Aboriginal People and the Magistrate's Early Referral Into Treatment (MERIT) Program
Hunter New England Area Health Service
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The State Health Plan 2010 strategic directions include:
- improve health outcomes
- prevent illness
- treat illness effectively
- create a better experience for people using health services
- reduce harm associated with drug and alcohol use.
It acknowledges the importance of early referral into treatment and working with the criminal justice system.
A key strategy in the HNEH Drug and Alcohol Services Plan 2007 -2011 is to provide accessible and culturally appropriate services for Aboriginal people.
The strategies implemented have assisted Aboriginal people, the justice system and the MERIT team to develop procedures and practices in accordance with Interagency Guidelines.
Rationale for the program
The Magistrate's Early Referral Into Treatment (MERIT) Program is an intensive, individualised illicit drug treatment program. It is a diversion program for adults who have an illicit drug problem and matters before the local court. The aim of the program is to assist clients to break their drug/crime cycle by addressing their illicit drug problems. Positive outcomes are submitted to the Magistrate in a final court report and are taken into account at sentencing.
We needed to undertake this program because we had identified that Aboriginal clients were not engaging in the program and were therefore at a greater risk of incarceration in the criminal justice system.
Aim
To enhance and strengthen relationships with Aboriginal clients referred from Tamworth local court to the MERIT program to increase retention in treatment and improve health and social outcomes.
Objectives
- To engage aboriginal clients active participation in treatment.
- To reduce number of aboriginal clients bail conditions being revoked for non participation in MERIT program.
- The aboriginal clients make informed choices and decisions to improve health and break the crime / drug cycle.
Output
Improved health, employment prospects, family and social relationships.
Key performance indicators
- Number of aboriginal clients accepted onto program
- Number of aboriginal clients completing program
- Number of Aboriginal clients participating in employment / job seek programs
- Improved psychosocial wellbeing (entry and exit scores)
Development of the program
The 2001 ABS data indicates that Aboriginal people comprised 6.4% of the local population in the Peel Cluster. Aboriginals were over represented for referrals from the local court and accounted for 38% of all referrals to Tamworth MERIT.
It was identified that the majority of clients bailed to attend the Tamworth MERIT Program by the Court frequently did not present for assessment or were difficult to engage and retain in treatment. As a result a high proportion of these clients returned to the courts for sentencing for failing to comply with their bail conditions. They had a higher probability of being given a custodial sentence. The State wide MERIT Information Management System (MIMS data base) identified the low rates of Aboriginal participation and retention in treatment was a statewide problem.
In 2005 78% of Aboriginal client referrals to the service did not attend for the initial assessment appointment. Despite attempts to be culturally sensitive, including flexible appointments, varied meeting places, providing transport to appointments and court appearances and a reduced number of urine drug screens being conducted the Aboriginal clients continued to choose not to participate. 22% of total referrals for Aboriginal people commenced the program, half of these were breached and the other half withdrew. No Aboriginal clients completed the 2005 program.
To address the poor participation rate, staff did an extensive literature review. Clients were asked for their personal account of why they did not want to participate in the program. Lessons learnt from information gained from the in-depth literature review and the personal stories of the impact of colonization, the staff's knowledge of the concept of healing and why fear and mistrust existed was enhanced.
Staff gained a deeper understanding of the cultural needs of the Aboriginal people and altered clinical practices to accommodate their needs and encourage participation in the program. Many changes were subtle and aimed at empowering Aboriginal clients. Even though the client was on bail from the court the staff worked in collaboration with the Aboriginal clients to address issues in a person centered model of care.
Implementation
The most significant change was the clinical use of urine drug screens (UDS). Urine drug screen results are an objective measure of drug use and can be used as one of the tools to monitor the progress of patients during treatment. The clients viewed the urine drug screens as an attempt to catch them out, to shame and fail them; it was essentially a fear based procedure.
Staff started planning collection of urine samples in agreement with the client and which coincided with when their drug use was most likely to be at a minimum level. Staff negotiated an agreed time frame with the clients to work towards reducing their drug use. Instead of clients feeling they had to cease drug use immediately they could do it over a period of time. This proved to be manageable and achievable and they actually looked forward to receiving their drug screen results and comparing them with their baseline and ongoing results as they progressed through the program. Being able to see the reducing level of drugs in the results made them feel proud of their progress and achievements.
Overtime, this positive approach to a historically fear based procedure and participation in the program has lead to an increase in retention of clients and a reduction in drug use.
The staff, in collaboration with the interagency teams, (police, Aboriginal Liaison Officers and legal aid representatives) work together with the client to develop strategies and monitor progress to ensure the best possible outcomes. Family members when appropriate are engaged as active participants and provide vital social supports for the clients.
Instead of addressing all areas of concern the case management plan focuses on drug use, relapse prevention and referral to job seek programs to enhance employment prospects. Focusing on just two areas rather than all issues has had a cascade effect and enriched other areas of their life.
Evaluation
Feedback from clients indicates that they are more willing to participate in this model of care where they are involved in the decision making and possess autonomy in the healing process. They have taken on more responsibility and they are held accountable for their actions. The clients are more compliant with treatment, which is reflected in attendance at all case-management appointments and court sittings, reduced drug use and improved completion rates. The reduction in the level of intake of drugs has improved and enhanced family relationships.
At the completion of the MERIT Program most clients are actively seeking or have obtained employment. 70% of people either gained employment or are still actively involved with job search. At program exit at the end of three months the mental, physical and social functioning of a great majority of the clients has improved considerably as evidenced by measures of health psychological adjustments scores.
Another positive change was that the clients became more accountable for their own actions, evidenced by attending all appointments and organizing their own transport to court. There was also an expectation that they would actively seek employment and were enrolled in a job search program. Working more collaboratively with the client increased the input and support from their families and the Aboriginal Community including the Aboriginal Legal Service.
As demonstrated in the graph below, 60% of clients referred to the program attend an initial appointment and are accepted into treatment compared with 20% in 2005.
As demonstrated in the graph below, in 2008 60% of clients commencing treatment successfully completed treatment compared to 0% in 2005. There have been dramatic reductions in the number of clients being breached from treatment – 50% in 2005 compared to 35% in 2008 or withdrawing from treatment 50% in 2005 to seven 7% in 2008.
Impact of the program on the target group
This project identified barriers to participation and improved retention rates. Staff have actively pursued learning opportunities to increase their knowledge and skills. This resulted in breaking down barriers and implementation of strategies in collaboration with clients to address issues.
The success of these strategies has resulted in a change in practice for all clients (Aboriginal and non- Aboriginal) of the Tamworth MERIT program and overall improved rates of participation and completion in the program.
This has improved the client's feelings of trust, respect and dignity and they are able to achieve their goals. Staff have developed and shared this autonomous person centered model of care with other service providers and the Aboriginal community. This has positive impact for long term improved health outcomes for this client group.
These strategies have the potential to be utilised as part of a case management plan for clients engaged in other court programs, opiate treatment programs and for probation and parole clients.
Contact
Quality Analyst Clinical Governance, Hunter New England Area Health Service
Phone: 02 4921 4041
