchment based plan has been developed. While the focus is on
MHCSS providers and the service they offer, recognition of the broader policy and service response to people
requiring assistance across a range of human service needs is influential in the plan.
3.1.1
Policy Overview
Catchment Based Planning is undertaken with a focus on the local and informed by broader policy and initiatives.
The plan was developed to reflect this approach. A number of state and federal policies inform mental health service
provision broadly. The policies and initiatives include:
-
Fourth National Mental Health Plan
-
Review of National Mental Health Services and Programmes
-
Victorian 10 year Mental Health Plan (in development)
-
National Disability Insurance Scheme
-
Victorian Public Health and Wellbeing Plan 2015-2019
-
Specifications and guidelines for MHCSS and Catchment Based Planning
3.4 MHCSS Service Scope
The plan’s focus is on MHCSS and people aged 16 – 64 years with a psychiatric disability and their family/carers.
It covers four catchments – South West Melbourne, North West Melbourne, North Melbourne and Inner North
Melbourne.
3.5 MHCSS Principles
The following principles have been developed at the state level to guide and inform the way high quality MHCSS are
organised, planned and delivered:






Achieving best outcomes for clients Rights and responsibilities
Client-centred and directed
Choice
Consumer and carer participation
Priority access
Accessible and responsive
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018










Responsive to local need
Recovery oriented
Family inclusive
Effective
Safe
Organised for quality
Driven by information
Skilled competent workforce
Service continuity and partnership
Public accountability
3.6 MHCSS Guiding Framework
The planning framework for the MHCSS Planning function is guided by the MHCSS service specifications and the
following guiding framework established by the Department of Health and Human Services:

Determinants of health and their interactions - identify and address the factors which directly impact on the
achievement of mental health, wellbeing and social and economic outcomes for people with a psychiatric
disability.

Address health inequalities - the plan will take into account social, economic, geographical, legal and
cultural influences that impact on mental health status and create inequality. The Plan will:
o Identify priority at-risk or high needs populations in relation to mental health and psychiatric
disability
o Identify and consider underserviced population groups and the reasons why.

Human rights principles of non-discrimination, equality and empowerment – the plan will take into
account the possible impact on the human rights of all those directly and indirectly affected by the
development and implementation of the MHCSS strategic plan. The human rights that belong to all people in
Victoria, without discrimination, are set out in Part 2 of the Charter of Human Rights and Responsibilities Act
2006.

Driven by evidence – the plan will use robust evidence, information and analysis to understand service
demand, identify service gaps and help drive improvements in service delivery and responsiveness.

Continuum of need – the plan will identify critical service gaps across the spectrum of prevention of
psychiatric disability and interventions (including early intervention to reduce the burden of disability). The
plan will identify, consistent with a focus on the determinants of health, the range of health and community
services and strategies required to provide a more comprehensive spectrum of service responses and
interventions for people with a psychiatric disability.

Strategic focus – the plan will include a strategic mix of strategies across the continuum of need that address
population needs and diversity, with a focus on high priority /at risk groups.
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018

Consumer and carer engagement – the formulation, implementation and review of the plan will be
informed by the views of consumers and carers/families. Governance structures and processes will be
designed in a manner that ensures this outcome.

Collaboration across sectors and levels – the plan will actively engage with sectors and groups having a
stake in mental health outcomes, for example, housing, corrections, education, Aboriginal health and
community services, and child protection.

Demonstrate accountability for health outcomes – the plan will be collaboratively reviewed annually
against agreed milestones and outcomes by its key stakeholders.
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
3.7 MHCSS Client and System Strategic Goals and Intended Outcomes
The Department of Health and Human Services has developed the following goals and outcomes.
System-focused
People-focused
Strategic goals
Intended Outcomes
Best health outcomes for people
with severe mental illness and
psychiatric disability
•More people with poor mental health have better
physical health and are living longer
Minimise long term disability and
improved quality of life
•Improved housing status
•Improved economic participation
•Improved relationships and social connections
•Improved daily living skills
•More people with poor mental health living a
meaningful and contributing lfe
People are managing their mental
health better
•Improved capacity for self-management
•Reduced level of psychiatric disability experienced by
consumers
People have the best rehabilitation
and recovery support possible
tailored to their individual needs
and preferences
•More consumers and carers having a positive experience
of support
•Improved involvement of consumers in decisions relating
to their support
•Improved responsiveness to carers and family members in
their caring role
•Improved responsiveness to population diversity
•Best rehabilitation and suppport service possible
Mental health community support
services that are consistent, highquality and readily accessible
•Improved access to community mental health services
•Improved quality of community mental health support
services
Mental health community support
services that are highly productive,
cost-efficient and sustainable
•Services that are cost-effective and productive
•Services that are sustainable
A joined up response with clinical
mental health, primary healthcare
and human services to meet the
needs of poeople with psychiatric
disabilty and their families
 Improved consumer engagement with health, human
services and other key social supports
 Improved continuity of care
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
4
North Western Region
A map outlining the 14 local government areas (LGAs) is below. The region is more broadly divided into 4
catchments, Inner North, North, North West and South West.
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
4.1 Inner North Catchment
The Inner North catchment includes the cities of Melbourne, Yarra, Moonee Valley and Moreland and
has a population of almost half a million people. With the majority of the catchment within 8km of
the CBD it has good access to transport, health services and amenities. While population growth will
continue to 2021, only in the City of Melbourne is it expected to be significant and remain much
higher than the State average. Yarra LGA will transition to the National Disability Insurance Scheme in
July 2016, with other LGAs in this catchment transitioning in 2018.
Cultural diversity is high across the catchment compared to Victorian averages, with 37% of people born overseas. The City of
Melbourne has a very high number of new settler arrivals (although only 1% of these are for humanitarian reasons). The
proportion of Aboriginal and Torres Strait Islander people is lower than the State average.
Despite median incomes being close to or higher than the Victorian average and low rates of mortgage and rental stress, there
are a number of indicators suggesting socio-economic disadvantage.






With the exception of Yarra, the proportion of people reporting poor health is higher across the catchment than the
state average.
Gaming losses are high in both Melbourne and Moonee Valley, but low or average in Yarra and Moreland.
Higher rates of unemployment in Yarra; ranking 12th of LGAs across Victoria.
Very high proportion of social housing (except in Moreland), and Melbourne has the highest rate of new dwelling
approvals.
Total number of offences per 1000 population is higher across the whole catchment than the Victorian average, and
very high in both Yarra and Melbourne (crimes occurring in a LGA could be perpetrated by people living elsewhere).
High rates of alcohol and marijuana use by 15 – 17 year olds.
The attraction of people into the city and the concentration of accommodation around universities explain some of these
characteristics and in Melbourne and Yarra there is a much higher proportion of young adults (15 - 44 years); and a high
proportion of people seeking professional help for mental health problems.
Moreland stands out for people reporting high levels of psychological distress and adolescents who report being recently
bullied. Relative to its high rate of registered mental health clients per 1000 population, Moreland has a low rate of MHCSS
clients per 1000 population. Moreland is also the only LGA area within the Inner North catchment where less than 85% of the
population believe there are good facilities and services.
Priorities in the Inner North catchment
1.
Client need
Responding to a diverse client population and improving understanding of the client profile and service use for:
 Ageing drug users
 Aboriginal & Torres Strait Islanders
 Culturally & linguistically diverse groups
 People who are homeless or people with housing issues
 Young people (including the student group in particular)
 GLBTIQ
 People with a dual diagnosis
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Key Data in the Inner North
Melbourne
Estimated eligibility in community
1092
High/ Very High reported
Psychological Distress in
community
Help Seeking professional help for
mental illness in community
Persons reporting fair or poor
health
People born overseas
Speaking a language other than
English at home
Drug Use & Possessions Offences
per 1000
AOD Clients per 1000
Needs Register September 2015
8.80%
MHCSS clients per 1000
Number of people accessing MHCSS
below 25 years of age
Gender of MHCSS clients
Female/ Male %
Aboriginal and Torres Strait
Islander clients
Living with family or others/alone
Dependant Children
Clinical Provider of MHCSS clients
(AMHS/ GP/ Private Psychiatrist)%
People from culturally and
linguistically diverse backgrounds
Top 5
Moreland
Yarra
1350
785
10.10%
14.40%
7.60%
13.7%
10.4%
10.9%
16.4%
16.7%
18.5%
18.2%
14.8%
53.6%
43%
28.9%
31.1%
36.0%
41.7%
31.3%
25.2%
16.8
4.1
2.9
9.4
4.1
5.8
5.5
11.1
91
1.16
0
2.18
8
0.93
0
2.09
16
52 / 48%
41 / 59%
50 / 50%
45 / 55%
0
2%
3%
5%
40/60%
1.9%
67/33%
2.4%
64/36%
14.9%
59/41%
7.8%
N/A
N/A
23/55/16
41/43/11
China 9%
Malaysia 6%
Indonesia 3%
India 3%
Singapore
2%
India 3%
Italy 3%
Vietnam 2%
China 2%
Greece 1%
India 4%
Italy 3%
Lebanon 2%
China 2%
Turkey 2%
Vietnam 4%
China 1%
Malaysia 1%
India 1%
Greece 1%
Referral Source to MHCSS
Top 5


