Keynote 2_A Perspective of Integrated Models

7/27/2019 Keynote 2_A Perspective of Integrated Models

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A Perspective of Integrated ModelsA Perspective of Integrated Models – –Effective Management of MultiEffective Management of Multi--

Stressed Families through EvidenceStressed Families through Evidence--based Practice and Researchbased Practice and Research

Joe LeungJoe Leung

ProfessorProfessor

January 2010January 2010

Outline• Families are the basic building blocks of all societies.

• Modern families are increasingly vulnerable: their problemsare multi-dimensional, inter-related and mutually reinforcing.

• Families and marriages are changing: declining marriagerates (more co-habiting and lone parents); rising divorce rates,and step-families, fewer children; more children born outside

marriages; same sex relationships; longer life expectancy – grand parenting.

• Formation and evaluation of Integrated Family ServiceCentres in Hong Kong: the welfare system; changing natureof family-related problems; development of the IntegratedFamily Service Centres (IFSCs); issues involved; lessons tolearn.

• Evidence-based Programme reviews by HKU commissionedby the Hong Kong Government review family needs andfamily welfare services (2000-2001), explore the different pilotmodes of forming IFSCs (2002-2004), and the effectivenessof full implementation (2008-10).



UK Longitudinal Study on

Families at Risk (Cabinet Office, 2008, 2009)

• Families are suffering from a combination of linked andmutually reinforcing problems (18 markers on socialexclusion): Around 45% families with children were exposedto multiple risk markers (4-7% experienced multiple riskpersistently).

• Families did not experienced multiple disadvantages for along time. Some can successfully make a transition out ofclusters characterized by multiple risks.

• Poor outcomes can be transmitted from one generation to the

next. Children from the most at risk families also experiencedlow levels of well-being, and their risks often reflected those oftheir parents.

Drivers of social exclusion

• Characteristics of at risk families: more likely to be loneparents, those with four or more children, young mothers,mothers from Black ethnic groups, social tenants and thoseliving in urban areas.

• Marriage/ separation/ divorce (single parenthood) andemployment/ unemployment: key factors affecting thetransition of families in and out of the at risk situation.

• Impact of economic downturn: increase vulnerability ofdisadvantaged families with disabled people, ethnic minorities,lone parents, older people and low-skilled people, living indeprived communities (Stafford and Duffy, 2009).



Implications for Family

Services• Tailored, integrated and whole family approaches: address the

diverse and different risks experienced by both parents andchildren. Families may access support from public services froma range of different service entry points. User-centred services:Coordination and integration of different services to address thefull range of need among such families.

• “If we are to reach out to families at risk we need to identify andexploit opportunities to build the capacity of systems andservices to ‘think family’. This means a shift in mindset to focus

on the strengths and difficulties of the whole family rather thanthose of the parent or child in isolation” (Cabinet Office, 2008).

• Family-friendly economic and social policy (work-life balance)(OECD, 2008)

UK Family RelationshipGreen Paper (2010)

• Whole families approach stresses the importance of looking atthe family as a unit and of focusing on positiveinterdependency and supportive relationships. This approachtakes the family’s resilience and social capital as the

foundations for achieving positive outcomes. Interactionsbetween children and their families play a vital role in thedevelopment of children’s social and emotional skills. Thesupport that parents give to their children’s cognitivedevelopment is important, as is the instilling of values,aspirations and support for the development of widerinterpersonal and social skills. Adults’ and children’s serviceshave a role to play together in helping to build family stability



Family Life: A Private Matter?• “Marriage is a personal and private decision for responsible

adults with which politicians should not interfere. Thegovernment supports couples who choose get married; formany families it offers the best environment in which to raisechildren, and remains the choice of the majority of people inBritain.”

• “family life is essentially private. Therefore this Green Paperfocuses mostly on supporting family relationships by enablingfamilies to help themselves.”

