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We Help Ourselves (WHOS)

WHOS operates seven residential therapeutic community projects across NSW and Queensland with the aim of fostering personal growth within alcohol and other drug therapeutic programs incorporating harm minimisation and co-existing mental health initiatives. Its change management strategy was employed as part of the NADA Practice Enhancement Program (PEP) Seeding Grants project.

About the complex needs project

What key areas did you cover in your organisational approach to complex needs?

The PEP project was designed around organisational change management principles. In summary, it's essential to first determine what changes are required to determine whether staff and management perceive change to be necessary. Ensure that an implementation process is adopted that links policy and procedure change with training to support staff attitudes and skills and the organisation's resources are equipped to adopt the change. It's also essential to look at how evidence of change within the organisation will be evaluated.

1. Gathering evidence/data collection

The literature review conducted by NADA suggested that cognitive impairment would be an issue for the client group accessing WHOS. However, the exact extent of the problem was unknown prior to the PEP project commencing. To rectify this, a literature review was commissioned to determine if there was an existing assessment that would be an appropriate assessment tool for WHOS. 'Appropriate' meant that it would be quick to administer and score (staff are already under enormous administration pressure), would not require special qualifications to administer (e.g. a psychology degree) and would not have any costs (e.g. copyright).

A number of tools were identified, with the Montreal Cognitive Assessment (MoCA) tool most closely suiting the needs of the organisation. However, this tool had been designed to detect early signs of dementia, with only one study using it for an alcohol and other drugs population. To validate this assessment within this population, the University of Wollongong was approached and an honours research student was engaged to validate the tool as part of her research.

In addition, WHOS modified the client treatment outcome data collection to screen for traumatic head injury resulting in a loss of consciousness, learning difficulties and or diagnoses. This data was collected/readministered with all clients across WHOS and, as such, that data will now be available not only for individual treatment planning but for research and long-term service planning to improve service to people with cognitive impairment.

2. Policy and procedure review

The WHOS Assessment and Admissions Policy was reviewed and client assessment procedures modified to make sure appropriate data was being collected. Further modifications were made to the Discharge Policy to make sure that staff were aware of the importance of ensuring safe discharge for people with cognitive impairment.

Staff were also encouraged to review issues of cognitive impairment for people who tended to have difficulty fitting into the therapeutic community and following instructions. It was recommended that, if these issues were present, trained staff were to administer the MoCA to determine if the issue was one of either engagement/motivation or capacity.

3. Training

A training needs analysis was conducted to determine if staff viewed cognitive impairment as something they wanted to understand better. It was found that the vast majority of staff viewed the issue of alcohol and other drugs clients and the impact of cognitive impairment as important and something they'd want to be trained in.

This meant we could engage in training to provide information, rather than try to motivate them to view this client group as a core part of their work. A specialist trainer was engaged to provide all staff with one full-day training session and a half-day booster session. The focus of the training was common causes of cognitive impairment, symptoms of cognitive impairment, and key strategies for working with people with cognitive impairment.

A number of key staff were also trained to administer the MoCA so that, if staff identified potential issues, this tool could be administered to screen for cognitive impairment.

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Observations and recommendations

What were the challenges and what would you have done differently?

The biggest challenge was the short length of the project. It's really important to make sure that, even though many new projects arise as a knee-jerk reaction when funding becomes available, comprehensive planning is needed to ensure the viability of project outcomes in the long term. We wouldn't have done anything differently for this project.

What are the benefits and key outcomes for the organisation?

The benefits for the organisation and for our clients is that there's now an awareness of causes, impacts and strategies for working with people with cognitive impairment. Of key benefit to the industry is the existence of a useful screening tool for people with cognitive impairment.

What cost-effective strategies could you recommend?

Services should incorporate basic screening questions for cognitive impairment into their standard assessment, as these can provide strong indications of potential cognitive damage even if a service doesn't have formal assessment for cognitive impairment. It's good to incorporate training for working with cognitive impairment into the staff training calendar or, if a service doesn't have training funds, to apply to NADA's training grant scheme to access training funds.

What are your strategies for the long-term implementation of the gains made?

WHOS has the advantage of being successful in obtaining ongoing funding for what was originally the Improved Services Initiatives (ISI) project. In our new funding submission, we've incorporated clients with cognitive impairment into the definition of clients with multiple and complex needs. This has ensured that we'll be able to focus on the needs of this group over the next three years.

What recommendations do you have for services considering becoming complex needs capable?

If the service is already working with a drug and alcohol population, it's already working with incredibly complex clients. Our most important recommendation is to adopt an organisational change management approach incorporating the following approaches:

  1. Gather the evidence for how your service currently operates. What does your service's data suggest and what does the research literature suggest? What are your staff's views about suggested changes?
  2. Identify what's required and plan how the changes will be implemented into your service, focusing on organisational systems such as policy and procedure, targeted staff training and linkages and partnerships.
  3. Evaluate in multiple ways the outcome of the changes.
  4. Most importantly, persevere and continue to learn from people who may have been badly managed by your service or who you were unable to assist. Each service needs to know its limitations but also needs to continually explore how to improve service delivery to clients.
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