Assertive Outreach is a non-clinical crisis support for clients with psychosocial or complex transport accident injury-related needs who require proactive support to (re)engage with services to achieve their transport accident injury goals.

Assertive Outreach is a specialised form of Case Management which supports clients with more complex support needs to overcome a range of barriers caused by their transport accident injuries, including:

• significant mental injury
• drug and/or alcohol dependency
• homelessness
• interactions with the justice system
• behaviours of concern
• breakdown of TAC-funded supports or services.

The Assertive Outreach role can include:

• assessing and managing client risk, including completion of needs and risk assessments
• initiating and building client engagement with the TAC and a treating team, ensuring alignment of treatment and supports
• developing service implementation plans
• supporting the client to overcome barriers to service access or achievement of transport accident injury-related goals
• engaging with guardianship and VCAT administration applications
• navigating non-TAC related legal matters that impact the client’s accident injury goals.
• completing and submitting progress and exit reports to the TAC
• developing and implementing plans for client transition out of or between Case Management services.

The TAC can pay for the reasonable cost of approved Assertive Outreach provided to TAC clients who, due to their transport accident-related injuries, require intensive and assertive support to (re)engage or coordinate services. Prior written approval from the TAC for Assertive Outreach must be provided by the TAC before payment for services can be made.

The TAC will pay the reasonable cost of:

• Assertive Outreach services delivered face-to-face
• Assertive Outreach services delivered via phone or video-conferencing (Telehealth) where appropriate
• completion of client progress reports requested by the TAC.

The TAC will not pay the reasonable cost of:

• Assertive Outreach services provided by persons who do not meet the Provider Guidelines or comply with the TAC Support Navigation policy
• Assertive Outreach support that does not relate to the client’s transport accident injury supports or goals
• Assertive Outreach support that is not evidence based, reasonable, clinically justified and outcome focused
• Assertive Outreach support that exceeds a reasonable duration
• support for client goals that have not been approved by the TAC
• costs associated with referring a TAC client to a service not approved by the TAC Claim Manager
• Assertive Outreach if the client is already accessing a generalised case management service at the same time. When providing concurrent services, Support Navigation providers are expected to work in close communication.

The TAC will gather information from the client, their treating team, support providers and networks when developing a referral.

The referral will outline primary and secondary reasons for referral and any known client goals.

The TAC matches clients with providers based on expertise, experience and location.

In general, the TAC approves services for three months at a time and requires 3-montly progress reports. Extensions depend on client progress and need.

Service Standards:

It is expected that Assertive Outreach providers:

• Incorporate person-centred, strength-based approaches
  Recognising the client as an expert in their own circumstances, client engagement should be maximised to ensure support is tailored to individual goals, strengths and interests.
• Promote client independence
  Assertive Outreach aims to build the client’s capacity to plan, coordinate and navigate systems to achieve future goals independently. Providers should avoid client dependence by performing activities on the client’s behalf only when necessary.
  
  For clients who require significant support, the Assertive Outreach provider may work towards empowering the client to lead the support process in incremental stages:
  • First Phase – Do for
    The Assertive Outreach worker contacts a support provider to discuss the client’s requirements.
  • Second Phase – Do with
    Alongside the client, the Assertive Outreach worker contacts the support provider to organise an appointment
  • Third Phase – Do for themself
    The client schedules their own appointment with support. Once the client has developed capacity to complete tasks independently, the Assertive Outreach worker oversees transition of remaining support requirements to attendant care or the client’s natural supports.
• Be goal-oriented and time-limited
  Assertive Outreach is a point-in-time intervention to assist in the achievement of a specific goal(s) during a period of crisis or disengagement. It is expected that providers plan for clients to be transitioned out of Assertive Outreach as goals are achieved. While service duration will vary, the TAC expects that most clients will transition out of Assertive Outreach within 12 months.
  
  Some clients may require multiple periods of Assertive or General Case Management support across their lifetime due to the complexity of their injuries. It is expected that clients are transitioned from Assertive Outreach to Case Management if their situation significantly stabilises, but they still require case management support. Support hours should be tailored to reflect periods of stability and instability.