Changing Family Services• Individualised approach, clinically oriented (single service,

single problem) to multiple, tailored-make and integratedservices/ intervention (no one-size-fits-all approach); familysupport and preventive work (early identification)

• Deficit/ problem/ emergencies/ crisis-led oriented to strengthsoriented (identifying and building family capacity andresources); passive to active users/ family engagement/ responsibility/ conditionality

• Child protection/ individual assessment to whole of the familyneed assessment (risks, strengths, relationships and needs).Inter-relationship between family members, and how theseimpact on individual within the family (Kendall, et al. 2010)

• Fragmented services to joint-up and coordinated actions withservice partners.



Issues• Difficulties of engaging at risk families: resistance to usesocial services (poor accessibility due to cultural and servicedelivery design -- stigmatisation, suspicion, lack of trust, helpseeking culture, “hidden families”).

• Cultural resistance of social work practitioners towardadopting a new perspective (Egan, 1998; De Jong and Berg, 1998; Sousa, 2008).

• Professionals know what is best for the families: families knowwhat they need and professionals should provide it (customer-oriented and rising expectations); professionals areresponsible for intervention efficacy and inefficacy is theprofessionals’ fault.

• Development of valid common assessment tools (genograms,mental health, risk assessment, screening tools)– provision ofrelevant and coordinated services

Summary

• Traditional family services are in fact children services,focusing on child protection and welfare, rather than focusingon the needs and resources of the whole family. Engagingand supporting families with multiple problems presents adistinctive challenge to family services. Facing multi-facited

family problems and needs, there is a need for a more tailored,flexible and holistic services, working with the whole family,tapping into family strengths, resilience and protective factors- Promote positive family relationships, effective and positiveparenting style, build social and emotional skills.



Welfare Ideology of

Hong Kong• A “productivist state”: residual or remedial welfare, where the

individual and the family are the major source of socialwelfare.

• Under the principles of “big market and small government”and “market leads, government facilitates”, the role of thegovernment is to create the right conditions for markets todevelop. The “right conditions” include maintaining the rule oflaw; keeping taxes low; keeping tax law simple; nurturingtalent; investing in infrastructure; and helping businesses tap

markets outside Hong Kong.

Small Government• Recurrent public expenditures in 2009-2010: 19.2% of total

GDP.

• Public spending (% of GDP) on education, social welfare andhealth are 3.1%, 2.4% and 2.2% respectively. Social servicesstill account for 58% of recurrent government spending.

• Lacks compulsory social insurance coverage in retirement,health care and unemployment (Mandatory Provident Fundwith low contribution rate introduced in 2000)

• Social security expenditure constitutes 70% of welfareexpenditures. NGOs are major providers of personal socialservices (24% of the budget). The government maintains coreservices – social security, family and child protection, medicalsocial services, and correctional services.



Distribution of WelfareDistribution of Welfare

Expenditures (%)Expenditures (%)• 1987-88 1995-96 1999-00 2007-08 2008-09 2010-11• --------------------------------------------------------------------------------------------------• Social security 66.8 66.6 72.59 73.0 73.5 71.5• Elderly 4.2 8.6 8.7 9.6 9.5 10.2• rehabilitation 5.8 7.2 7.3 7.2 7.9 8.6• Youth 7.3 5.8 3.8 3.8 3.9 4.0• Family 10.9 8.7 5.6 4.2 4.1 4.6• Correction 2.5 1.5 1.0 0.8 0.8 0.8• Community 2.5 1.5 0.9 0.4 0.4 0.4• -------------------------------------------------------------------------------------------------• NGO (billionHK$) 0.6 3.3 6.2 6.8 8.2 9.6• (21%) (25%) (21%) (20%) (21%) (24%)• Total 2.8 13.3 29.0 34.0 38.5 39.6

•

Demographic Shift

• 2009 2039

• -------------------------------------------------------------------

• Population (million) 7 8.89

• Median age 40.7 47.6• Dependency ratio 337 625

• Sex ratio 889 744

• Age distribution

• 0-14 12% 11%

• 15-64 75% 62%

• 65 & over 13% 28%

• Ageing population; declining working population; low fertility;

population increases due to migration; imbalanced sex ratio.



