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Coordination of wrap-around services for individuals with multiple and complex needs

leadership group pic

The activities of this working group have come to an end with our mandate having been fulfilled. The working group were able to develop a series of resources to enhance the coordination of services for individuals with multiple and complex needs. Links to these resources can be found below.   


Coming together is beginning; keeping together is progress; working together is success. Henry Ford

Just as the complex social issues facing our region demand cross-sector collaboration, so the multiple and complex needs of individual members of our community require a coordinated response from all service providers involved. One of the South West Metropolitan Partnership Forum’s four priority projects is to improve the coordination of services for individuals with multiple and complex needs. While there already are a few service coordination models in place in the Cockburn, Fremantle and Melville region that share this objective (for example, Strong Families), these groups are largely government-driven and focus on the priority presenting need of a lead government agency (for example, a child protection concern or a mental health court order). The SWMPF project seeks to build on the learnings from these service coordination models and add to them, not only by focusing on the needs of the individual (and family) as a whole, but also by involving the client at all stages of the proposed intervention plan, and drawing on the resources available in the not-for-profit and community sectors, as well as government service providers. The SWMPF project aims to provide a blueprint for client-led, inter-agency (government and non-government) collaboration for all communities in WA seeking to support individuals and families with multiple and complex needs. Note: This project is concerned with the effective coordination of services, not the different models of ‘case management’ in operation.

SWMPF working group

The working group charged with improving the coordination of wrap-around services to individuals with complex and multiple needs comprises the following members:

Chair: St Patrick’s Community Support Centre

The roles and responsibilities of the working group members are detailed in the CWS Terms of Reference

Action plan – how the SWMPF is supporting service coordination and improved outcomes

Building the capacity of existing inter-agency working groups

The overriding concern of the SWMPF working group is to add value at all times; that is; to avoid duplication and to build on some of the great initiatives already under way in the region to improve service coordination.

So the first action the working group has taken has been to identify all the different inter-agency groupings that operate in the region, find out what their functions are and see how they are travelling. The resulting Inter-Agency Groups Directory was launched at a function held at the Cockburn Integrated Health Centre on 4 February 2016.  If you are aware of any other inter-agency groups working in the region that are not listed in the directory, please let us know.

The second action is to support inter-agency groups in their efforts to work collaboratively in order to improve client outcomes. The SWMPF held the first ever workshop for inter-agency groups on Thursday 27 August 2015. The purpose of this workshop was to obtain participants’ input into the development of a set of best practice guidelines for inter-agency groups. What came out of this collaborative process was the 10 building blocks for effective collaboration

It is anticipated that both documents will prove to be a valuable resource for those agencies looking  to join, develop or consolidate an inter-agency group.

Facilitating information sharing

All the inter-agency groupings identified to date have advised the SWMPF that one of the key barriers to service coordination arises from the absence of information sharing among agencies providing multiple interventions on behalf of the same client. This means not only that the client has to repeat their story many times over to the different service providers, frequently finding themselves on the ‘referral run-around’, but that the outcome for the client is necessarily compromised. Informed client consent, information sharing and widespread misunderstanding as to what information can and cannot be shared under Australian privacy legislation were also key concerns raised by participants at the SWMPF Planning Day on 1 April 2014. The SWMPF working group has therefore given priority to exploring ways to overcome these significant barriers to service coordination.

Shared informed consent The sharing of information between agencies is essential if clients are to receive a seamless multi-agency response. However, the issue of client confidentiality can often give rise to anxiety and/or confusion among workers who are not sure how, when or if information can be shared. The SWMPF has therefore put together some resources and tools to help support the effective exchange of information within your workplace and with other organisations. These resources include the current privacy legislation, principles and guidelines for the workplace, and relevant information sharing document templates.

Current privacy legislation The sharing of a client’s personal information is subject to Commonwealth privacy legislation. The Privacy Act 1988 sets out how a client’s personal information can be collected, used, stored and shared. The Schedule to the Act (Part 3: 6.1 and 6.2) outlines specifically under what conditions a client’s personal information can be shared. In essence, personal information can be shared with a third party/ies where the client has consented to the use or disclosure of that information. Such information must be relevant to the purpose of the use or disclosure (ie to provide a better service to the client).

Exception: Personal information can be shared without the client’s consent when there is a serious threat to the life, health or safety of any individual, or to public health or safety.  Under the new legislation – Privacy Amendment (Enhancing Privacy Protection) Act 2012 – this threat does not need to be imminent.

Principles and guidelines for the workplace Although the regulation of information sharing is set out in the legislation, it is recommended that each organisation have its own set of principles to assist staff in their everyday decision-making processes. Some useful resources to assist your organisation to facilitate information sharing is provided below. These can, of course, be adapted to meet the particular needs of your organisation.

Information sharing document templates In January 2015, the SWMPF’s CWS working group distributed two practical tools it had developed to support agencies that are seeking to facilitate informed consent and improve information sharing with other agencies.

The first tool is a template Shared consent form October 2015 to enable clients to give informed consent for the sharing of their personal information (please contact us to receive this document in Word so that you can insert your logo and organisation names, if applicable). This form has been reviewed and approved by the Fremantle Hospital and Health Service’s Consumer Advisory Group. The Shared consent form is a living document and will be reviewed every six months. We would therefore greatly appreciate any feedback you may have on this form.

The version provided here incorporates revisions made as a result of feedback received since it was first distributed in January 2015. Guidelines for the use of the Shared Informed Consent Form have also been developed to assist organisations in its implementation.

The second tool is a Collaboration and Information Sharing Partnership Agreement that seeks to support service providers in responding to the needs of clients who have authorised the sharing of their personal information by clarifying what personal information they are legally able to share.

It is clear that some service providers already have formal information sharing arrangements in place. These tools are designed to support those service providers that do not, by providing the means with which to facilitate informed client consent and coordinate service provision. The tools should be used in accordance with each organisation’s information sharing policies and procedures.

Note: Please let us know if you use either of the above tools as we would greatly welcome your feedback on their usefulness and any suggestions for improvement!

At the same time, the SWMPF working group is seeking to draw on the wealth of knowledge and expertise provided through the SWMPF’s diverse membership to establish a problem-solving forum of last resort – or ‘Think Tank’ – for agencies and/or organisations who believe they have exhausted all options in seeking to deliver outcomes on behalf of their clients. The working group is currently trialling case studies among its membership and finalising the information that will be required from agencies wishing to refer to the SWMPF Think Tank.

All initiatives undertaken by the working group will be driven and informed by the clients we are seeking to serve. The means used to engage clients will depend on the individual initiative; for example, most recently drawing on the expertise of Alma Street’s Consumer Advisory Group in relation to the development of the Shared Consent Form.

Shared project outcomes

The SWMPF working group is charged with delivering the following project outcomes:

To find out how the working group is monitoring its progress in achieving these outcomes, check out CWS outcomes and indicators

Follow the SWMPF’s progress

Updates on the progress of the SWMPF in developing and implementing this model will be provided on this page. To view the minutes of the group’s meetings, please click below as appropriate:

In July 2017, the Coordination of wrap-around services project was closed as it had achieved it’s mandate.