Mental health services and supported residential services

In Victoria, mental health services may refer some people to supported residential services (SRS) for accommodation and support.

SRS are private businesses that provide accommodation and some personal support services for people who need assistance with daily living. SRS are not clinical environments and staffing skills and levels may not meet the requirements of people with severe mental illness.

Clinical mental health services are not always aware of the level or type of support that can be provided by an SRS. SRS often lack information about the support needs of the individuals referred to them and the support services available within the community. A lack of coordination between services heightens the risk of homelessness or readmission to hospital for people referred to SRS who have complex needs.

Placing individuals, families and communities at the centre of service design and delivery is recognised in Victoria's 10-year mental health plan (Department of Health 2015). Stable and affordable housing is one of the building blocks of mental health and wellbeing. Improving coordination between the mental health system and the SRS sector will enable better outcomes for consumers of the mental health system.

These guidelines are for staff working in mental health services and SRS. They provide advice to ensure referrals from health services to SRS are appropriate, transitions from mental health services to SRS occur smoothly, and appropriate follow-up support is provided.

'They said "We told you all we think you needed to know" - but it wasn't enough and other residents and our staff were at risk.'
- SRS proprietor

'SRS are really important and we need to support them.'
- Service manager, mental health service

'If someone has run out of SRS, there is nowhere else to live.'
- Case worker, mental health service

Summary of best practice process

These steps will improve coordination between mental health services and SRS.

Referral to SRS

Mental health services:

• Consider if the SRS is an appropriate option.
• Arrange a meeting.
• Gain consent to share information^*.
• Share information about the person, including signs of mental health deterioration and who to contact in a crisis.

^* Where the person is on a Treatment Order, the Mental Health Act 2014 allows disclosure of health information where this disclosure is reasonably required by a carer to determine the nature and scope of the care to be provided and to prepare for that role, having regard to the person's views and preferences.

Supported residential services:

• Meet with the person and the mental health service.
• Provide information about your SRS.
• Consider if you can support this person.
• Consider if additional services are required.
• Ask for written information.
• Call the case manager.

Moving in

Mental health services:

• Provide the SRS with time to prepare.
• Ensure the SRS understands the signs of mental health deterioration and who to contact in a crisis.
• Ensure timely mental health follow up.

Supported residential services:

• Plan and prepare for the person.
• Complete an interim support plan with input from mental health service.
• Ensure staff understand the support plan and know who to contact in a crisis.
• Ensure the person understands the house rules.

Ongoing support

Mental health services:

• Arrange post-discharge follow up, ideally within a week.
• Refer to other community-based services if required.
• Let the SRS know of changes to the case manager or agency providing care.

Supported residential services:

• Employ staff with training in mental health.
• Support staff to attend mental health training.
• Know the health services in your area.
• Maintain relationships with mental health services.
• Know how to access support services.

Referral to SRS Step 1: Identify when an SRS is appropriate - for the mental health service

Mental health services need to determine whether an SRS is a suitable accommodation option for a person within their care.

To determine the suitability of the SRS:

• Visit the SRS and establish relationships with SRS proprietors in the area.
• Consider the demographics of other residents within the SRS.
• Consider the skills and qualifications of SRS staff.
• Consider the ability of the person to live in a group setting with other residents who may have challenging behaviours
• Arrange a meeting between the person, their next of kin, guardian or nominee, the social worker or case manager and the SRS proprietor.
• Make sure the person understands what an SRS is and what it might be like to live in one.
• Wherever possible, include the person in all decision making about their living arrangements.
• Wherever possible, refer a person to an SRS within the catchment area to ensure continuity of care for follow-up. If this is not possible, refer them to the relevant Adult Mental Health Service (AMHS).

SRS have a legislated minimum staff to resident ratio of 1:30.

The 2018 Supported Residential Services Census found that 51 per cent of staff providing support to residents in SRS had a Certificate III in Aged Care; this was the most commonly held qualification.

Only 2 per cent of staff providing support to residents in SRS had a certificate IV in mental health.

Referral to SRS Step 2: Make a referral - for the mental health service

Before discharging a person from an inpatient mental health service:

• obtain informed consent to share information
• prepare a written referral
• establish a meeting between the individual, their next of kin, guardian or nominated person, the social worker or case manager and the SRS proprietor.

The purpose of the meeting is to establish shared agreement between all parties with regards to the person's ongoing support needs and the types of supports available within the SRS.

The written referral should include:

• information about the person and their support needs
• details about mental health conditions, physical health conditions, medications, social and cultural history, functional status and level of support required for activities of daily living
• clearly documented observable signs of mental health deterioration and who to contact in a crisis
• contact details for the mental health service, general practitioner and any community-based services the person is being linked in with.

Use the behaviour risk checklist at the end of this guideline.