Poverty• 1-6/2010: 1.26 m. people lived in poverty (household income

below the median level);

– 0-14: 24% (growing significantly)

– 15-24: 20.1%

– 25-44: 10.5%

– 45-64: 16.6%

– 65 & over: 33.9%

• Social assistance recipients

– 1991: 102,240 recipients (71,294 cases) – 2009: 482,001 recipients (289,139 cases)

• Able-bodied recipient cases increased from only 15% to over30%.

Eroding Family Solidarity

• Declining and late marriage: declining number of firstmarriages (bounced back after 2000s); Crude marriage rate(M/F) 16.5/17.5 in 1981, 9.9/9.5 in 2001 and 15.4/14.0 in 2006.Median age of first marriage rise from 24/27 (F/M) in 1981 to

28/31 (F/M) in 2006.• Rising number of divorces and remarriages: The number of

first marriages of both parties fell by 19% from 1981 to 2006.The number of divorce decrees granted in 2006 were eighttimes that in 1981; re-marriages of either or both partiesconstituted 33.6% of all marriages in 2006, as compared with4.3% in 1981.

• Cross-border marriages: the number of males marryingfemales from the mainland increased from 15,776 in 1986 to28,145 in 2006 (vulnerable marriage due to age differences)



Births to Mainland Mothers• Births to mainland mothers are around 40,000 to 50,000 births

a year (around 45% of the total births). 85-90% of bothparents are not HK residents.

• Survey indicated that for those with HK spouses, 48% of themwill leave HK after births, and 84% will return to HK before theage of 21. For those whose spouses are not HK residents,95% will leave immediately, and 50% will return to HK beforethe age of 21.

• Family reunion migration has become a great challenge tofamily structure to Hong Kong (poor human resources)

Single Parents

• Single parents increased from 36,541 in 1986 ,42,309 in 1996to 72,326 in 2006 (rising divorces)

• 79.8% single parents were divorced or separated. Singlemothers increased from 19,282 to 45,400. The proportion ofnew arrivals increased from 5.4% to 10.2% (cross bordermarriages are vulnerable).

• They have lower level of education, and economicparticipation.



Statistics on Family

in 2009 (2005)• Life expectancy 79.7 M/ 85.9 F

• Median age of women at first child birth 29.8 years (28.1 in 1991)

• Number of births 82,100 (57,100)

• Number of marriages 51,200 (43,000)

• Age of first marriage 31 M (31.2)/ 28.5 F (28)

• Crude marriage rate 7.3 (6.3)

• Dependency ratio

– Child 167 (193)

– Elderly 171 (167)

– Overall 337 (360)

Family Related Issues

• Suicide deaths 1997 2003 2008

• 777 1,227 934

• Youth problems 1998 2000 2008

• - juvenile arrested 5,834 6,229 4,178

• - young drug abusers 2,131 4,020 3,430

• Domestic violence cases 2004 2008

– Battered spouse 3,371 6,843*

– Elder abuse 622 882

– Child abuse 329 647*



Family Services Before the

Re-organisation• Family service centres established in 1940s to address a wide array

of problems: financial, child and youth protection, marital relationship,mental health, rehabilitation, and old age.

• Specialized units established tackling special needs (child protection,family violence, material assistance, school social work, medicalsocial work, family life education, family aide, family activity andresource centre, carer support teams, single parent centers, post-migration centers, family education projects, family crisis centers, andspecialized services for youth with behavioral problems).

• Family services centres were casework dominated: in-ward-looking,

segmented (no clear division of role between government and NGOcentres), passive, reactive, remedial, overloaded (heavy caseloads),over-lapping (no clear service boundaries), manpower notstandardised, and over-stretched. Office-like (medical clinic) andhighly stigmatized (only interview rooms).

Review of Family Services byHKU in 2000-2001

• Review of related overseas and local documents andresearch reports on family needs and service development.

• Review of the client information system and service statistics(not computerised and not valid).

