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ACHRF 2014
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Right intervention at the right time: working with complexity, mental health and disability in
Victorian compensation settings
Karen Sait, Health & Disability Strategy Group
4th Australasian Compensation Health Research Forum
19 November 2014
Focus of presentation
1. Victorian compensation schemes – the Transport Accident commission (TAC), and the Victorian Workcover Authority (VWA)
2. Complexity, mental health and disability 3. Strategy and implementation 4. Sharing learnings 5. Next steps
Systems approach “We know from national surveys that the public consistently rate mental health as one of the top priorities they want governments to tackle. The work of beyondblue, SANE, Mental Health Australia and others has ensured that mental illness is now out of the shadows. Everyone knows that mental ill health will affect us all one day” Professor Patrick McGorry, Executive Director Melbourne University’s Orygen Youth Health Research Centre
Compensation = Complexity Research shows poorer overall outcomes of individuals who have a compensation claim: – Barriers to treatment and recovery outcomes
due to pressures and uncertainty regarding claim acceptance
– Often compounded for those with mental health, pain, other issues → ongoing disability and dependence
Compensation Definitions
1. Primary mental injury (no physical injury) - post traumatic stress, nervous shock/stress (with or without proximity to the accident or injury), adjustment disorder, stress and related anxiety, depression
2. Secondary mental injury consequence of physical
injury and often related to pain – anxiety, depression
3. Persistent Pain - “constant daily pain for a period of 3 months or more”- may lead to secondary mental injury due to delay in identification/treatment; and requires different yet complementary treatments
4. TBI/ABI (traumatic/acquired brain injury) – may have pre-existing mental health and/or other issues
The TAC and the VWA 1. ‘No fault’ schemes underpinned by legislation:
‒ Transport Accident Act 1986 legislation
‒ Workplace Injury Rehabilitation and Compensation Act 2013 (plus safety legislation)
2. Similar health and disability issues and shared providers
3. Committed to efficiency and collaboration regarding expertise, capability and resources
4. Continually strive for outcomes for injured workers and clients through innovation and adaptation
Transport Accident Commission ‘Recovery’ and ‘Independence’ Branches. Annually: ~19,000+ new claims
~45,000 people supported with services and benefits
~Road trauma estimated to cost more than $4 billion
Independence - 3% of new claims and 70% of outstanding liabilities
Compulsory transport related personal injury insurance
Owned by Victorian Government with independent Board and ~800 staff. Headquarters Geelong. Key areas:
1. Prevention: promote road safety and reduce accidents
2. Response: internal claims management - treatment and benefits for people injured in transport accidents
Victorian Workcover Authority Primary role of regulator ~270,000 workplaces in Victoria
~3 million workers covered
~30,000 claims each year
~90% of claims musculoskeletal
~Payouts of about $1.5 billion
Owned by Victorian Government with independent Board and ~1000 staff. Headquarters Melbourne. Self-funded from employer premiums. Key areas:
1. Enforcement: prevent workplace injuries
2. Prevention: OH&S and reduce injuries
3. Response: claims management by five Agents – Allianz, CGU, QBE, Gallagher Bassett and Xchanging plus TAC for those with catastrophic injuries
Health & Disability Strategy Group (HDSG)
Shared TAC and VWA service to meet corporate
objectives of both: • client outcomes; • client experience; and • scheme viability
Collaboration and partnerships:
internally and with health and disability sectors to develop and implement new
models and strategies
Evidence and research: internal and external health
and disability data, research, trends, and client and provider evaluations
Outcomes focussed: rehabilitation and support at reasonable and sustainable costs - focused on return to
work, health and independence: ”life back on track”
Emerging Scheme Issues
– Mental injury claims up from 36% to 80% ~7 years; 1 in 3 clients with physical injury and 4 of 5 pain claims secondary
– Referral post injury 12 months (median of 7 months);
more females (54%) than males (46%) and ~25% by 30 – 49 years
– TAC clients <30% impairment who also claim some
mental injury benefits: cost on average double their peers 3 times more likely to claim income post 12 weeks 10 times more likely to claim income for full 3 years
Snapshot Scheme Experience: overlap of return to work, mental health, pain
(TAC Recovery Branch 2012/13)
PersistentPain
MentalHealth
RTW$20K
$36K$32K
$79K $81K
$77K
$151K
No Complexities
RecoveryAve cost per claim per year
% of claims
32%
2%
2%3%
3%
1%
2%
54%
$9K
PersistentPain
MentalHealth
RTW
No Complexities
RecoveryTotal ave cost per year
$54M
$17M
$7M
$22M
$26M
$8M
$7M
$41MTotal ave no. of claims
per year 2,8004,600
260
270
175
210
85
180
Service provision “alarms” In 2009 our journey began: Clients not satisfied with available options; and providers unclear re their roles We were: 1. Focused on outputs rather than outcomes 2. Had low expectations: return to work, health,
independence 3. Using biomedical rather than psychosocial and
interdisciplinary models - outreach and flexible services not utilised