Referral to SRS checklist:

• Health conditions
• Medications
• Signs of mental health deterioration
• Who to contact in a crisis
• Contact details for mental health service and GP
• Support needs
• Behavioural risk form

'Social workers who work in inpatient units need to have a relationship with SRS proprietors. They need to visit SRS to build the proprietor's capacity and get a good understanding of the resident mix.'
- Senior social worker, mental health service

Referral to SRS Step 3: Accept a referral from a mental health service - for SRS

SRS proprietors are responsible for ensuring the safety and wellbeing of all residents.

When deciding whether to accept a referral from a mental health service:

• Meet with the person and the mental health service; find out about the person and their support needs.
• Provide the person and the health service with information about the SRS, including clear expectations about living in an SRS and the SRS house rules.
• Consider if SRS staff have the appropriate skills and qualifications to support the person.
• Identify that the mental health supports available to your SRS are sufficient for this potential resident.
• Identify other community support services this person will need and determine who will facilitate access to services.
• Consider how this person will affect your current residents.
• Ask the referring mental health service to complete a referral form and a behaviour risk checklist.
• Call the person's mental health case manager to discuss their support needs and strategies to manage risks or challenging behaviours.

Ideal practice: Ensure you and your staff have completed mental health training, such as 'Residents and mental health: Better practice in SRS' training program or the two-day mental health first aid course.

'Referral forms need to ask the right questions - in addition to the issues and risks, you need to give SRS the solutions. We need to be preventative.'
- Case worker, mental health service

'It isn't good enough to only see a referral form - you need to talk to the case manager, the family, other proprietors. You need to meet the person and talk to them and explain the house rules.'
- SRS proprietor

'SRS need to demand complete referral information - hold mental health services accountable and don't accept short cuts.'
- Manager, mental health service

Moving in

A positive transition requires clear communication between the referring mental health service and the SRS.

A positive transition from mental health services - for mental health services

• Provide the SRS with adequate time to plan, prepare and coordinate services.
• Ensure the SRS understands who will provide follow up mental health care.
• Give the SRS contact details for the mental health service case manager or contact person and the general practitioner, and details of follow up appointments.
• Note that if the person's mental health deteriorates, and an urgent response is required, an SRS proprietor is likely to call triage to request assistance. Make sure the triage service in your catchment knows that the person is living in an SRS.
• Where a person is being referred to an SRS in another mental health catchment area, ensure that the mental health service is aware of the move.

A positive transition to the supported residential service - for SRS

Transitions from clinical environments can be disruptive and challenging. As an SRS proprietor, it is in your best interest to ensure your SRS is prepared to support an individual.

• Prepare an interim support plan with the person within 48 hours of moving in. Use the information supplied by the referring mental health service.
• Ensure SRS staff understand the support plan, including observable signs that the person is becoming unwell and strategies to manage risks and challenging behaviours.
• Ensure all staff in the SRS know who to contact in the event of deterioration or crisis.
• Make sure the person is aware of the house rules.

Ideal practice: Staff working in mental health triage need to understand what an SRS is, and understand that an escalating situation within an SRS will impact upon other SRS residents.

'Discharge is a crucial transition point and unless carefully managed there is a risk that the individual's ongoing treatment and care may be disrupted adversely'
- Discharge planning for Adult Community Mental Health services, Chief Psychiatrist's Guideline

'Discharge to an SRS can take three to four days. Same-day discharge to an SRS is almost impossible'
- Case worker, mental health service

'Case manager role is really helpful. You can talk to them.'
- SRS proprietor

Mental health services and SRS have a duty of care to ensure the safety and wellbeing of the individuals they support.

Ongoing support in practice: mental health services - for mental health services

• Timely follow up by mental health services is important to ensure the person has safely transitioned from an inpatient unit to an SRS.
• Follow up with the SRS proprietor within the first fortnight and ensure the person has settled in. If the person is being case managed, this should occur within the first week.
• Alert community care teams of any emerging issues or signs of deterioration.
• Consider whether other community-based services and programs may address other needs the person has: allied health within community health services, peer support programs, the National Disability Insurance Scheme.
• Tell the SRS if you transfer case management responsibilities to another service or agency.
• Where possible, seek feedback from SRS residents about their experience of the SRS and provide this back to the referrer.

Ongoing support in practice: supported residential services - for SRS

• If you are providing accommodation and personal support to people with mental illness: employ managers and staff with qualifications in mental health and experience supporting individuals with mental illness and challenging behaviours
• maintain relationships with mental health services in your area
• ensure your SRS can facilitate access to mental health supports and other services
• understand medication for mental illness and the importance of accurate medication administration
• you are in the best position to notice if an individual doesn't seem himself or herself. You are responsible for communicating with case managers and support services frequently.