Moonee
Valley
964
Community Mental Health 30%
Self 25%
Community Health 5%
Police 4%
Housing Provider 3%
Further details about each local government area is available as attachments to this document,
unless otherwise specified MHCSS data is from December 2014
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Aligned planning priorities in the Inner North
The City of Melbourne Council Plan incorporates its Health and Wellbeing plan. Its vision is to be
bold, inspirational and sustainable. Smoking rates and experience of anxiety and depression are
highlighted and health and wellbeing priorities include social inclusion and opportunities to
participate and connect with others and community safety, including reducing family violence and
the use of alcohol and other drugs
The City of Moonee Valley Health and Well Being Plan has five key themes. Its people theme
includes a strategic objective to promote positive mental health with a focus on youth and
providing support. It also includes a commitment to identify emerging issues, in which a
focus on young people and risk taking behaviour such as drug and alcohol use is identified. The plan also identifies that
smoking amongst adolescents is the highest level in metropolitan municipalities for 15-17 year olds.
The vision for the Moreland Health and Wellbeing Plan is that “people’s health and wellbeing is
at the centre of all planning and decision making.” Long term goals include improving mental
health and decrease alcohol and other drug use. Under its theme of people , there are a number
of strategies to reduce alcohol and drug consumption including providing information,
partnerships which support harm minimisation and promoting drug, alcohol and regulation of
smoking and alcohol sales.
The vision of the City of Yarra Health and Wellbeing Plan 2013-2017 is: “Helping
communities flourish through health promoting environments”. Priority populations include
people living with long term disadvantage, Indigenous Australians, people living with a
disability, people from diverse cultural backgrounds, and women. Due to the significant
community safety issues in Yarra, people who inject drugs, and people experiencing
homelessness and housing insecurity are also given particular consideration. There are four
priority areas – 1) health promoting environments including to promote mental health and wellbeing through
creating opportunities for people to be involved in and connect with their community; 2) community safety; 3)
reducing the harm from alcohol, tobacco and other drugs – including reducing the harm resulting from alcohol
misuse, reduce impacts of illicit drug use and reduce rates of smoking; 4) close the gap on indigenous health.
The City of Yarra Safer Yarra (2011-2014) plan sets out strategies to respond to safety issues including illegal drug
use. Strategies are largely based on managing amenity issues such as discarded syringes and working with police and
other service providers.
The INWMML comprehensive needs assessment identifies 5 key priorities – 1) the need to
coordinate care across service system issues 2) Prevention and Management of Chronic Disease 3)
Health Literacy 4) Mental and Emotional Health and Wellbeing and 5) Alcohol and Other Drugs.
Both the mental health and AoD response include stakeholder consultation/ forums in early 2015
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
and discussion papers to further identify issues. The mental health response also aims to increase access to ATAPS and
counselling services, including for young people, the PACER response, an after hours nurse outreach program and a GP
mental health education series. The AoD response includes support for the pharmacotherapy network. 1
The Inner North West PCP has a vision of strong partnerships, equitable outcomes and
health communities. It has two strategic priorities 1) Prevention of violence against
women (inclusive of children and families) and 2) Improve system capacity to increase
prevention and support people from priority populations with chronic disease and its co morbidities. Health promotion
priorities are identified as mental health, physical activity, harm from addiction/dependence (alcohol, tobacco, gambling
and other drugs); health impacts of climate change; access to nutritious food, prevention of family violence and reducing
health inequalities (including for Aboriginal people).
1
Having just replaced Medicare Locals in July 2015, PHNs have not had yet developed plans so priorities identified by Medicare
Locals are still a good indication of regional priorities.
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North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
4.2 Northern Catchment
The Northern Melbourne catchment includes the cities of Whittlesea, Nillumbik,
Darebin and Banyule and has a combined population of half a million people. The
catchment can be characterised by two distinct corridors – with Whittlesea and
Darebin out to the North; comparatively disadvantaged on a number of socioeconomic indicators and Banyule and Nillumbik out to the North East;
comparatively advantaged. Banyule and Darebin are closer to the city while
Whittlesea and Nillumbik are located on the urban/rural fringe, which has an
impact on service access.
A challenge for this catchment is planning for and responding to the very different
age, resident and service access profiles across each of the LGAs. For example, only
Banyule has a ‘normal’ age distribution; Whittlesea has a higher proportion of children (under 14 years), Nillumbik
has an over representation of the 0–24 and 45–65 year old groups and an under representation of the 25–44 year
olds, and Darebin has a much greater proportion of 25 – 44 year olds. Both Whittlesea and Darebin are culturally
diverse with more than 40% of residents in each LGA speaking a language other than English at home, comparatively
this group represents just 7% of the population in Nillumbik and 17% in Banyule. Whittlesea is also the only LGA in
the catchment with strong projected population growth.
As described above, Whittlesea and Darebin are comparatively disadvantaged on many social economic indicators.
They have higher than average rates of unemployment, gaming machine losses, poor self-reported health status and
residents who do not feel safe walking alone after dark. Whittlesea has a higher than average rates of family
incidents; and Darebin a high rate of child protection orders. They contrast starkly with Banyule and Nillumbik
where almost all indicators are within the average or suggest advantage - it is important to note, however that there
is a significant pocket of disadvantage within Banyule in the Heidelberg West area which is disguised by LGA-wide
averages.
Some notable exceptions to this general pattern are the:





High rate of alcohol-related family violence in Banyule.
High pharmaceutical-related ambulance attendances and emergency department presentations in Nillumbik.
High rates of alcohol, marijuana and tobacco use among 15 – 17 year olds across the whole catchment.
Whittlesea also has a very high rate of glue sniffing or chroming.
Illicit drug use (and use of AoD services for illicit drug use) is also high in Banyule.
Banyule records a very high rate of life time prevalence of anxiety and depression for females.
Service access is generally better in Darebin and Banyule, with the rates of allied health, pharmacies, dental services
and general practitioners all higher for these areas than the outer areas. The rate of GP attendance is very high in
Darebin and Whittlesea (with the latter ranked second in the State). MHCSS services and AoD services have higher
utilisation rates in the inner areas. Darebin has the North catchment’s highest rate of AoD service use for alcohol,
pharmaceuticals and illicit drugs and Banyule second for pharmaceuticals and illicit drugs. The proportion of
registered mental health clients, however, does not follow this pattern. Nillumbik records one of the lowest rates of
access to mental health services in the State, and Whittlesea and Banyule are also below average.
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October 2015 – June 2018
The proportion of people seeking help for a mental health problem is lower than average in Whittlesea, and but
higher than average in Banyule.
Priorities for the Northern catchment
1. Growth corridor:
Strong population growth and a need for responsive resources in light of emerging trends.
 Service distribution - demand outstrips supply
 Poor infrastructure - transport & other community resources
 Reallocation of services - there is concern that this will take services away from areas that still need
them.
2. Client need:
Specific client groups require local planning attention.
Service access issues were identified for
 Young people
 People with disabilities (including respite care)
 Older people
 Culturally and linguistically diverse groups
 People who are isolated
Complexity in the client group:




Bush-fires affected communities
People with dual diagnosis
Family violence
Gambling
3. Service sector / System change
 Access issues: identifying the right people & the right entry points
 Awareness & promotion of the new services & system change
o For clients
o For other services
 Seamless client pathways
 Collaboration
 Funding: we need more, not just different
17
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Key Data in the North
Banyule
1037
Darebin
1254
Nillumbik
555
High/ Very High reported
Psychological Distress in
community
Help Seeking professional help for
mental illness in community
Persons reporting fair or poor
health
People born overseas
Speaking a language other than
English at home
Drug Use & Possessions Offences
per 1000
AOD Clients per 1000
Needs Register August 2015
14.7%
11.7%
7.7%
13.6%
14.5%
13.7%
11.7%
10.1%
16.7%
20.8%
9.4%
22.8%
23.1%
20.3%
36.0%
41.0%
15.4%
8.3%
35.2%
44.5%
2.6
3.9
1.7
3.3
4.6
5.2
3.0
4.8
MHCSS clients per 1000
Number of people accessing MHCSS
below 25 years of age
Gender of MHCSS clients
Female/ Male %
Aboriginal and Torres Strait
Islander clients
Living with family or others/ alone
Dependant Children
2.14
11.6%
2.71
8.1%
0.69
15.6%
0.78
5.5%
54/46
48/52
63/38
73/27
2%
1%
0
1%
73/27%
15.3%
69/31%
16.6%
79/21%
20%
68/32%
28.6%
51/20/24
62/17/16
38/<5/38
35/41/22
China 1.3%
India 0.9%
Italy 0.7%
Malaysia .4%
Sri Lanka .4%
India 4%
China 4%
Italy 2%
Vietnam 2%
Greece 2%
Italy 1.1%
Germany .5%
Malaysia .4%
Greece 0.4%
India 0.35%
India 4.6%
Macedonia
4.4%
Italy 2.9%
Vietnam 2.3%
Greece 1.8%
Estimated eligibility in community
Clinical Provider of MHCSS clients
(AMHS/ GP/ Private Psychiatrist)%
People from culturally and
linguistically diverse backgrounds
Top 5
Referral Source to MHCSS
Top 5
Whittlesea
1398
158
Self 27%
Clinical AMHS 16%
Partners in Recovery 16%
Community Health 11%
Carer 3%
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Aligned planning priorities in the North
The Banyule People Health and Wellbeing Policy and Strategy identifies six key directions 1) Promote and
support health and wellbeing, 2) Provide services for people at important life stages, 3) Develop and
promote safety and resilience in our community 4) Celebrate and promote Banyule’s diversity and
heritage; 5) Support people to achieve their economic potential and 6) Plan and prepare for emergency
events. Key target groups are under four year olds and people living in areas of high concentration of
public housing. Neither mental health issues nor alcohol and drug issues are specifically identified.
The City of Darebin Health and Wellbeing Plan names a long list of groups of people who are
considered at risk of exclusion and who needs are considered in the plan, including people with a
mental illness. It has five main goals which target early years, lifelong education and learning,
freedom from discrimination and violence as a basis for emotional and social wellbeing, safe and
accessible places and to protect and promote physical health including reducing smoking and limiting harm from alcohol and
other drugs.
The Shire of Nillumbik identifies three strategic directions of health planning, health protection
and health promotion. It includes promoting mental health access to services for young people
and older adults – including advocating for counselling support and treatment services and
working towards a headspace in Greensborough. It also promotes the safe use of alcohol and
drugs to young people, parents and families in partnership with schools, health providers and
local agencies and will undertake research and report on the issues associated with binge drinking and harm associated
with risky drinking in the community.
The City of Whittlesea Health and Wellbeing Plan has seven future directions 1) inclusive and
engaged community; 2), accessibility in, out and around our city – which includes a focus on
access to health services, including mental health services, and particularly for young people;
3) growing our economy; 4) places and spaces to connect people; 5) health and wellbeing –including to address smoking
rates and harmful use of alcohol; 6) living sustainably and 7) good corporate governance.
The Northern Melbourne Medicare Local has a focus on systems reform including supporting
planning, integrations and coordination of primary health care services across four key areas –
including mental health and service access and quality. Under mental health NNML will lead planning;
integration and coordination of primary health are services for people with a mental illness, involving
workshops and preparation of paper. Under service access and quality, NNMP will support the active
integration of after hours pilot of ReGen AoD service and NPACER program and funding to extend a joint police and mental
health clinical project to provide a dual secondary response.
The NE PCP strategic plan identifies people with a mental illness as one of its four target groups. Its
focus is on collaboration, integration and innovation. The NEPCP auspiced the physical health matters
too project to improve physical health screening for people with a mental illness.
North East Mental Health Alliance has identified improving dual diagnosis capability and service pathways for people with a
mental illness and an Alcohol or other drug issue as key priorities.
19
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
4.3 North West Catchment
The North West Melbourne catchment includes the cities of Maribyrnong, Brimbank,
Melton and Hume and is home to over 560,000 people. A significant challenge for the
catchment will continue to be its significant growth, most pronounced in the growth
corridors of Hume and Melton, as well as Maribyrnong (to a lesser extent). Only in the
City of Brimbank will growth be minimal. Melton in particular also has a very high
proportion of children (under 18 years of age).
The catchment is characterised by its significant cultural diversity and high proportion of
new settler arrivals. In Brimbank, almost 50% of the population are born overseas.
There is a high overall level of disadvantage as evidenced by:
 Low household incomes (except for Melton which is similar to the average)
 High unemployment rates
 High gaming machine losses
 High levels of mortgage and rental stress (except for Maribyrnong)
 High rates of family incidents (except Maribyrnong)
 High rates of total offences.
There are also a number of indicators suggesting poor health, particularly related to young people. In some areas, the rates of
drug use in young people are among the highest in the State. In Hume 28.6% of 15-17year olds have used other illegal drugs
compared to a state average of 3% and 14% of children are developmentally vulnerable on two or more domains (compared to a
state average of 9.5%).
Catchment wide issues include:





High rates of reported fair or poor health
High rates of reported high/very high levels of psychological distress (in all except Hume)
Higher proportion of children with emotional or behavioural problems at school and adolescents who report being
recently bullied (Melton and Hume only)
High rates of young people drinking alcohol
High rates of young people using marijuana (in all except Hume).
There is some evidence of service access challenges across the catchment, which becomes more pronounced with increasing
distance from the city. Service use rates for Mental Health Community Support Services (MHCSS) and Alcohol and Drug (AOD)
services are lower than average in both Hume and Melton. The rate of registered mental health clients is similar across the
catchment, but slightly higher in Hume. The usage rates of General Practitioners are amongst the highest in State even though
there are a lower than an average number of general practitioners per 1000 population (particularly in Hume and Melton).
Priorities for the North West catchment
1.
Growth corridor
Respond to strong population growth and a need for responsive resources in light of emerging trends. Melton and
Sunbury identified as hot spots.
 Poor infrastructure: transport
 Limited service availability: location, choice, specialists
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018

