Outreach services guidelines

These guidelines should be read in conjunction with our General provider guidelines.

Who can provide outreach services?

The Outreach Service (OS) can only be provided by a non-government organisation which can evidence:

  • Registration with the TAC to deliver Outreach Services, and
  • A service agreement with the Victorian Department of Health and Human Services to deliver Mental Health Community Support Services; or
  • Registration with the National Disability Insurance Agency

What services will the TAC pay for?

The TAC can pay for Outreach Services that have been approved in writing when required as a result of a transport accident injury for clients who have psychosocial, mental health, behaviours of concern and other support needs. The Outreach Service includes:

  • The total number of hours necessary to deliver support to the client
  • Services provided with a ratio of at least 1:1 support delivered within an assertive outreach model
  • As appropriate, the development of a range of management and support plans which may support the client in their recovery and independence journey

About Outreach Service

The Outreach Service (OS) supports TAC clients with:

  • Psychosocial and mental health support needs
  • Behaviours of concern
  • Co-morbidity
  • and/or Dual diagnosis.

OS is 'assertive outreach', delivering support in a style and pace that aligns with the client's readiness and capability to engage in support. Support is holistic and based on the needs and circumstances of the client.

The OS will support the client to achieve specific goals and can provide support to increase social inclusion, develop activities of daily living skills, return to health and work, access, and maintain appropriate accommodation, and, where appropriate, risk management.

OS is person-centred, and clients will be supported to exercise choice and control over the supports and services they receive and build their capability to be self-directing, making informed decisions in their lives.

The OS may be one of a range of service options the client requires. For example, while the OS will address and manage many of the client’s support needs this does not include personal care requirements. Similarly, if a client requires formal therapeutic support this should be provided by the relevant, registered practitioner e.g. a psychologist.

The Outreach Service consists of the following components:

Assertive outreach model: It is the responsibility of the OS provider to maintain contact with the client and to provide flexible support.

Evidence based practice: OS providers will use evidence based practice to support the client, such as recovery-oriented practice; Trauma Informed Care; intensive behaviour support; Positive Behaviour Support and Active Support.

Care coordination: OS providers will provide care coordination i.e. coordinating additional supports, as well as directly supporting the client.

Crisis management: Where necessary OS providers will provide crisis management.

Increasing client capability: OS providers will take active and evidenced steps to increase the client's capability to exercise choice and control, to make informed decisions and to be self-directing in their lives.

Achieving client goals: OS providers will support the client to achieve their goals, to progress their recovery and return to health and work journey, and increase independence.

Building self-advocacy: OS providers will support the client to build their self-advocacy skills and where necessary, provide advocacy to ensure clients enjoy the full rights and range of citizenship.

Risk management: Where necessary OS providers will coordinate a risk management plan for clients who are at risk of harm to self and others.

The aims of the OS are to:

  • Support the client to achieve their recovery, return to health and work journey and, independence goals
  • Support the client to exercise optimal choice and control over the services and supports they receive
  • Support the client to be self-directing
  • Support the client to increase their social inclusion and be engaged in the community

A clinical team will provide clinical direction to the OS providers. The OS providers will work collaboratively with the clinical team, incorporating clinical direction and recommendations into their support and engagement of the client.

Outreach Service Definitions

Outreach Service (OS): An assertive outreach service designed to improve individual outcomes through psychosocial support, Positive Behaviour Support and, coordinated service intervention.

Assertive outreach model: A model which considers all aspects of a client’s situation, such as psychosocial, biosocial, physical, emotional and economic needs. Support is flexible and matches the needs and circumstances of the client. It is the responsibility of the OS provider to maintain contact and provide support to the client.

Clinical team / Treating team: The occupational therapist, psychologist and neuropsychologist involved in the support and management of the client. This includes any other specialist clinical support such as a neuropsychiatrist/psychiatrist and clinicians/providers with mental health and brain injury expertise.

Co-morbidity: Presence of one or more disorders, e.g. clients who have an acquired brain injury, a diagnosed mental illness, intellectual impairment and/or alcohol and other drug support needs.

Dual Diagnosis: Presence of a mental health illness and one or more disorders, e.g. an intellectual impairment, alcohol and other drug use.

