Getting It Together: Multiple and Complex Needs Initiative

Getting It Together: Multiple and Complex Needs Initiative

Getting it together
A guide for individuals, carers, and services on accessing the Multiple and Complex Needs Initiative.

To receive this publication in an accessible format phone03 9096 8477, using the National Relay Service 13 36 77 if required.
Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.
© State of Victoria, Department of Health and Human ServicesNovember 2017.
Where the term ‘Aboriginal’ is used it refers to both Aboriginal and Torres Strait Islander people.
ISBN 978-1-76069-086-1 (Print)
ISBN 978-1-76069-087-8 (pdf/online)
Available on the Specialist disability services page on the Services website


What is the Multiple and Complex Needs Initiative?

The legislation

Eligibility for MACNI

Who can make referrals?

MACNI service model

How do you access MACNI?


Pre-MACNI service coordination

Making a referral to MACNI

Care plan

What is the role of the care plan coordinator?

Reviewing and closing a care plan

Post-MACNI support

MACNI contacts

Making a complaint

Appendix 1: Potential referrer self-assessment

What is the Multiple and Complex Needs Initiative?

The Multiple and Complex Needs Initiative (MACNI) is a time-limited service response for people aged 16 years and older with multiple and complex needs.

People will have a combination of mental illness, substance use, intellectual impairment, and acquired brain injury, and will benefit from a coordinated service response to meet their needs and goals.

MACNI is funded by the Department of Health and Human Services, the Department of Justice and Regulation, and the Director of Housing.

MACNI involves the partnership of the two departments and numerous service providers who provide both specialist and generic services to clients, such as:

•Aboriginal community-controlled organisations

•mental health services

•housing services

•justice and correctional services

•drug and alcohol services

•disability and health services.

Focusing on a more effective and coordinated approach to support, MACNI aims to:

•stabilise housing, health, social connection and safety issues

•pursue planned and consistent therapeutic goals for each individual

•provide a platform for long-term engagement in the service system.

Participation in MACNI is voluntary. A person can decide to discontinue MACNI services at any time during the process.

Key elements of MACNI

•Human Services (Complex Needs) Act 2009

•information, consultation and referral

•care plan development and coordination

•Service provision framework (MACNI)

•Complex Support and Systemic Review Interdepartmental Group.

The legislation

MACNI is underpinned by the Human Services (Complex Needs) Act 2009. This Act establishes the authority for a collaborative and coordinated approach to planning service delivery for people with multiple and complex needs.

Eligibility for MACNI

For a person to be eligible for MACNI, they must meet the eligibility criteria in section 7 of the Act.

An eligible person is a person who:

(a)has attained 16 years of age; and

(b)appears to satisfy two or more of the following criteria—

(i)has a mental disorder within the meaning of the Mental Health Act 2014

(ii)has an acquired brain injury

(iii)has an intellectual impairment

(iv)has a severe substance dependence within the meaning of section 5 of the Severe Substance Dependence Treatment Act 2010, and

(c)has exhibited violent or dangerous behaviour that caused serious harm to himself or herself or some other person or is exhibiting behaviour which is reasonably likely to place himself or herself or some other person at risk of serious harm; and

(d)is in need of intensive supervision and support and would derive benefit from receiving coordinated services in accordance with a care plan that may include welfare services, health services, mental health services, disability services, drug and alcohol treatment services or housing and support services.

Who can make referrals?

Anyone can make a referral to MACNI,for example:

•referrals from individuals for themselves

•family members or significant others

•existing service providers working with the person

•court support services

•correctional services

•mental health services

•Aboriginal community-controlled organisations

•community service organisations.

Appendix 1 is a brief referral checklist that gives potential referrers an indication of the information needed for a MACNI referral.

MACNI service model

MACNI provides a continuum of targeted support for people with multiple and complex needs.

The MACNI service modelincludes:

•MACNI entry and consultation

•Pre-MACNI service coordination

•MACNI referral and (where eligible) care planning

•Post-MACNI support.

The MACNI service model offers an escalating pathway of interventions and supports aimed to respond to the person’s needs and goals before a person is determined as eligible under the Act.

A referral to MACNI is considered and supported as appropriate when consultation and pre-MACNI service coordination is not sufficient to address the person’s issues.

The provisions of the Act only apply to those people who are to be considered for eligibility determination and those who are determined as eligible under the Act.

Figure 1 presents a summary view of the MACNI service model.

Figure 1. MACNI service model

Steps in the cyclical MACNI service model Existing service system MACNI entry and consultation Pre MACNI service coordination MACNI referral Area panel MACNI eligible and care plan Post MACNI support

How do you access MACNI?

The Department of Health and Human Services consists of four divisions responsible for oversight and coordination of local areas that provide direct services across Victoria.

Each division has at least one MACNI coordinator, who is the first point of contact to discuss a potential referral to MACNI.MACNI contacts are listed at the end of this booklet.


The MACNI coordinator’s role at the first point of contact with a potential referrer is to provide information and advice. TheMACNI coordinator works with the referrer to consider whether the person appears to meet the eligibility criteria for MACNI and to explore if available options of support have already been implemented or considered.

The key tasks at this stage are:

•information and practice advice

•system navigation and problem-solving


•service coordination.

The consultation process may involve several discussions over an extended period of time, during which the MACNI coordinator may request that case conferencesof involved services be held to more fully understand the situation and to ensure the coordination of an improved response for the person.

Where options appear to have been exhausted and no alternative supports are available, the MACNI coordinator will work with involved services to discuss next steps, including the use of pre-MACNI service coordination or a MACNI referral.

Pre-MACNI service coordination

Pre-MACNI service coordination may be needed where:

•a person appears to meet the Human Services (Complex Needs) Act 2009eligibility criteria

•the presenting issues were not adequately resolved through consultation, local problem-solving and collaboration

•there is evidence to suggest that a particular assessment or support intervention is likely to positively impact on the person’s situation and longer-term outcome.

This approach enables the development of enhanced options and interventions through the use of limited brokerage funding with the aim of effectively meeting the person’s immediate needs.

For some people, the use of pre-MACNI service coordination may not be sufficient to meet their needs and goals. This may be:

•determined after the approach has been tried; or

•because evidence indicates that a higher level of service coordination and care planning is required - a formal referral to MACNI is immediately progressed.

The MACNI coordinator will be in regular liaison with the person’s care team.A single referring service will be identified for the completion of the referral form.Before completing the MACNI referral form, the referrer should ensure that the person is awareof and agrees to participate in MACNI.

Making a referral to MACNI

Referrals to MACNI must be made through the MACNI coordinator, the single access point to the MACNI referral process.

The MACNI coordinator is available to helpa referrer complete the referral and ensure all of the referral requirements are met.

Once they receive a referral form, the MACNI coordinator will review it and present the referral to the local area panel for its assessment and recommendation of eligibility.

Area panels

For MACNI referrals, the role of an area panel is to:

•consider referrals and endorse eligibility (as relevant)

•provide advice on care plan development and coordination,and appoint a service to perform the roles

•monitor and evaluate the progress and effectiveness of care plans

•endorse agreed service responses, care plans and brokerage allocations

•provide information and guidance on best practice principles and evidence-based responses.

If the panel decides to progress the MACNI referral, the MACNI coordinator will seek the endorsement of the relevant departmental director or deputy secretary.

What happens if the person is eligible?

If the person is determined to be eligible for MACNI, the MACNI coordinator will notify the person and the referrer of the eligibility determination outcome.

An area panel will meet to arrange for a service to develop a draft care plan for that person. This plan will be based on a thorough understanding of the person’s needs, goals and best interests, including cultural identity and safety, cultural planning and self-determination.

Care plan

The care plan enables a coordinated response to the needs of the person.It seeks to promote stabilisation in housing, health and wellbeing, safety and social connectedness, including the promotion of cultural identity.

A care plan is initially developed for a 12-month period and may be extended to a maximum of 36-months.

The care plan outlines the:

•areas of the person’s life which have been identified as a priority

•priority goals for the person

•strategies to engage the person

•services and supports required and their roles and responsibilities

•crisis intervention and contingency plans specific to the person.

The Human Services (Complex Needs) Act 2009 permits services to share an eligible person’s personal, sensitive or health information if it is in the best interests of that person.

The care plan will identify a care plan coordinator. This will be either an existing service provider to the person or an alternate service, depending on which is best placed to provide care plan coordination.

What is the role of the care plan coordinator?

The care plan coordinator role involves:

•coordinating the services provided to the person in line with the care plan, including negotiating changes to the service provision as needed

•steering the direction of the care plan with a future-oriented approach

•being the key contact for the department and other service providers through the life of the care plan

•monitoring the implementation and progress of the care plan and the person to whom the care plan relates, and providing written or verbal reports to the department.

A care plan coordinator is appointed by an area panel when a care plan for a person is approved.

Reviewing and closing a care plan

Care plan review is the key mechanism for the care plan coordinator, the services involved in delivering the plan and the area panel to monitor the progress and effectiveness of the care plan. Reviews are held every six monthsand additionally upon request.

Area panels can seek to change and close a care plan based on the input of the care plan coordinator, with the approval of the relevant departmental director.

Throughout the life of the care plan, and particularly in its last sixmonths, the care plan coordinator also ensures transition planningis in place for the provision of services to meet the needs of the person beyond the life of the MACNI care plan.This planning will need liaison and negotiation with the relevant departmental area and the services to remain involved with the person.

Post-MACNI support

A small number of people supported by MACNI may not be able to fully transition to sustainable engagement with the existing service system by the time their MACNI care plan is closed. This applies in particular to people whose care plan has been in place for the maximum period.

The department and services engaged in the care plan can continue to provide coordinated care for an agreed time-limited period to ensure the person’s needs can be effectivelymet by the existing service system.

MACNI contacts

There are four Department of Health and Human Services divisions. Each division has MACNI coordinators, who are the first point of contact for MACNI queries.

MACNI coordinators

West Division

Ballarat03 5333 6530

Footscray 03 9275 7222

Geelong 03 5226 4540

North Division

Bendigo03 5434 5555

Fitzroy03 9412 5300

Mildura03 5022 3111

East Division

Box Hill03 9843 6000

Wangaratta03 5722 0555

South Division

Dandenong03 8765 7575

Warragul03 5624 0600

Making a complaint

The department wants our services to work for people who need and use them. We can always do better and we listen to people using our services, their advocates and representatives.

We want to know if you:

•feel a service is unsatisfactory

•did not receive enough information or choice

•were denied respect, dignity or privacy.

Take the following steps to get your complaint resolved:

•Step 1. Discuss your complaint with your worker or another staff member, including the MACNI Coordinator at your local office.

•Step 2. If you have tried to resolve your concerns but you are still dissatisfied with the outcome, you can refer your complaint to the Manager, Complex Clients or another senior manager at the local office.

•Step 3. If your complaint cannot be resolved at Step 1 or Step 2, the department’s Complaints and Privacy unit will assist you and can be contacted on 1300 884 706.

Appendix 1: Potential referrer self-assessment

This list of questionsgives potential referrers an indication of:

•what questions the MACNI coordinator will ask during the initial consultation, and

•what will need to be answered on the MACNI referral form.

Eligibility criteria

•Does the person appear to meet the eligibility criteria?

Service response

•Has there been, or is there, a current coordinated service response or case plan for the person? Can you describe what has worked and not worked for the person?

•What are you expecting MACNI to achieve with and for the person?

•Does the person have involvement with other services?

•Have you made contact with these services?

•Has a case plan meeting been conducted with the existing service providers to establish the nature of the issues, or to identify alternative response options?

•Does your CEO or program manager support this potential referral?

Confidentiality and privacy

•Has the person been informed of the potential referral?

•Does the person agree to the referral?

•Does the person have a parent, carer or guardian?

•Have you discussed the potential referral with the parent, carer or guardian?

•Does the person know that the information about them will be shared with the area panel and among other involved service providers?