Lack of prescribing GPs
2.
Service / sector coordination
 Opportunities for cross sector collaboration for problem solving & innovation
 Enhanced service coordination
3.
Client need
Specific client groups require local planning attention.
Service access issues were identified for:
 Culturally and linguistically diverse groups
 Aboriginal and Torres Strait Islander peoples
Complexity in the client group
 Culturally and linguistically diverse groups
 Young people
 People with gambling challenges
 Family violence related need
 Clients with medical co-morbidities
21
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Key Data in the North West
Estimated eligibility in community
Brimbank
1690
Hume
699
Maribyrnong
1510
Melton
948
High/ Very High reported
Psychological Distress in
community
Help Seeking professional help for
mental illness in community
Persons reporting fair or poor
health
People born overseas
Speaking a language other than
English at home
Drug Use & Possessions Offences
per 1000
AOD Clients per 1000
Needs Register August 2015
14.4%
10.8%
15.9%
20.7%
13.7%
11.2%
11.2%
10.2%
23.8%
16.9%
21.8%
20.7%
49.6%
59.7%
43.1%
46.3%
34.2%
43%
29.3%
30.5%
6.1
7.7
3.9
3.9
10.7
6.4
5.6
5.4
MHCSS clients per 1000
Number of people accessing MHCSS
below 25 years of age
Gender of MHCSS clients
Female/ Male %
Aboriginal and Torres Strait
Islander clients
Living with family or others/ alone
Dependant Children
1.56
11.6%
2.16
5.8%
0.79
10.4%
0.94
5.3%
57/43
50/50
65/35
61/39
2%
2%
2%
1%
77/23%
24.8%
55/45%
<5%
71/29%
20.8%
74/26%
30.2%
39/33/21
41/37/11
41/41/14
32/26/31
Clinical Provider of MHCSS clients
(AMHS/ GP/ Private Psychiatrist)%
People from culturally and
linguistically diverse backgrounds
Top 5
Referral Source to MHCSS
Top 5
4
Vietnam 13%
India 5%
Philippines
3%
Malta 2%
Macedonia
2%
Vietnam 11% Iraq 5%
India 5%
Turkey 5%
China 4%
India 3%
Philippines
Lebanon 2%
1%
Italy 2%
Bangladesh
1%
Community Mental Health 30%
Self 22%
Community Health 5%
Housing Provider 5%
Child and Family Providers 3%
22
India 2%
Philippines
2%
Vietnam 1%
Malta 1%
Macedonia
1%
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Aligned planning priorities in the North West
The Community Plan 2009 – 2030 is a strategic plan with long term goals. It informs the Council Plan and incorporates the Health and
Wellbeing Plan. It identifies that key challenges are: education and lifelong learning - ensuring residents have opportunities to engage
in culturally appropriate, high quality education and learning activities that are relevant to their needs; transport: ensuring the
community has access to high quality, safe, affordable and environmentally sustainable transport options suitable to their needs;
employment: ensuring Brimbank is attractive to employers and that residents have the skills and education to enable them to take
advantage of new employment opportunities as they arise; housing: ensuring residents have access to high quality, affordable housing that is
suitable for their needs across their lifespan. Neither mental health or alcohol and drug issues, nor any other health issues are specifically
identified. The City of Brimbank has a number of other plans which fall out of the Community Plan, including and location specific plan, and aged
plan.
The Brimbank Community Safety Framework and Action Plan provide specific actions for different areas. There is a strong emphasis on improving
needle syringe disposal and exchange programs and using other networks to increase awareness of alcohol and drug issues and services. Some
other specific activities include conducting a mapping exercise of the number of prescribers and dispensing pharmacies for opiate substitution (e.g.
methadone, buprenorphine) in Brimbank and investigating what Council can do to increase these services; analysing the feasibly of the
introduction of a safe injecting facility in Brimbank, and developing a program to address the issue of drinking in public places in Sunshine by
incorporating direct engagement with at risk community members engaging in this activity in locations such as parks and adjacent bottle shops.
The Hume City Council Health and Wellbeing Plan (2103 – 2017) identifies four strategic directions around creating
environments for health – built environment, social environment, natural environment and economic environment. It
identifies high or very high levels of psychological distress and high smoking rates as issues and people with a disability or
mental illness identified as a population group at higher risk. The plan’s principles are to improve health and wellbeing for
all, promote social justice, support environmental sustainability, acknowledge people’s diversity and build partnerships for health.
The Melton Health and Wellbeing Plan has four themes - Healthy Places; Healthy Community; Healthy People; and
Healthy Lifestyles. It notes high levels of psychological distress, high rates of mental and behaviour disorders and
fewer mental health clients. It also notes low alcohol and drug service users, average rates of AoD use and high
smoking rates. Mental health is a named priority action area under Healthy Communities; and includes working
with the community to understand the impact of mental health issues, initiatives to support social inclusion for
people with a mental illness and initiatives to address prevalence of mental health issues in the community. Smoking and alcohol and drugs
are named priority action areas under Healthy Lifestyles and focus on harm minimisation and harm reduction initiatives.
The Melton City Council Community Safety Plan (2010-2014) identifies priority areas for action: community connectedness, a safe, clean
and welcoming environment, family violence prevention, reduction of antisocial behaviour, alcohol and substance abuse harm minimisation,
partnerships to improve community safety and safer access and movement. Specific actions to address alcohol and substance abuse include:
Providing services & community education; adherence to responsible service of alcohol and considering impact of liquor licensing permit
applications, and alcohol and drug free events for young people.
Macedon Ranges and North West Melbourne Medicare Local comprehensive needs assessment (2014 – 2015) identifies a high
level of mental health issues amongst the refugee population and high smoking rates across all age groups and locations.
Responses include improving information for GPs to assist with referral to the correct health service, integrating care for
patients as they access different health services from multiple providers, and improving access to mental health services
through establishment of mental health nurses in GP clinics and other health services.
The Health West Partnership Strategic Plan (2103- 2017) has four key result areas of service coordination/ integrated chronic
disease management, prevention, aboriginal health, home and community care and four activity streams of health literacy,
integration, community participation and collaborative action. The integrated mental health services for refugee asylum project aims
to improve access and participation by refugees to mental health services. AoD does not specifically feature in 2013 – 14 activity but
past prevention and advocacy work has included increasing access to needle, syringes and opioid replacement therapies; and alcohol
and other drug issues in the west.
23
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Better Health Plan for the West (BHPW) is a partnership of over 20 agencies across primary care, acute
health, government, social support and other sectors delivering services in the Western Region of
Melbourne. BHPW is a 10 year plan that identifies mental health as one of three high priority health
issues, and details the area’s planned response to this issue. It has key initiatives under health literacy,
models of care, human resources, service provision, e-health, research, partnership coordination.
North West Mental Health and MHCSS partnership has four priorities: AoD interface, priority access issues, service
coordination/client pathways and residential services.
24
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
4.4 South West Catchment
The South West Melbourne catchment includes the cities of Hobsons Bay and Wyndham
and has a current population of almost 270,000. A significant challenge for the
catchment is managing and responding to the differences in the two local council areas.
Hobsons Bay is relatively advantaged, close to the State average in many key socioeconomic indicators, well serviced by public transport and health service provision and
its growth rate remains below average. In contrast, indicators suggest higher levels of
disadvantage in Wyndham, including higher than average rates of unemployment,
mortgage/rental stress, food insecurity, family incidents, alcohol related family violence and lower rates of service provision
(including fewer pharmacies) and transport challenges. It is also the second fastest growing municipality in Victoria and the
proportion of young people is greater than the State average.
Despite the differences, the two LGAs are similar in relation to:




Cultural diversity: both have high rates of people born in a non-English speaking country and speaking languages other
than English at home. People from India represent the largest group from a non-English speaking country. The rate of
new settler arrivals in Wyndham is much higher than the state average.
Gambling measures: both LGAs are ranked within the top 20 LGAs for gaming machine losses per head of adult
population.
Alcohol and other Drug (AOD) risk taking in young people: a range of indicators show particular vulnerability amongst
young people aged 15 – 17 years – including high rates of smoking and alcohol, marijuana and illicit drug use.
High rates of use of AoD services for alcohol and high number of presentations to emergency departments for
pharmaceutical use, particularly for the 15 – 24 year old age group in Hobson’s Bay.
Both catchments have lower rates of registered mental health clients. However, Wyndham has a lower rate of MHCSS clients per
1000 population than the regional average and Hobsons Bay is higher. The rate of people seeking professional help for a mental
health problem in Hobsons Bay is also higher than the State average although other indicators of psychological issues are similar.
Priorities for the South West catchment
1. Wyndham the growth corridor
Wyndham was repeatedly raised as an area of specific priority.
 Allocation of resources
 Poor infrastructure: transport, service provision
 Specific area demographics, representing priority need
2. Service system
Specific needs raised around:
 GPs: more training & awareness in recognising AOD issues / needs in their patients, pharmacotherapy permits
 Opportunities for cross sector collaboration for problem solving & innovation
 Need for CALD services, young people, people with gambling problems and families.
3. Client need
Specific client groups require local planning attention.
25
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Service access issues were identified for:
 Young people


Culturally and linguistically diverse groups (especially refugees)
Families
Complexity in the client group
 Cultural & linguistically diverse groups (especially refugees)
 People with gambling issues
 People with medical co-morbidities
26
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Key Data in the South West
Estimated eligibility in community
Hobson’s Bay
756
Wyndham
1470
High/ Very High reported
Psychological Distress in
community
Help Seeking professional help for
mental illness in community
Persons reporting fair or poor
health
People born overseas
Speaking a language other than
English at home
Drug Use & Possessions Offences
per 1000
AOD Clients per 1000
Needs Register August 2015
12.1%
11.2%
14.5%
12%
15.8%
17.4%
32.7%
30.9%
35.5%
32%
3.6
3.2
5.8
5.1
MHCSS clients per 1000
Number of people accessing MHCSS
below 25 years of age
Gender of MHCSS clients
Female/ Male %
Aboriginal and Torres Strait
Islander clients
Living with family or others/ alone
Dependant Children
1.59
8.1%
1.03
20.9%
45/55
56/44
0
1%
62/38%
11%
79/21%
17%
48/39/11
36/30/28
Clinical Provider of MHCSS clients
(AMHS/ GP/ Private Psychiatrist)%
People from culturally and
linguistically diverse backgrounds
Top 5
Referral Source to MHCSS
Top 5
24
India 4%
India 6%
Vietnam 2%
Philippines 3%
Lebanon 2%
China 2%
Philippines 1% Malaysia 1%
China 1%
Vietnam 1%
Community Mental Health 28%
Self 22%
Partners in Recovery 7%
Housing Provider 5%
Police 4%
27
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Aligned planning priorities in the South West
The City of Hobsons Bay Health and Wellbeing Plan 2013-2017 identifies mental health issues for young
people with psychological distress and hospitalization. Alcohol and drug issues are not specifically identified.
The plan has four goals and number of strategies within the remit of local government. Goals include an
inclusive, resilient and healthy community; well planned, vibrant and sustainable places, quality infrastructure
and public open spaces and places and to be an innovative, proactive and leading organisation. It states that the council will
provide a range of accessible, high quality services and social supports, foster community wellbeing, protect and promote
public health and community safety and work in partnership with key stakeholders to attract and advocate for the services
needed in Hobsons Bay.
Wyndham City Council Health and Wellbeing Plan 2013-2017 identifies mental disorders (particularly depression) as
the leading loss of healthy life and the importance of social connections a strong factor in emotional health. It also
notes a high prevalence of daily smoking and consumption of alcohol. It sets out five priorities, three of which directly
address AoD and MH issues.

Priority 3 a safe and confident city involves working to reduce the harms arising from alcohol and other drug use, and the incidence of
injury, particularly among young people. Within this they will measure the percentage of people at long term risk of alcohol related
harm.

Priority 4 an inclusive and resilient city aims to increase availability of mental health services, early support to children and young people
experiencing mental health and emotional health challenges as well as social inclusion strategies.

Priority 5 an active and healthy city aims to build the capacity of communities to address the underlying causes of chronic disease by
reducing harmful consumption of alcohol and reducing smoking.
South Western Melbourne Medicare Local 2013 Needs Analysis details smoking, alcohol consumption and mental
health as areas of community concern. Refugee, housing and AOD services are finding it hard to adequately deal
with clients with unaddressed trauma. Key actions include training for local health professionals in areas of
specialised mental health including forced adoption, personality disorders, perinatal depression, eating disorders,
anxiety, depression and suicide prevention. Other relevant, but not explicitly targeted to mental health or AoD issues include improving health
literacy, a focus on Laverton and improving service access and coordination for refugee clinics within general practice.
The Health West Partnership Strategic Plan (2103- 2017) has four key result areas of service coordination/ integrated
chronic disease management, prevention, aboriginal health, home and community care and four activity streams of health
literacy, integration, community participation and collaborative action. The integrated mental health services for refugee
asylum project aims to improve access and participation by refugees to mental health services. AoD does not specifically
feature in 2013 – 14 activity but past prevention and advocacy work has included activity to increase access to needle,
syringes and opioid replacement therapies; and alcohol and other drug issues in the west.
The Child and Youth Pathways – Western Mental Health Project (2013) was auspiced through the Health West Partnership with an aim to
provide young people with mental health issues living in Melton and Wyndham with the best possible opportunity for receive appropriate
referral in a time manner to the most appropriate service provider. It developed an interagency care planning and information sharing
protocol.
Better Health Plan for the West (BHPW) is a partnership of over 20 agencies across primary care, acute health, government,
social support and other sectors delivering services in the Western Region of Melbourne. BHPW is a 10 year plan that identifies
mental health as one of three high priority health issues, and details the area’s planned response to this issue. It has key initiatives
under health literacy, models of care, human resources, service provision, e-health, research, partnership coordination.
The South West Mental Alliance Enhancing Client Pathways and Transition through mental health services project (2012) identified the
difficulties in navigating services and moving through the system and recommended a number of actions to improve this. A planning forum in
2014 identified as a priority an “orientation” program for service providers to each other.
28
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
5
The North Western Region Catchment Based Plan 2015-2018
Six key priorities have been identified to inform the work across the North
West region. Underpinning the key priorities is a number of key activities
and actions that will occur. Some of these activities will occur at the
regional level, while others are focussed at the local level. The priorities
have been formed through the use of population and service data, through
stakeholder engagement and to align to other local planning.
The priorities enable activities to be collated in themes and ensure activity
is focussed on the identified objectives of MHCSS and catchment based
planning.
Following is a more detailed breakdown of proposed activity, including an
initial identification of locally focussed activities. It is anticipated this will
change and grow in response to further learning and identification of new
system pressures. The catchment based planning function through its
communication strategy will provide ongoing monitoring and evaluation of
these activities. Similarly the function will enable the sharing of learning
derived from activities across MHCSS providers, with consumers, carers,
family members, the broader community, clinical services, and other
human services across the North West.
Priority 1: Focus on consumer
choice and identified service
priorities.
Priority 2: Build a collaborative
service approach within MHCSS
in the North Western region and
catchments and across the
health, mental health and
community support service
system.
Priority 3: Improve access for
people from disadvantaged or
vulnerable groups in the
community.
Priority 4: Partner with
consumers, community and
service providers to assist with
changes to the MHCSS service
landscape, including the
transition to NDIS.
Priority 5: Develop and
implement an effective
consumer participation strategy
to inform catchment based
planning and service
development.
Priority 6: Extend and develop
the availability of data which
supports planning and
continuous improvement.
29
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
5.1
Action Planning Overview
Priority 1: Focus on consumer choice and identified service priorities.
A number of possible action areas were identified through data analysis and consultation. This creates a picture of
those areas in which there appears to be a readiness and commitment to introducing change and those areas in
which more information is needed.
As more information becomes available through access to new data sources and the outcomes from other
discussions and consultation with other stakeholders, it is possible that the interest in these action areas may change
and/or new areas will be added.
For each of the action areas described below, a small report will be produced. Depending on the need, this will
generally involve:
•
Identifying key partners from within MHCSS service providers, mental health and health partners and other
key stakeholders to build collaboration
•
Targeted consultation with key partners
•
Additional data collection (if relevant)
•
Mapping of existing activity
•
Identification of potential strategies to address the issue and/or a process to identify a strategy.
•
Identify if the area needs further investigation through a learning based report.
These reports will be produced in the first half of 2016. An activity brief will be created for each area. It is expected
that the process of creating these reports, will in itself deliver a benefit through bringing people together to
understand and explore the issue and create information to support service delivery and other planning decisions.
However, they will ultimately be used to provide the basis for ongoing work to enhance the service responsive to
consumer choice. The reports will be shared across the service network through distribution within the Governance
Groups and across Mental Health Alliances and be published on the cohealth website to ensure broad distribution.
Ongoing activities will be approved by MHCSS Providers and Governance Groups.
Physical health
It is well documented that people with a mental illness experience higher rates of morbidity and premature
death than the general population. While most clinical and MHCSS services now incorporate physical health
screens into their assessment processes, it appears that additional effort is needed to ensure that action is
taken, and in particular accessing primary health care services and responding to comorbid needs. There is a
growing research base to support this approach. Increasing numbers of people who are overweight or obese
in the general community present an additional challenge. The short report will focus on confirming the level
of screening being undertaken, identifying the barriers (for support workers and consumers) to accessing
primary health carer services and identifying opportunities for primary health care provider engagement to
30
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
ensure more integrated care. It is predicted partnerships with key local community groups focusing on
physical activity and well-being will be developed. Other opportunities include building linkages to General
Practice, and enhancing health literacy.
Supporting family and carer inclusive practices
Currently, under-identification of carers is evident in MHCSS data. Opportunities to enhance carer
identification and linking carers to appropriate supports has commenced with better identification occurring
in recent months and further enhanced by the implementation of carer identification tools across MHCSS.
The next phase of work will include improving awareness of the issues, information/ resources about access
to carer support services, potential mapping of services and identification of service gaps across the North
Western Region, and explore with carer services whether they can monitor/report on referral rates from
MHCSS.
The stakeholder consultation also suggested the need to rethink service models to ensure that they are
responding to the needs of parents with a mental illness in the context of their family, with families living in
the growth corridors highlighted for attention.
Improve identification of vulnerable children
MHCSS are expected to identify and respond to vulnerable children. Almost 50% of the initial MHCSS service
user data identifying whether service users had children was missing. This will be explored in future data
analysis. Based on the analysis, work will be undertaken to enhance identification of vulnerable children and
improve linkages to agencies supporting vulnerable children.
Other opportunities to improve the responsiveness of MHCSS services to identified consumer choice in line
with the goals of MHCSS. This includes services responding to the needs of consumers, enhancing self
management and reducing the impact of disability, and consumers are involved in their care.
Activity areas:
-
Improved physical health outcomes
Family and carer inclusive practice
Identification of vulnerable children
Identify other key and emerging issues impacting people with mental illness
Services respond to the identified needs of consumers
Consumers are involved in decisions impacting their care
Priority 2: Build a collaborative service approach within MHCSS North Western region and catchments and across
the health, mental health and community support service system.
The catchment based planning function works alongside, supplementing and supporting the range of existing
planning and service coordination mechanisms which already exist. The strong connections between the Governance
31
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
group and the existing networks, supported by the catchment based planner, helps create a strong mechanism to
align effort and create a framework to define and promote activities which are focussed on agreed goals.
While the focus of this planning exercise is for MHCSS, maximum value from the effort will come through making
links to and supporting a range of other planning activity, particularly to those services and organisations that are
responding to people with a mental illness as part of their target group or addressing social determinants of health
which can have a significant impact on health and wellbeing outcomes. Our recent stakeholder forum identified:
•
Concern about multiple planning processes and the need to align and/or coordinate these.
•
The importance of (sharing) data and information to guide service delivery decisions, understand
client need and identify trends.
•
Importance of ensuring planning occurred across the continuum from prevention through to
treatment services.
A key role of the catchment based planning function is to facilitate and coordinate, including providing practical
resources and support, to enable organisations to work together and form agreed and shared priorities to improve
outcomes for people with a mental illness. In particular, a focus on enabling services to respond in an integrated and
joined up manner will be used through the planning process. It is intended cross sectorial forums are supported
through to 2018. Currently, a forum has been scheduled with the Alcohol and other Drug and the Homelessness
sectors in December 2015. This will include representation of senior staff and managers across the three sectors,
developing approaches to integrated service for people requiring service across the three sectors. It is anticipated
100 stakeholders from the three sectors will attend this forum, with a clear goal to develop working parties beyond
the forum to address key themes. The forum will focus on opportunities to enhance integration across the sectors.
Improving referral from key potential partners, such as General Practitioners, will be explored through the life of
catchment based planning.
Activity areas:
-
Improve service coordination and enhance understanding of MHCSS
Encourage referrals from key potential partners
Respond to population changes across growth corridors
Participate in and respond to locally identified activities and priorities as they emerge
Work collaboratively with Mental Health Alliances, Primary Health Networks, Primary Care Partnerships and
other stakeholder groups
Map the service system and facilitate partnerships across North Western Region
Collaborate with other planners in the North Western region and across the state
Support and build CBP governance groups to ensure they inform planning processes
Publish resources and other information to inform future activities.
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Priority 3: Improve access for people from disadvantaged or vulnerable groups in the community.
Access to MHCSS for people from disadvantaged or vulnerable groups was identified through data analysis and
through consultation with stakeholders. Initial service user data analysis suggests a lack of cultural diversity in the
client group (particularly when compared to the local population) and a service user age distribution which is
inconsistent with the population. This was drawn from the initial data collection in December 2014. It is anticipated
some improvement in diversity of background of service users will be shown in subsequent data reports. The
population summaries and data in the previous section highlighted variability across and within the catchments.
Ongoing work will occur to further monitor, analyse and support activities to improve access for people from
disadvantaged or vulnerable groups
A number of brief reports will be generated to highlight opportunities to improve access for the following groups:
Ensure young people are accessing MHCSS
Across the catchment young people under the age of 25 years are under-represented in the data. This
priority will be further investigated with youth mental health services, including headspace and Orygen, to
gain a better understanding of expected demand from young people, potential barriers and what services
may be used by this cohort. Consideration of gender issues and how these may be affecting access will also
be included.
Improve access to MHCSS by Culturally and Linguistically Diverse Groups.
We will explore the lack of use of MHCSS by people from culturally diverse backgrounds as shown in the
initial data (with a focus on people born in India, but other groups would include people born in Turkey and
Iraq (particularly in Hume), China and Vietnam. We will analyse data and consult with Action on Disability in
Ethnic Communities (ADEC) and relevant communities. We may also include investigate the extent to which
MHCSS are responding to newly arrived communities, including those from Africa and refugees, including
consideration of new settler arrival data. There are also a number of existing networks and projects in the
Region to build upon, including the North West Partnership Integrated Mental Health Services for Refugees
and Asylum Seekers Project and the North West Area Mental Health Service five ways to wellbeing
framework. Particular consideration of gender issues will also occur.
Ensure access pathways for people who are experiencing homelessness
The focus of this priority would be to better understand access issues and/or service pathways for people
who are experiencing homelessness to MHCSS. Consultation is suggesting that some people may be finding
it difficult to access services and/or referral processes are yet to be established/ are not always working for
people who are experiencing homelessness. The MHCSS service user data suggests that there may be an
under-representation of people who are homeless in some areas. Housing service providers are responsible
for between 3 – 7% of referrals (which although low they are fourth or fifth highest referrers after mental
health service, self or other). Currently work is underway to capture data across the homelessness, Alcohol
and Other Drug and mental health sectors. This has included a data snapshot undertaken by frontline staff
across the three sectors outlining service demand and if services are meeting those needs. Additionally, a
survey of workers perceptions of the opportunities and challenges in working across the three sectors has
been undertaken. Both of these data sources will inform the AOD/ Mental Health and Homelessness forum
in December 2015.
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Ensure appropriate response for people experiencing family violence
The focus of this priority would be to appropriately identify and respond to people currently or who
previously experienced family violence. Across the North Western region, just under half of current MHCSS
clients live in families. An opportunity is available to better link the mental health and family violence sectors
to enhance identification and service responsiveness to the needs of people currently experiencing or who
have experienced family violence through the planning process.
Ensure appropriate access to MHCSS by Aboriginal and Torres Strait Islander people
While Aboriginal and Torres Strait Islander people are over-represented in the MHCSS service user data
when compared to the population, it is possible that this is still an under-presentation compared to service
need. Anecdotally, it appears that Aboriginal people are moving away from the traditional inner area service
hubs to the growth corridors. In the first instance investigating this action would aim to build a more
comprehensive picture of demand for services. This will be supported by engaging with local stakeholders
and community organisations.
Improve understanding of and responses to people who have a dual diagnosis
In the first instance this will involve quantifying the numbers of MHCSS services users who also have an
alcohol or other drug issues. Also, work with the AOD catchment based planning function to identify referral
patterns between the service systems (currently no referrals to MHCSS from AOD services), potential
demand and service barriers. Over the medium to long term may involve considering workforce issues and
opportunities for working across catchments, to improve responsiveness to the client group
Improve understanding of and responses to people who have other comorbid conditions
People often have a complex set of needs that require response from a variety of providers. The planning
process will explore opportunities to develop more integrated approaches to care that place the person at
the centre of a joined up service response.
Improve access for people in the growth corridors
While not necessarily drawing people from disadvantaged or vulnerable groups, the growth corridors
represent unique opportunities to explore service usage in locations with expected increases in demand
particularly from younger families.
Activity areas:
-
Ensure young people are accessing MHCSS
Improve access to MHCSS by people from culturally and linguistically diverse backgrounds
Ensuring access pathways for people experiencing homelessness
Ensure appropriate response to people experiencing family violence
Ensuring appropriate access to MHCSS for Aboriginal and Torres Strait Islander people
Improving understanding of and responses to people who have a dual diagnosis
Improve understanding of and responses to people who have other comorbid conditions
Improve access for people in the growth corridors
34
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Priority 4: Partner with consumers, community and service providers to assist with changes to the MHCSS service
landscape, including the transition to NDIS.
The recent announcement of the NDIS rollout dates across Victoria has provided an opportunity to focus activity on
the successful planning with consumers to reduce any impacts of the transition process. This is particularly so in the
Northern catchment and Yarra LGA which will transition in July 2016. The other locations are scheduled to transition
during 2018. This will be a period of significant change and great opportunity. Work will be undertaken to develop a
greater understanding of the changing landscape through consultation with key stakeholders.
Activity areas:
-
Identify system gaps and pressures emerging from the transition to NDIS
Work with service providers to identify challenges and opportunities in the changing landscape
Work with MHCSS providers to identify workforce challenges and encourage shared learning opportunities
Promote understanding of NDIS and psychosocial disability across service sector
Identify and respond to new information on NDIS and other changes that occur.
Priority 5: Develop and implement an effective consumer participation strategy to inform catchment based
planning and service development.
Consumer and carer participation is a key principle for mental health community support services. It involves
organisations actively facilitating consumer and carer participation at the individual and organisational levels in
order to improve safety and quality outcomes. The catchment based planning service specification also requires that
the views of consumers and carers inform the development and review of the catchment-based strategic plan and
are represented in other relevant planning forums.
The catchment based planning project has established a Consumer Representative Working Group (CRWG) as part of
its overall governance structure. It currently meets monthly. This group has representation from paid consumer staff
from the four providers and current consumers from each of the services.
A key role of this group is to bring a consumer perspective to the identification of priorities and the development of
strategies and responses to issues identified. The group is currently designing an effective strategy to assist it in this
undertaking. The aim is to create an ongoing dialogue with consumers through active feedback.
A consumer and carer participation officer is employed as part of the Catchment Based Planning function to support
the working group in partnership with the MHCSS providers.
