Multiple and Complex Needs Model

What is the Multiple and Complex Needs Model?

The Multiple and Complex Needs Model (MACNM) is a time-limited specialist service for individuals 16 years and older identified as having multiple and complex needs, often including those individuals who are vulnerable and who pose a risk to themselves and/or to the community.

The aim of the service is to support a client to increase stability, quality of life and independence by providing assessment, care planning, cross sector service coordination and positive behaviour support.

Support is holistic and based on the needs and circumstances of the client.

Who is it for?

MACNM may meet the needs of complex TAC clients who have exhausted all other applicable service options, have behaviors of concern and who appear to have two or more of the following:

a mental health illness
an acquired brain injury
intellectual disability
a substance use issue
significant physical injury
exhibited violent and dangerous behaviour that has caused harm to self or others or is exhibiting behaviour that is likely to place self or others at risk of serious harm
need of intensive supervision and support and would derive benefit from coordination of a range of services

What does it provide?

The MACNM provider works to identify and provide support to:

areas of the individual’s life which have been identified as a priority
prioritise goals for the individual
identify strengths and resilience
deliver strategies to engage the individual
identify services and supports and their roles and responsibilities
provide crises intervention and contingency plans specific to the individual as required

At the end of the service the provider will develop a comprehensive exit/transition plan that will include client learnings and recommendations for ongoing support and/or transition to other services.

How will MACNM assist?

MACNM was based on extensive research and service development and is a time-limited specialist service that involves a coordinated approach to supporting individuals to achieve stability in health, housing, social connection and safety.
The MACNM service provides comprehensive ongoing support and assessment, care planning, cross sector service coordination (e.g. disability, mental health, justice and health) and positive behaviour support.
The TAC works directly with the Indigo Program through cohealth, the primary statewide provider of the DHHS Multiple and Complex Needs Initiative (MACNI), and has a separate referral processes to DHHS.

How do I know if MACNM is suitable?

MACNM could be a suitable service for your patient if they:

have exhausted all applicable and suitable existing services and/or other support options
require intensive supervision and support
would derive benefit from receiving coordinated services that may include welfare services, health services, mental health services, disability services, alcohol and other drugs treatment services or housing and support services

How will MACNM benefit the person?

Support provided via MACNM may assist to:

increase stability, quality of life and independence
reduce formal levels of care to 1:1 or 2:1 care
impact and reduce the severity of a client’s behaviours of concern
increase capacity for local services in the community to manage the client

What does the service model look like?

MACNM services are delivered in two stages:

Care Plan Development (CPD). This is based on a comprehensive needs assessment and is developed by the provider in consultation with the treating team.
Care Plan Coordination (CPC) delivered by the provider.

How do I refer?

Any member of the client's treating team can request a referral to the service.

Contact your client's TAC support coordinator to discuss the service and referral further.

How will it change the way I work?

As the treating practitioner, you will be part of the client’s care team and work in collaboration with the MACNI provider who will lead the development of a care plan
The provider will deliver the care plan, cross sector service coordination (e.g. disability, mental health, justice and health) and positive behaviour support but will work with you to develop effective communication strategies, review existing processes and where appropriate, recommend changes to current service delivery strategies


Multiple and Complex Needs Model What is the Multiple and Complex Needs Model? The Multiple and Complex Needs Model (MACNM) is a time-limited specialist service for individuals 16 years and older identified as having multiple and complex needs, often including those individuals who are vulnerable and who pose a risk to themselves and/or to the community. The aim of the service is to support a client to increase stability, quality of life and independence by providing assessment, care planning, cross sector service coordination and positive behaviour support. Support is holistic and based on the needs and circumstances of the client. Who is it for? MACNM may meet the needs of complex TAC clients who have exhausted all other applicable service options, have behaviors of concern and who appear to have two or more of the following: a mental health illness an acquired brain injury intellectual disability a substance use issue significant physical injury exhibited violent and dangerous behaviour that has caused harm to self or others or is exhibiting behaviour that is likely to place self or others at risk of serious harm need of intensive supervision and support and would derive benefit from coordination of a range of services What does it provide? The MACNM provider works to identify and provide support to: areas of the individual’s life which have been identified as a priority prioritise goals for the individual identify strengths and resilience deliver strategies to engage the individual identify services and supports and their roles and responsibilities provide crises intervention and contingency plans specific to the individual as required At the end of the service the provider will develop a comprehensive exit/transition plan that will include client learnings and recommendations for ongoing support and/or transition to other services. How will MACNM assist? MACNM was based on extensive research and service development and is a time-limited specialist service that involves a coordinated approach to supporting individuals to achieve stability in health, housing, social connection and safety. The MACNM service provides comprehensive ongoing support and assessment, care planning, cross sector service coordination (e.g. disability, mental health, justice and health) and positive behaviour support. The TAC works directly with the Indigo Program through cohealth, the primary statewide provider of the DHHS Multiple and Complex Needs Initiative (MACNI), and has a separate referral processes to DHHS. How do I know if MACNM is suitable? MACNM could be a suitable service for your patient if they: have exhausted all applicable and suitable existing services and/or other support options require intensive supervision and support would derive benefit from receiving coordinated services that may include welfare services, health services, mental health services, disability services, alcohol and other drugs treatment services or housing and support services How will MACNM benefit the person? Support provided via MACNM may assist to: increase stability, quality of life and independence reduce formal levels of care to 1:1 or 2:1 care impact and reduce the severity of a client’s behaviours of concern increase capacity for local services in the community to manage the client What does the service model look like? MACNM services are delivered in two stages: Care Plan Development (CPD). This is based on a comprehensive needs assessment and is developed by the provider in consultation with the treating team. Care Plan Coordination (CPC) delivered by the provider. How do I refer? Any member of the client's treating team can request a referral to the service. Contact your client's TAC support coordinator to discuss the service and referral further. How will it change the way I work? As the treating practitioner, you will be part of the client’s care team and work in collaboration with the MACNI provider who will lead the development of a care plan The provider will deliver the care plan, cross sector service coordination (e.g. disability, mental health, justice and health) and positive behaviour support but will work with you to develop effective communication strategies, review existing processes and where appropriate, recommend changes to current service delivery strategies