In most circumstances, The TAC does not consider ongoing, continuous Assertive Outreach with consistent support hours to be reasonable.

• Engage the client’s support network
  Where appropriate, providers should work with the client’s formal supports (such as attendant carers) and natural supports (such as family and friends) to develop sustainable strategies for supporting the client. This should include building the skills of the client’s support network to maintain structures established by the Assertive Outreach worker upon client transition and exit.
• Develop and implement transition plans
  Providers are expected to develop robust plans to support client transition out of Assertive Outreach services. It is expected that the transition plan is shared with the TAC and relevant members of the client’s support network to ensure ongoing stability.
• Be delivered in an appropriate format by providers with necessary skills and specialised knowledge
  The TAC recognises that providers who specialise in a specific area are more likely to achieve positive client outcomes. Providers are expected to:
  • be equipped with specialised skills and knowledge directly related to client goals, including knowledge of the service systems in the client’s local area where required
  • only take on client referrals that align with their recognised area of expertise
  • deliver services face-to-face, using telehealth only where necessary.

Registration

• employs staff with relevant qualifications, skills and experience
• delivers safe and high-quality services.

Qualifications

Assertive Outreach workers must be qualified and experienced in working with clients with complex needs, including service breakdowns, behaviours of concern, or crisis events.

Safeguarding

TAC Safer Services Support provides TAC clients and the community a pathway to raise concerns or complaints about the quality and safety of TAC funded services.

Reporting

Progress reports:
Providers are required to complete 3-monthly progress reports updating the TAC on the client’s progress. Reports will identify and record progress toward TAC approved client goals which are specific, measurable, achievable, realistic, and timely (SMART).

When making decisions about funding for further support, the TAC considers whether the progress report demonstrates evidence that the support is reasonable, clinically justified and outcome focused.

Exit Reports:

The Assertive Outreach worker must submit a Exit Report to the TAC upon conclusion of the service.

The Exit Report must include a summary of supports provided, the outcomes of the service, key areas of support moving forward, risk management information and how support roles have been handed over to key stakeholders (natural supports, attendant care providers, community access providers or other services).

The TAC uses the following principles to aid socially and economically responsible decision-making in line with the Transport Accident Act 1986:

1. Entitled:

A client is entitled to Assertive Outreach if:

• the TAC has accepted liability for the accident-related injury or disability that relates to the Assertive Outreach service
• the client requires intensive and assertive support to (re)engage with services or manage during a crisis to overcome barriers to achieving their transport accident injury goals.

2. Reasonable:

When determining whether Assertive Outreach services are a reasonable cost in the circumstances, the TAC considers:

• if the Assertive Outreach service is necessary because:
  • The client is unable to achieve their transport accident injury goals independently
  • The client’s natural support system (family, friends) is unable or does not have the skills to support the client to achieve their goals
  • The supports cannot be provided by an attendant carer.
• If the cost of the service is reasonable in relation to the service (see the Assertive Outreach Fee Schedule).

3. Clinical Justification:

When deciding if Assertive Outreach is clinically justified, the TAC considers whether:

• The support is recommended by the client’s treating team (e.g. General Practitioner, occupational therapist or psychologist) or is necessary to connect the client with clinical services.
• The requested hours of support and duration of support are appropriate for the client’s condition and transport accident injury goals. While support duration may vary depending on client need, the TAC expects that most clients will not require Assertive Outreach for longer than 12 months.

When considering requests for additional support hours, the TAC considers whether reports provided to the TAC contain evidence that:

• The effectiveness of the support has been measured and demonstrated
• The support provider has adopted a biopsychosocial approach
• The provider has taken steps to build client independence and self-management
• The support aligns with client goals
• The support is based on best available research and evidence, including through compliance with the Assertive Outreach Service Standards.

4. Outcome Focused:

When deciding if Assertive Outreach is outcome focused, the TAC considers whether:

• The service is progressing or achieving the referral goals
• The service promotes self-management and independence
• The support approach is adapted to the client’s progress, including tapering of services as the client’s situation stabilises.