• Focus groups with stakeholders including users, socialworkers and other related social service professionals, unions,NGO supervisors/ administrators, and communitystakeholders. Consultation through open reporting forums,submissions, and website discussion room.

• Consultant worked closely under the Steering Committee,comprising representatives from stakeholders



Primary:

Prevent of Problems and Crises :

Publicity, Education, Empowerment,Early Identification

Secondary:

Range of support services :

from Developmental Programmesto Intensive Counselling

Tertiary:

Specialised Services and Crisis Intervention :

e.g. domestic violence, child abuse,suicide

Government

Re-organisation

strengthens

community-

based service

planning and

delivery

NGO

Lump Sum

Grant allows

more flexibility

and cost-

effective use

of resources

A Three-tiered Model to

Support Families

Formation of Integrative FamilyService Centres

• Three-tier system: A continuum of services with preventive,developmental, educational, supportive, empowerment andremedial functions provided through the major components of anIFSC.

• Resource unit – universal, open, preventive and developmentalservices – drop-in, volunteering (users turn volunteers),outreaching, family education (mass education and socialprogrammes).

• Support unit – supporting at risk families with skill training,tangible services, emotional support, brief counseling and mutualhelp (supportive groups)

• Counseling unit – remedial and treatment focused (casework andtherapeutic groups).

• Emphasis: Strengths-oriented; related to the specific communityconditions; bottom-up initiatives; one-stop services; informalsupport



Initiatives at Secondary Level

Model Structure of

Integrated Family Service Centre (IFSC)

Family Counselling Unit

Family Resource Unit

Treatment-

oriented

Supporting families at risk(practical, emotional

& training support)

Open, developmental & preventive

Family Support Unit

Initiatives at Secondary Level

Partnership with Communityand Social Service System

IFSCs

Socialservice unitsSSFUs, MSSUs,rehabilitation units,elderly centres etc.

Government departments&

public organisationsHospital Authority (hospitals, clinics),Departments of Housing, Labour,Legal Aid, Health (MCHCs) etc.

Community-based socialservice unitsITs, CCs, C&YCs,

Educational bodiesSchools, PTAs etc.

Communityorganisationswomen’s and residents’associations, self-helpgroups etc.

Specialised unitsFamily Crisis Support Centre,FCPSUs, CPs etc.

Other professionalslawyers, medical practitioners,psychiatrists, educationalpsychologists



Implementation and Evaluation

of IFSC Pilot Projects (2002-04)• Provisions: physical design (drop-in areas, kitchen, group

rooms, computer facilities; 5,000 sq. ft.), evening and holidayopening hours, standardised staff provision, defined serviceboundaries, division of work between government and NGOs.

• To verify IFSC effectiveness and map out the implementationplan, 15 Pilot projects selected, each based on a differentmode of operation. No new resources were required. Thecore feature is that each consists of the three IFSC units.

– Self-transformed; merging of different services; newproject

– Strategic alliances between: government – NGO and NGOand NGO

– Integrating family, youth, and community services.

Formative and Outcome-basedEvaluation by HKU

• Data management systems on user and service informationand screening/ assessment tools

• Pre and post clinical measurements (child behavior and

marital relationship) and case studies; focus groups for users,

social workers, supervisors, stakeholders. Business plan and

half-yearly self-assessment reports.

• User ratings: satisfaction, social support, problem-solvingcapacity, knowledge of community resources, perceivedimprovements (protective factors).



Findings• User Profile :

– Vulnerable population. A typical IFSC user – female adult with no job andpoor education; High proportion of new arrivals, people without spouses,older persons and social security recipients.

• Service Render

– Continuum of family and community-based programs ranged from clinicalcase and group intervention; training, educational and supportive groups;family-oriented social activities and child care programs.

– Screening form and assessment tools to determine risk levels and serviceneeds for referrals for clinical intervention

• Service Outcomes

– All indicators showed high level of satisfaction; Evidence of promotingaccessibility, partnership, early identification and integration; Center premisesspace, staffing, program variety and choices, opening hours, communitynetwork and catchment areas defined and strengthened; Synergy achievedbetween family caseworkers and community/ group workers/ services.