Protective factors: Aspects of a client and their environment or personal experience that make it less likely they will experience risks and vulnerabilities associated with their support needs.

Activity Sampling Schedule: A document that may be developed by the client, clinical team and OS provider to provide the client with the opportunity to identify and access different activities and increase their social inclusion. This process will support the client to better understand and participate in activities they are genuinely interested in.

Behaviour Support Plan: Behaviour management tool which identifies the underlying causes of a particular behaviour. It is a management plan to identify environmental and other triggers to reduce behaviours of concern and to promote positive coping strategies of the individual. It also provides a clear response for the support worker to assist in the client’s management of the behaviour.

Exit Plan: Report the OS provider will develop on completion of the service intervention. It will provide a client profile, identify risk management issues, including mitigation strategies and identify key areas of support moving forward.

Risk Management Plan: A plan that identifies key risks and vulnerabilities associated with the client’s psychosocial and clinical presentation along with mitigation strategies.

Crisis Management Plan: A plan that outlines the steps required to manage and/or minimise an anticipated crisis event, i.e. breakdown in accommodation, recidivism, alcohol and other drug relapse. It will include key points of contact i.e. police, and mental health ACCESS Team.

Harm Minimisation Management Plan: Outlines the best practice management and response strategies for a client who engages in alcohol and other drug use.

Guidelines

Referral process and service initiation

The TAC Coordinator will make a referral using the TAC Outreach Service referral form. The referral will be sent to the OS provider's designated referral contact.

The OS provider will respond via email to advise capacity to accept the referral (or not) within a 48 hour period.

The OS provider will undertake the client needs assessment within a two week period from the date the referral is accepted. If the client is presenting in crisis the OS provider will attempt to prioritise the client needs assessment within a one week period.

Service delivery will commence within a two week period from the date the client needs assessment is undertaken. If the client is presenting in crisis the OS provider will attempt to commence service delivery as soon as is possible.

Services are delivered in collaboration with the clinical team. This includes but is not limited to:

At the commencement of the service the OS provider will undertake a needs assessment with the client. The purpose of this assessment is to identify support recommendations and the number of support hours required. Following the needs assessment the OS provider can commence client support.

The occupational therapist, as appropriate, will undertake regular client functional assessments and provide recommendations to the OS providers to incorporate into their engagement with the client.

The neuropsychologist will develop a comprehensive Behaviour Support Plan (BSP) in consultation with the OS providers i.e. OS providers will inform and contribute to the ongoing development of the BSP based on their engagement with the client.

Where appropriate, the neuropsychologist will have the capacity to deliver training to the OS providers in relation to the Behaviour Support Plan.

Where appropriate, the psychologist/neuropsychologist will have the capacity to provide specialist consultation services to the OS providers in relation to the clinical management of the client. This may include recommendations related to additional mental health and/or brain injury expertise/services which the client may benefit from.

Where appropriate, the psychologist/neuropsychologist will have capacity to maintain direct engagement and support with the client.

Reporting Requirements

Reporting requirements for OS will be based on measuring:

  • Access i.e. prompt access to the service
  • Service quality i.e. client outcomes

The TAC requires client progress reports for each client at three month intervals, including the following detail:

  • Funded support hours for each quarter
  • Time taken between referral acceptance and service delivery commencing
  • Changes in staffing team
  • Progress of client outcomes i.e. the recovery / SMART and independence goals and evidence to support this
  • Risk management and evidence to support this
  • Frequency of critical incidents

Exit report

At the conclusion of the OS providers must include an exit report:

  • The most appropriate support model for the client
  • Client profile i.e. strengths and protective factors
  • Risk management i.e. ongoing risk indicators and mitigating factors

Fees and invoicing

Please refer to the TAC Outreach services fee schedule.

What services won’t the TAC pay for?

The TAC will not pay for:

  • Treatment or services for a person other than the client
  • Treatment or services not authorised by the TAC under the Act
  • Treatment or services subcontracted to, or provided by a non-registered provider
  • Treatment or services provided outside the Commonwealth of Australia

Treatment or services provided more than two years prior to the request for funding except where the request for payment is made within three years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy