Reintegration in Queensland: A New
Partnership toward Social Inclusion
for People with Mental Illness
Prison Mental Health Service
&
Richmond Fellowship Queensland
Overview
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Description of both services – structure and service
model
Partnership – history, context
Case Example
Outcomes
Future
Prison Mental Health Service
Component of Queensland Health Forensic Mental
Health Service
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In-reach to 8 Correctional Centres in S.E. Qld
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Triage, Assessment and Treatment in Custody
Psychological Intervention
Diversion to health services
Transitional Care Coordination Program
Richmond Fellowship
Queensland - RFQ
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Established in Brisbane in 1974, RFQ is a
specialist provider of community rehabilitation
and support services for people who have
moderate to severe mental illness
RFQ successfully tendered to Queensland
Health to provide transition support for people
leaving correctional facilities in South East
Queensland and received funding in 2007
RFQ’s Transition Support Service has been
operational for over 3 years
RFQ Service Structure
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RFQ’s Transition Support Service office based
in Annerley, Brisbane
Coordinator and 6 Support Worker positions
Primary Worker/Team Model
Nominal individual caseload of 6 – 8 clients
Services provided to 8 men’s and women’s
correctional centres in South East Queensland
TCP / TSS Service Model
RELEASE DATE
1 month
prerelease
CUSTODY
Prison Mental Health Service
Prison Mental
Health Service
Care Coordinators
Up to 6 months
post-release
NGO support workers
(RFQ)
COMMUNITY
District Mental Health Service
DFLO +/- CFOS
District Mental
Health Service
Case Managers
Up to 3 months
pre-release
2 weeks post release
RELEASE DATE
Referral profile
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Prison Mental Health Service (PMHS) ‘open case’ load
of around 1100 people at any one time
Subset are eligible for Transition Care Coordination
(TCC) from PMHS (around 100+ per annum)
Who does PMHS select for TCC?
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Significant mental health needs
Mental Health Act Status
Active Illness
Complex medication problems
Requires case management in community
Risk to successful transition of care
At risk of homelessness
Subset of this group (-80%) are referred to RFQ
7
The Partnership begins..
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2007
 Early discussions
 TSS Established
 TCP established
 Referral criteria finalised
 meeting between clinicians and support workers
to discuss potential referrals
 RFQ received first referral
 Regular management meetings
And continued…
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2008
 Busy time for both services
 Meetings were less regular
 Mutual recognition that this did not meet our
needs for communication etc
 Decision taken to meet regularly on a monthly
basis (alternating management and clinical
meetings)
 Development of TOR, agendas and venue
2009 - Current
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Bi-monthly Management meetings
Bi-monthly clinical meetings
 Mutual case presentations
 Workshopping service models and processes
Commencement of Transition Evaluation
partnership
Development of Service Level Agreement
Shared CANFOR roll out & training
Shared Conference presentation
Management Meeting objectives
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To ensure a coordinated approach to
maintaining and improving the collaborative
relationship
To focus on improving the links between the
agencies
To provide a forum for discussion of broader
issues
To ensure ongoing monitoring and annual
review of the agreed Terms of Reference.
Clinical Meeting Objectives
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To focus on improving the working relationship between
the two agencies.
To improve the mutual understanding of each agencies’
role in relation to referral processes, transition planning,
community rehabilitation and support and case
coordination.
To provide a forum for information sharing; discussion
and workshopping of individual case reviews; and issue
identification and problem solving in relation to broader
non-client specific issues.
To provide a forum for discussion in relation to referral
trends and patterns
Case Example
38 year old Caucasian Australian female incarcerated
(second time) for fraud in Brisbane Women’s
Correctional Centre
Health history:
 Schizophrenia
 Decreased Thyroid function
 Prejudicial childhood – neglect, poor parenting
Social history:
 Limited social support network
 Parents deceased - Estranged from sisters
 Primary school education. Some experience as a
hairdresser
 Iterant lifestyle
Role of Transition Clinician (TC)
Pre-Release
Referred to transition program by her
Psychiatrist 18 months before actual release date.
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Illness/ Medication education
Liaison with formal networks: Lawyers, sentence
management and MHS districts
Brief CBT around problem thinking.
Illness early warning signs
Rapport building
Discussion of mental health follow up
Needs assessment
Referral process
PMHS TC Completed referral to RFQ June 2008
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Client consent for referral
Client completes RFQ Referral form
PMHS send referral form to RFQ
RFQ meet with client in correctional centre.
Support Worker allocated
PMHS informed of acceptance of referral.
Role of RFQ pre-release
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Explain RFQ service model and philosophy
Emphasise voluntary nature of service
Client written consent to information sharing
Discuss her needs and details of support provided
Begin goal setting and informal planning
Continue collaboration with PMHS
Transition Planning
Release date late December 2009 Court Ordered
Parole
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An Individual Service plan (ISP) was prepared
collaboratively with client
TC identified emergency accommodation
Client happy to stay in this accommodation until
better options became available
She also agreed to be referred to the district mental
health service
Emergency contact details were also included in the
ISP
Release Day activities
On the day of her release from BWCC Client was
extradited
to NSW to face a Magistrates court on other matters
 Released from court in NSW on the day of her trial
 Client organised a bus and promptly returns to Qld
 Client contacts RFQ and returns to previously arranged
accommodation
 TC informs MHS and confirms initial mental health
appointment
 TC and RFQ accompany Client to G.P appointment
2 ½ months post release
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Client living in a Public Housing accommodation- a one
bedroom unit on the esplanade in a Bayside suburb
Ella with white goods worth $1500.00 with non-recurrent
funds provided by Department of Communities. Washing
Machine, Fridge, TV, DVD, Toaster and Juicer
RFQ provides support 2 – 3 times per week and assists
client with goal setting and activities planning
RFQ
6 months post release
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Client now taking responsibility for parole obligations
Client keeping G.P and MH appointments
Mental state continues to be stable
Client has dental needs addressed and is more
fashion conscious
Client commencing TAFE
Considering renewing contact with sisters
Client Outcomes
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Early local outcome data positive
Good anecdotal evidence
High 6th month program engagement rate
High client satisfaction survey results
Partnership Outcomes
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Continued willingness to work collaboratively
Mutual respect and understanding
Forums established to problem solve/manage:
 Staff performance issues
 Management of risk
 Systemic Issues
 Complex and chaotic environment
Future Plans
• Continuing current meeting formats
• Research and Evaluation
•Data collection
•Improving inter-rater reliability (CANFOR,
HONoS)
• Collaboration in relation to roll out of Maryborough
TSS
•Increase collaboration & Network building
(Housing, D & A, Employment)
Contact Information
Julie Evans
(07) 32718729
Julie_evans@health.qld.gov.au
Larry Stapleton
(07) 33632640
Larry.Stapleton@rfq.com.au