In initial consultations, carer groups identified they were over consulted and time poor. This resulted in a carer
representative working group not being established. Currently, work is underway to partner with carers to
determine an effective approach to ensure appropriate influence and consultation on the catchment based planning
process and identified priorities and activities. This forms a key activity over the coming months.
Activity areas:
-
Develop a carer representative approach that meets the needs of carers
Support and build capacity of the Consumer Representative Working Group
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
-
Enable CRWG members to undertake consultation in local services and other opportunities as appropriate
Develop and implement an effective consumer participation strategy to inform catchment based planning
and service development
Increase the number of MHCSS consumers and carers available for consultation
Priority 6: Extend and develop the availability of data which supports planning and continuous improvement.
There is significant population level data available about the health and well-being of populations – including those
which impact on the social determinants of health. This data has been used in the development of this plan to
provide information about catchments that assist in understanding possible client and service related issues.
The Department of Health and Human Services holds all service user data at a catchment level. An initial data
collection in December 2014 was undertaken directly with the providers. All MHCSS providers contributed their data
for individual client support package recipients as at December 2014. This data set has been invaluable in identifying
potential access issues informing further investigation, data quality issues and information about service users. In
partnership with the Department, ongoing data collection, analysis and reporting are planned. The ongoing
gathering, analysis and reporting of key data will form the basis for monitoring activities of catchment based
planning and to provide an understanding of service need and use. This data will be made available on the cohealth
website.
Further consideration of exploring other data sources, such as Medicare data and service use data from
Commonwealth services will be undertaken to improve understanding of service availability, demand and gaps.
A proposed data dashboard is presented on the next page. It examines key data points about service delivery to both
monitor the impact of proposed activities and to provide a mechanism to identify and respond quickly to emerging
services gaps or pressures. The data collection items will be reviewed annually to ensure they are meeting the
requirements of the plan and are adequately informing providers about emerging themes.
Activity areas:
-
-
Publish population data
Gather, analyse and produce service data
o Identify and respond to any gaps in data
o Mapping, collating and publishing data dashboard
Identify and respond to opportunities for improvement
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Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Proposed Data Collection Dashboard (by LGA, Catchment and Region)
Needs Register
-
Number waiting LGA/ Catchment (total and by priority)- Monthly Data
Length of wait LGA/ Catchment (total and by priority)- Monthly Data
Number taken to assessment LGA/ Catchment- Monthly Data
Referral Source
Service
-
-
Number of clients
o PDRSS Transition Number LGA/ Catchment
o Intake LGA/ Catchment
o Bypass central intake LGA/ Catchment/ Type (Residential, 90 day re-entry, transfer)
Number of service units provided Number LGA/ Catchment, Percentage vs. expected service units
Length of service as at Quarter/ Total and Percentage
90 day service re-entry
Outcome Measurement Aggregate Sep 2015 onwards
o List by type
Amount of Support provided- Units
Percentage of support- face to face
CALD Background mapped to community profile
Aboriginal and Torres Strait Islander people mapped to community profile
Number of young people mapped to community profile
Number of carers identified
Family status
Dwelling status
Number of parents of children
Exit
-
Number of people exited
Length of service at exit (0-3 months, 3-6 months++)
Client turnover percentage (exit/ total clients)
Reason for Exit
37
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Inner North Data and Catchment Plan- Melbourne, Moonee Valley, Moreland and Yarra
In addition to the action areas across the North Western Region, planning activity will occur within catchments to
respond to more localised issues. These will typically occur in the context of:
-
Local demographic issues
Local service priorities determined in partnership with local stakeholder groups
Changing service landscape under NDIS and transition dates
Opportunities for partnership locally
Specific Activities Overview
Every year the Catchment Based Planning function will partner with local stakeholders and MHCSS Providers to
determine key priorities for the each catchment for the following year. These activities will be in addition to the
regional wide focus, which will have influence across the 4 catchments and in turn the 14 local government areas. In
addition to the specific activities, Catchment Based Planning will respond to key demographic differences across the
4 catchments. This will primarily be reflected in priority 3 of the plan. The demographics of the local populations vary
across the North Western region, and the planning process is sufficiently nuanced to respond to these characteristics
at a local level.
The learning from these projects will be shared widely across the 4 catchments and be used to shape catchment
based planning in subsequent years. While specific activities are initially planned for a financial year, it may be
necessary to continue projects beyond this timeframe
2015-2016
Specific Activities- Inner North Catchment
1. NDIS transition- Yarra (Aligned to Priority 4)
The focus on the transition to the National Disability Insurance Scheme has been informed by the impending
transition of MHCSS service provision in Yarra, along with the 4 LGAs in the North Catchment into the NDIS in
July 2016. While providers will embark on their own planning for this transition, scope exists for Catchment
Based Planning to work with clients and communities to assist in planning for this transition. In turn, learning
through the transition period will be shared across other locations in the region for their transition in 2018.
2. Homelessness and Alcohol and other Drugs response (Aligned to Priority 2 and 3)
Partnering with key local stakeholders, the activity will focus on bringing service partners together to
develop effective approaches to working collectively for people who access multiple services, particularly in
response to people accessing homelessness and alcohol and other drug services. This project will be shared
across the catchments. Initially a data collection snapshot, coupled with a worker survey will inform a joint
forum to identify key opportunities to build collaborative practice.
38
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
North Data and Catchment Plan- Banyule, Darebin, Nillumbik and Whittlesea
In addition to the action areas across the North Western Region, planning activity will occur within catchments to
respond to more localised issues. These will typically occur in the context of:
-
Local demographic issues
Local service priorities determined in partnership with local stakeholder groups
Changing service landscape under NDIS and transition dates
Opportunities for partnership locally
2015-2016
Specific Activities- North catchment
1. NDIS transition (Aligned to Priority 4)
The focus on the transition to the National Disability Insurance Scheme has been informed by the impending
transition of MHCSS service provision into the NDIS in July 2016. While providers will embark on their own
planning for this transition, scope exists for Catchment Based Planning to work with clients and communities
to assist in preparation for this transition. In turn, learning through the transition period will be shared
across other locations in the region for their transition in 2018.
2. Needs Register response (Aligned to Priority 2)
This catchment has the largest number of people on the needs register across the North Western region. The
number of people is projected to grow over coming months. An opportunity presents to examine what can
be done to alleviate this list in partnership with the MHCSS providers.
3. Population Growth Corridor Response (Aligned to Priorities 2 and 3)
The growth corridors in Melbourne represent a challenge to service delivery, with the potential for demand
to outstrip supply. This growth enables the catchment based planning function to bring together key local
stakeholders to create solutions that meet local needs. The collective impact methodology will provide a
mechanism to bring partners to work on innovation solutions. This priority will be used across several
catchments, however, the work is anticipated to be localised, calling on local stakeholders. The learning will
be shared across catchments.
39
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
North West Data and Catchment Plan- Brimbank, Hume, Maribyrnong and Melton
In addition to the action areas across the North Western Region, planning activity will occur within catchments to
respond to more localised issues. These will typically occur in the context of:
-
Local demographic issues
Local service priorities determined in partnership with local stakeholder groups
Changing service landscape under NDIS and transition dates
Opportunities for partnership locally
2015-2016
Specific Activities- North West Catchment
1. GP Access (Aligned to Priority 2)
The focus on the transition to the National Disability Insurance Scheme has been informed by the impending
transition of MHCSS service provision into the NDIS in July 2016. While providers will embark on their own
planning for this transition, scope exists for Catchment Based Planning to work with clients and communities
to assist in preparation for this transition. In turn, learning through the transition period will be shared
across other locations in the region for their transition in 2018.
2. Asylum Seekers and Refugees Response (Aligned to Priority 3)
A major focus of the local mental health alliance, the catchment based planner will partner with a number of
local agencies to explore strategies to enhance care for asylum seekers and refugees within the North West
and South West catchments.
3. Population Growth Corridor Response (Aligned to Priorities 2 and 3)
The growth corridors in Melbourne represent a challenge to service delivery, with the potential for demand
to outstrip supply. This growth enables the catchment based planning function to bring together key local
stakeholders to create solutions that meet local needs. The collective impact methodology will provide a
mechanism to bring partners to work on innovation solutions. This priority will be used across several
catchments, however, the work is anticipated to be localised, calling on local stakeholders. The learning will
be shared across catchments.
40
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
South West Data and Catchment Plan- Hobson’s Bay and Wyndham
In addition to the action areas across the North Western Region, planning activity will occur within catchments to
respond to more localised issues. These will typically occur in the context of:
-
Local demographic issues
Local service priorities determined in partnership with local stakeholder groups
Changing service landscape under NDIS and transition dates