4. Not leveraging off contemporary public sector 5. Locked into a fee for service that often disincentivised
discharge and created dependency
Research and listening – External “advisory think tank” of experts – Foundation piece – Mental Health Framework – Researched best practice mental health, pain,
disability and complexity models and options – Reviewed internal processes, tools, staff
capability and most importantly communicated, consulted, and reviewed
– Endorsed joint Board TAC/VWA Strategy 2010/2011
– Commenced implementation in 2011/2012
Mental Health Strategy 3 – 5 Years……
Vision: TAC clients and injured workers with mental injuries or at risk, have access to the right intervention at the right time to enable
return to work, health and independence
Claims capability
Improve staff capability to manage
mental injury and pain claims, with a
focus on identifying clients at risk earlier, and integrating with claims management
processes
Client capability
Empower clients to take control of their
journey through facilitating awareness and self-management
Provider capability
Develop the capability of providers to
effectively work with TAC clients and injured workers
Intervention options
Expand the range of evidence-based
services available to clients based on a
stepped care approach
Enablers: Research/Partnerships/Data Mental Health Framework
Key initiatives Achievements to date
Claims capability
• Information, resources, training and tools • Model of ‘stepped interventions’ • Screening process based on current TAC Longitudinal Study • Purpose designed service catalogue
Client capability
• Information sheets and links to national e-therapy services
Provider capability
• Provider capability framework • New partnerships for example community managed mental
health sector • Disability Service Reform Working Group and Primary Care
Advisory Group
New Intervention options
• Psychosocial outreach services • Intensive outreach Services • Peer support • Partnership with Austin Health re PTSD program
Psychosocial outreach support Community managed mental health sector is a valued
component of a modern system based on recovery principles, care coordination and community connections
Implemented within TAC early 2014 - 36 referrals to date
Example of a client outcome: Prior to receiving outreach services unable to use public transport or attend community activities due to anxiety and panic attacks post transport accident. After engagement with the local outreach service, this client now has strategies to deal with her anxiety and has overcome her fear of using public transport. She has reconnected with family, friends and attending health appointments and community activities independently.
Screening process Research also indicates early intervention leads to better outcomes. The screening process draws on research from the TAC Longitudinal Study and is a two-stage process for new clients:
Initial screen identifies clients most likely in need of assistance and screens out about 60% of clients (0-3 months post-accident)
Second screen validates the first screen for remaining 40% and provides a pathway to the most appropriate services and actions (3-5 months post-accident)
Initial Screen (at the first call)
Low 60% Med 20% High 20%
Low ~8% / Med ~12% / High ~12% / Severe ~8% Second Screen (~3 months post accident)
Information / Supports
Range of treatment, referral, support options
Client risk of mental health or pain issues
Return on Investment Undertaken significant work that demonstrates early and positive outcomes: 1. Improved scheme viability
2. Potential common law benefits
3. Contribution to improved client outcomes
4. Improved client experience
Key Learnings Positives of note Lessons to note
1. Paradigm shift for clients and providers 2. Claims capability and new intervention
options positively impacted staff 3. Gave rise to ‘champions’ at all levels 4. New data set on mental injury and pain 5. Screening process and new support
options → to better meet client needs 6. Potential to reduce common law due to
earlier identification of claims at risk 7. Screening process may inform and
influence NDIA models for clients with psychosocial needs and/or psychiatric disability
1. Compensation system is not a health system –competing demands
2. Collaboration is challenging - find ways to work and complement strengths
3. Earlier focus on change management 4. Amount of resources and input required 5. Priorities shift and staff move–remain
optimistic and constantly communicate 6. Screening tool is ‘only a tool’ - capability
of claims managers is critical 7. Screening may identify increase in
numbers of clients at risk and initially increase liability costs - need to be upfront
8. MOST IMPORTANTLY there are many benefits in shifting from a model of compliance to a culture of care and trust with assurance
Next Steps 1. Embed, evaluate and refine the screening process 2. Implement psychosocial outreach and e-therapy
within VWA and develop targeted approaches 3. Expand client self-management 4. Collaborate with GPs on pain and mental health
issues for compensable clients and link to our other initiatives for example, the health benefits of safe work
5. Review high risk pharmaceutical use 6. Standardise multi-disciplinary pain services 7. Continue to develop new partnerships and
models for compensable clients
Further Information Victorian WorkCover Authority (VWA)
vwa.vic.gov.au Phone: 1800 136 089
Transport Accident Commission (TAC)
tac.vic.gov.au Phone: 1300 654 329
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