Full Implementation (2005-06)

• Provision of a more open, user-friendly, proactive, responsive,flexible, accessible and integrated service to users.

• Re-structuring of existing family services (pooling of existingresources) to form 61 IFSCs; 40 managed by SWD and 21 byNGOs. Each IFSC serves a population size of 90,000 to150,000 depending on district needs (as reflected bycommunity social indicators). Defined service boundaries

• 61 centres, initially involving around 750 social workers (now1,000 registered social workers, 14-18 social workers in eachcentre); supervisors, from 62 to 91 (1.5 per IFSC). Statutory / emergency cases remain responsibility of the governmentIFSC.



• Each IFSC team comprises 14 to 18 social workers,dynamically deployed for the three units, rather than beingpredominately assigned to work in a single unit; supported byclinical psychologists.

• Each centre has around 5,000 sq. ft., equipped with kitchen,play room, group room, interview rooms, computer room,drop-in area.

• Development of a new Funding and Service Agreement with

defined service output indicators

Funding and ServiceAgreement (www.swd.gov.hk)

• 1. Number of new/ reactivated cases receiving intensivecounselling/ brief counselling I supportive casework

• 2. Number of therapeutic groups / supportive / educational / developmental groups / mutual-help groups;

• 3. Number of educational/ developmental programmes

• 4. Number of family support persons

• 5. Number of individuals / families newly engaged in centreservices or community services under the Family Support

• 6. Outcome Indicators: Service users indicating satisfaction

• after receiving IFSC service; enhanced problem solvingcapacity

• with enhanced support network; perceived improvement inthe main problem



Implementation Process• A new service delivery mode is a new challenge to social workers – multi-skilled, developing community networks and partnerships, re-engineering of the services, rationing workloads and manpowershortage, managing public expectations, increased administrativework.

• Training programmes for social workers (updating community andgroup work skills, team building)

• Consultation with the sector to ensure stakeholder support - NGOs,professional associations and staff unions, legislative council, andpolicy advisory bodies.

• The whole exercise is cost-neutral, involving no staff redundancy.• Logistics: formulation of funding and service agreement with defined

outputs and service standards; locating of new premises; drawing ofservice boundaries; redefining responsibility between NGO andGovernment IFSC; transition plans (transfer of cases); publicity planfor the service.

2008-10: Evaluative Studyby HKU

• Objectives: Examine effectiveness in implementing the IFSCdirection and four principles; meeting needs of specific targets;identifying facilitating and inhibiting factors; reviewperformance standards

• Methodology: Not feasible of adopting a controlledexperimental design due to the multiplicity of social workintervention and heterogeneity of family service users.Formative evaluation – facilitate interpretative dialogue amongthe programme stakeholders with the aim of attainingconsensus about the programme’s values and outcomes, andincorporating into their roles, the concepts of internalprogramme evaluation and formative feedback



Multiple Approach• Centre self-assessment reports: background, community

needs, service priorities, user needs, operational mode,factors affecting implementation and suggestions.

• Service statistics on output and outcomes: statisticalinformation system and outcome standards (user satisfaction,enhanced problem solving, social support network, perceivedimprovements)

• District focus groups with key stakeholders (administrators,frontline social workers, and community stakeholders)

• Selected centre case study (annual plan, focus group withusers, social workers, and district stakeholders, selected casereview)

• User survey: users of the three units (1,502 interviews)

• Good practice casebook on IFSC implementation

Key Findings

• Major targets are deprived families (female; new arrivals,single parents, victims of DV, families with mental healthproblems, ethnic minorities).

• Problems included emotional problems, relationships, child

care and parenting, mental health, drug abuse, elderly care,poor families.