Opportunities for partnership locally
2015-2016
Specific Activities- South West Catchment
1. Family Inclusive Practice (Aligned to Priority 1)
This piece of work will extend on the work of local partners addressing family inclusive practice. There is a
higher than average proportion of service users living with family or others in Wyndham. Sixty four per cent
of women live with their family in this LGA (compared to 39% of men). There are also a comparatively high
number of service users (all of whom are women) with dependent children identified. The learning from this
activity will be shared across the other catchments.
2. Physical Health response (Aligned to Priority 1)
The physical health needs of people in this catchment are borne out in the population level data. An
opportunity exists to partner with existing strategies locally to support the needs of people receiving services
through Mental Health Community Support Services through 2016. This project is expected to deliver results
for people across other catchments as well.
3. Population Growth Corridor Response (Aligned to Priorities 2 and 3)
The growth corridors in Melbourne represent a challenge to service delivery, with the potential for demand
to outstrip supply. This growth enables the catchment based planning function to bring together key local
stakeholders to create solutions that meet local needs. The collective impact methodology will provide a
mechanism to bring partners to work on innovation solutions. This priority will be used across several
catchments, however, the work is anticipated to be localised, calling on local stakeholders. The learning will
be shared across catchments.
41
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Catchment Based Implementation Plan October 2015- June 2018
Catchment Based Planning- Implementation MHCSS North Western Region
Action
Activity
Responsibility
Due Date
Data collection
Develop agreement with DHHS to
provide data
Develop draft strategic plan
Catchment Based Planner
DHHS
Catchment Based Planner
October
2015
October
2015
November
2015
Strategic Plan
Seek approval for draft strategic plan
- Consumer Representative
Working Group
- MHCSS Providers
- CBP Governance Group
- DHHS
Priority 1: Focus on consumer choice and service priorities
Catchment Based Planner
Priority Analysis
Catchment Based Planner
April 2016
Catchment Based Planner
MHCSS Providers
Catchment Based Planner
MHCSS Providers
Local Partners
Catchment Based Planner
MHCSS Providers
Local Partners
June 2016
Response to priority
analysis
Implement priority
activities
Monitor, evaluate and
respond to priority
activities
Explore, analyse and report against
priorities identified in initial planning at
region and catchment level:
- Physical Health
- Family and carer inclusive
practice
- Identification of vulnerable
children
- Services respond to the identified
needs of individual consumers
- Improved capacity for self
management and reduced
impact of disability
- Consumers are involved in
decisions impacting their care
- Identify other key and emerging
issues impacting people with
mental illness
Develop regional, catchment and LGA
level response to identified opportunities
Implement priority activities through
locally convened project groups
Monitor, evaluate, and respond to
priority activities in partnership with
locally convened groups on a quarterly
basis
42
December
2017
June 2018
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Catchment Based Planning- Implementation MHCSS North Western Region
Action
Activity
Responsibility
Due Date
Priority 2: Build a collaborative service approach within MHCSS North Western region and catchments and across
the health, mental health and community support service system
MHCSS Governance Group
Increase representation and attendance
at Governance Group meetings
Establish meeting schedule across MHCSS
providers
- MHCSS CBP Senior Group
- MHCSS CBP Project Group
Develop map of local stakeholder groups
- Mental Health Alliances
- Primary Care Partnerships
- Services Connect
- Other local groups
Attend mental health alliance meetings
regularly
Attend other groups as available
Report findings at local stakeholder
groups
Catchment Based Planner
Ongoing
Catchment Based Planner
MHCSS Providers
October
2015
Catchment Based Planner
December
2015
Catchment Based Planner
Ongoing
Catchment Based Planner
June 2016
Build partnership with local partners to
address key themes and implement
project opportunities
Promote collective impact to guide
project implementation
Establish linkages with planners across
other sectors
Establish linkages with CBP across
Victoria
Catchment Based Planner
June 2016
Catchment Based Planner
Ongoing
Catchment Based Planner
December
2015
December
2015
Partner with Primary Health Network to
map health services and other service
systems
Actively facilitate MHCSS involvement in
cross sectorial forums
Facilitate shared learning opportunities
Catchment Based Planner
Map service data against expected data
for population
Aboriginal and Torres Strait Map service data against expected data
Partnership with local
MHCSS providers
Map local stakeholder
groups
Attend local stakeholder
groups
Report on findings of
priority analysis to local
stakeholder groups
Identify local priority
projects
Implement collective
impact methodology
Partner with other
planners in North West
Partner with Catchment
Based Planners across
Victoria
Map the service system
across North West
Cross Sectorial Forums
Catchment Based Planner
March 2016
Catchment Based Planner
MHCSS Providers
Build collaboration
Catchment Based Planner
between MHCSS Providers
MHCSS Providers
Priority 3: Improve access for people from disadvantaged or vulnerable groups in the community
Ongoing
Young People
Catchment Based Planner
Quarterly
Catchment Based Planner
Quarterly
43
Ongoing
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Catchment Based Planning- Implementation MHCSS North Western Region
Action
Activity
Islander People
People from CALD
backgrounds
People at risk of
homelessness or currently
homeless
People with dual diagnosis
for population
Map service data against expected data
for population
Map service data against expected data
for population
People in growth corridors
Produce summary reports
on the identified groups to
inform future activity to
improve service access
Identify project
opportunities to address
needs
Other groups
Map service data against expected data
for population
Map service data against expected data
for population
Summary reports produced:
- Young People
- Aboriginal and Torres Strait
Islander people
- People from CALD backgrounds
- People at risk of homelessness or
currently homeless
- People with dual diagnosis
- People in growth corridors
It is anticipated these reports will include
local and catchment wide approaches
Respond to gaps and pressures based on
quarterly data
Responsibility
Due Date
Catchment Based Planner
Quarterly
Catchment Based Planner
Quarterly
Catchment Based Planner
Quarterly
Catchment Based Planner
Quarterly
Catchment Based Planner
May 2016
Catchment Based Planner
July 2016
Identify pressures and gaps impacting
Catchment Based Planner
Ongoing
other population grouping
Priority 4: Partner with consumers, community and service providers to assist with changes to the MHCSS service
landscape, including the transition to NDIS
Consumer Readiness for
Work with local providers, community
Catchment Based Planner
Ongoing
NDIS
and consumers to support transition to
CRWG
NDIS
Workforce Readiness
Provider Readiness
System understanding
Focus on North East- Banyule, Darebin,
Nillumbik, Whittlesea and Yarra
Share learning from NDIS implementation
in North East to help prepare workforce
in other locations
Share learning across sector from
implementation in North East
Promote understanding of NDIS and
psychosocial disability with other parts of
the mental health system and with the
44
Catchment Based Planner
June 2016
Catchment Based Planner
MHCSS Providers
December
2017
Catchment Based Planner
MHCSS Providers
Catchment Based Planner
December
2017
December
2017
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Catchment Based Planning- Implementation MHCSS North Western Region
Action
Activity
Responsibility
Due Date
broader human services
New opportunities
Share learning from NDIS implementation Catchment Based Planner
to inform new ways of working
Ongoing
Priority 5: Develop and implement an effective consumer participation strategy to inform catchment based
planning and service development
Establish carer
Consult with carers on appropriate
Carer Participation Officer
November
representation framework representation approach
Catchment Based Planner
2015
Implement presentation approach
Carer Participation Officer
February
Catchment Based Planner
2016
Monitor approach to determine
Carer Participation Officer
August
effectiveness
Catchment Based Planner
2016
Establish and maintain
Seek increased representation to
Consumer Participation
November
Consumer Representative
Consumer Representative Working Group Officer
2015
Working Group
Catchment Based Planner
MHCSS Providers
Establish Consumer
Produce a consumer participation
CRWG members
March 2016
Participation Strategy
strategy
Consumer Participation
Officer
Catchment Based Planner
Develop key consumer led Identify key project areas
CRWG members
March 2016
projects
Build partnerships and agreed goals for
CRWG members
September
projects
Consumer Participation
2016
Officer
Catchment Based Planner
Implement project activities
CRWG members
January
Consumer Participation
2018
Officer
Catchment Based Planner
Monitor and evaluate project activities
CRWG members
June 2018
Consumer Participation
Officer
Catchment Based Planner
Priority 6: Extend and develop the availability of data which supports planning and continuous improvement
Population Level Data
Service Level Data
Key Indicators
Continuous Improvement
Publish population data on website
Collate and publish service level data
Collate, publish, and evaluate changes
against data indicators
Identify opportunities to enhance service
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Catchment Based Planner
Catchment Based Planner
Catchment Based Planner
August 2015
Quarterly
Quarterly
Catchment Based Planner
Ongoing
Working together: Now and the future
North Western Region Catchment Based MHCSS Strategic Plan
October 2015 – June 2018
Catchment Based Planning- Implementation MHCSS North Western Region
Action
6
Activity
Responsibility
responsiveness based on data
MHCSS Providers
Due Date
Monitoring, Review and Opportunities to have a say
The plan was developed in partnership with the MHCSS providers, Catchment Based Planning Governance
Group, Consumer Representative Working Group and in consultation with local mental health alliances and
other local stakeholders. Reporting will be published on the cohealth website and any agreed changes will
occur with the approval of MHCSS Providers and the Governance Groups, and in consultation with other
local stakeholders.
The catchment based planning involves an annual review of the plan through a reporting process. The data
will be monitored on a regular basis, as will the projects and other emerging themes. It is intended the
planning process will respond proactively to emerging themes and system pressures identified through data
analysis. In this sense, the plan will develop over its life with annual reviews.
A series of surveys and other opportunities are planned. This may occur in the broadest planning sense or be
specific to key issues. Alternatively, people wishing to have a say are always welcome to contact the
catchment based planning team.
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