'Sometimes the SRS can aggravate the person's mental health by putting unnecessary restrictions on small things, like food or coffee.'
- Case worker, mental health service

'SRS proprietors regularly report to Community Visitors that they have great difficulty or little or even no success in getting mental health crisis assessment teams (CAT) to attend to assess & support very unwell residents'
- Community Visitors Annual Report 2015-16

'A lack of meaningful daytime activities can result in boredom that provokes long running disputes between residents, sometimes resulting in violence'
- Community Visitors Annual Report 2015-16

Crisis response: mental health services

A prompt response by mental health services is required when a person's mental state deteriorates significantly. If SRS staff are unable to cope with this change, the person's ongoing accommodation may be jeopardised.

When notified by the SRS of changes in the mental state or behaviour of a person that exceed those described in the support plan or that exceed the capacity of SRS staff:

• Visit the person as soon as practicable to review their mental state and treatment.
• Provide support to the person, paying regard to their views and preferences and contact family or carers as appropriate.
• Provide advice to the SRS appropriate to the skills and qualifications of staff members working across all shifts.
• Write a safety plan (also known as a crisis plan) with the SRS proprietor, manager or personal support coordinator (and, if possible, the person, family or carers) that gives clear guidance about the symptoms and behaviours that should prompt requests for help to psychiatric triage or emergency services.
• Ensure that psychiatric triage knows of the person's status and has a copy of the safety plan.

Crisis response: supported residential services

As an SRS proprietor, it is in your best interest to seek help quickly if there are changes in the person's mental state or behaviour that present risk to the person, other residents or staff, or where staff have insufficient skills or qualifications to manage safely.

When the person's mental state or behaviour changes to this degree:

• Contact the case manager or psychiatric triage to seek advice by telephone and to request a visit as soon as practicable.
• Ensure that the responses recommended by the mental health service can be implemented by staff, bearing in mind their skills and qualifications across all shifts.
• Ensure that the recommended responses are actually implemented.
• Encourage staff to activate the crisis plan when indicated.
• Remain in regular contact with the mental health service until the crisis resolves.
• Call 000 in an emergency to get a quick, safe response.

Supported residential services

SRS are private businesses that provide accommodation and some personal support services to people who need assistance with daily living. SRS are not clinical environments and SRS staff may not be trained to work with people with a mental illness or dual diagnosis. Each SRS determines the services it offers, the people it accommodates and its fee structure.

SRS are registered and regulated by the Department of Health on behalf of the Victorian Government to ensure compliance with the Supported Residential Services (Private Proprietors) Act 2010 and Supported Residential Services (Private Proprietors) Regulations 2012.

More information about SRS and a list of all premises in Victoria can be found on the department's website.

Dissatisfied or concerned about an SRS?

Raising your complaint with the SRS

If you have a concern about an SRS, where possible, you should raise concerns with the SRS first. SRS are required to have a complaints officer and a system for handling complaints.

Escalate your complaint to the department

If you are unhappy with the SRS' response to your complaint or if you witness or experience concerning practice at an SRS, notify an authorised officer at the Department of Health by calling 1300 650 172.

Talk to a Community Visitor

Community Visitors are empowered by law to visit residents of SRS at any time. They can talk to residents to understand their experiences and identify any issues, liaise with staff and management to provide feedback and resolve issues. Community Visitors can also raise concerns with the department.

Contact a Community Visitor via the Office of the Public Advocate (OPA) by calling 1300 309 337 or by visiting the OPA website.

Mental health services in Victoria

The Victorian Government funds specialist mental health services to provide clinical mental health treatment in bed-based and community settings for people experiencing severe mental illness.

Clinical mental health services are organised by:

• Location: the delivery of services can vary between different areas of Victoria. There are specialist statewide services, such as dual disability and personality disorder services.
• Age: child and adolescent services respond to the needs of people up to the age of 25 years; adult services are available for people from 16 years of age; aged persons mental health services for people from 65 years of age.

A list of local mental health services with contact details can be found at the department's website.

Mental Health Community Support Services (MHCSS) are community-based support services for people with severe mental illness and psychiatric disability. These services focus on improving life skills (self-care, social and relationship skills) and increasing community participation.

Dissatisfied or concerned?

Raising your complaint with a mental health service

If you have a concern about a mental health service, you should raise the matter with the service. You can contact the Clinical Director in the first instance; the complaint may be referred to a complaints officer.

Raising a complaint on behalf of individuals

If you have a complaint on behalf of a consumer about their experience of a mental health service, including their treatment and care, you can talk to the service directly. You can also speak with the Mental Health Complaints Commissioner. For more information about the Mental Health Complaints Commission, go to the Mental health Complaints Commission's website. It is important that you have the consent of the consumer to make the complaint.

My resident is in crisis - who do I call?

If you need urgent assistance for an SRS resident, call the mental health triage of your nearest public mental health service.

Each public mental health service in Victoria provides a triage and referral service 24 hours a day, seven days a week. Triage provides an initial assessment of a person with a mental illness (either over the phone or face-to-face) by a mental health clinician to determine the type and urgency of the response required. Triage will also determine if a further assessment is required.