• Accessibility improved – location, user-friendly and non-stigmatised environment, publicity, mobile and outreachingcampaign (50% by self/ friends/ neighbours referrals; 35% byformal services);

• Early identification – screening tool to identify risks; checkingwith mass media/ housing managers/ hospital reception/ police/ maternity clinics to identify families requiringassistance



• Integration - still dominated by individualised remedialcasework approach, relatively less efforts devoted tocommunity building approach and supportive groups. Usersturn volunteers. Same social worker providing the three levelsof services. Only 38% first time IFSC users were forcounseling (30.5% and 34.1% used FRU and FSU); 27.5%came to IFSC for non-counseling services, and eventually46% sought counseling services themselves and 29.7%recommended by the social workers

• Innovative programmes for specific targets encouraged;redevelopment, family violence projects, mental healthprojects, single parents, marital relationship, men’s groups.

• Partnerships (referral networks, other services – medical,probation, family and child protective service units, youthservices, district service coordinating committees, politicians,schools, businesses)

• User survey – 90% satisfied; perceived effectiveness 69-82%



Outstanding Issues:

Lessons for Singapore?• Management – teamwork, administrative support, training

important

• Multiple skills – generic social workers -- community work andgroup work skills

• Workload management – improved publicity creates demands --negotiating performance indicators (implications for resources)

• Centralised user information system – digital case recordings andfile management system underdeveloped

• Case manager responsible for each family/ case

• Gate-keeping administrative tasks – housing, financial aid, socialinvestigation reports for other government departments (hostileusers); “non-professional tasks?” “eroding clinical expertise?

• Competing with other services (youth service, elderly services,medical social service with counseling components)

• Community expectations: to handle all kinds family problems,family disputes, mental illness, general enquiries – what is thecore business of IFSC?

• Still pre-occupied with remedial casework. Should devote

more resources or engage community partners for familysupport.



Conclusion• Facing complex family needs, traditional family services have tobe vision-guided and re-engineered. The frontiers have to beextended, providing a pro-active, non-stigmatized, cost-effective,cross-sector, and integrative service – a more user-centeredservice.

• Social workers’ mindset and capacity are central to servicereforms and effectiveness; they need to work in a facilitativemanagement environment. A new paradigm (cultural) shift forsocial workers, multi-skilled and the use of supportive programs toempower family capacity. Not identified as “caseworkers”(generalist – specialist)

• Change management – evidence-based process, activeinvolvement and consultation of stakeholders (social workers,union representatives, community stakeholders, users) in thereview processes, and finalising the findings andrecommendations.

References• Cabinet Office, UK Government (2008). Reaching out: Think Family,

analysis and themes from the Families at risk Review, Social ExclusionTask Force.

• Cabinet Office, UK Government (July 2009). Understanding the risks ofsocial exclusion across the life course: families with children

• Census and Statistics Department (November 2007). Marriage and Divorce

Trends in Hong Kong, 1981 to 2006, Hong Kong Monthly Digest of Statistics .

• Census and Statistics Department (February 2008). Thematic report: single parents . The University of Hong Kong (2001). Meeting the Challenge:Strengthening Families, Hong Kong: Social Welfare Department.

• Stafford, B. and Duffy, D. (2009). Review of evidence on the impact ofeconomic downturn on disadvantaged groups, Working Paper no 68.Department for Work and Pensions.

• Department for Children, Schools and Families, UK Government (Jan.2010). Support for all: the families and relationships Green Paper..

• Department for Work and Pensions (2010). Families with children in Britain:Findings from the 2008 families and children study.



• The University of Hong Kong (Oct. 2004). The Steps Forward: TheFormation of IFSC, Hong Kong: Social Welfare Department.

• The University of Hong Kong (Feb. 2010 ). Building Effective Family Services: Review on the Implementation of the IFSC, Hong Kong: SocialWelfare Department

• Kendal, S. et al. (2010). The use of whole family assessment to identify theneeds of families with multiple problems, Department of Education, UKGovernment.

• Sousa, L. (2008). Strengthening Vulnerable Families . NY: Nova SciencePublishers.

Keynote 2_A Perspective of Integrated Models

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