Assertive Outreach and Support Service
In 2023 ACSO successfully launched Assertive Outreach and Support Service (AOS), an innovative initiative designed to deliver assertive outreach and case management services to participants with complex needs.
In early 2023, the Victorian Government released pilot specifications for an integrated service approach for people with complex needs who pose an unacceptable community safety risk.
By August 2023 the Department of Families, Fairness and Housing (DFFH) introduced the innovative 12-month pilot service AOS. ACSO is responsible for delivering this service in Melbourne’s South and East Metropolitan Regions, as well as expanding into the Gippsland region, while ermha365 provides services in the Northern and Western Metropolitan Regions.
Supporting complex needs participants
The mission statement of the AOS pilot – “Driven by our values, Assertive Outreach Service strives to empower and support change in complex lives by collaboratively reducing risk and fostering connection”— reflects its core goal: overcoming the barriers that often prevent people with complex needs from accessing essential support services. These barriers include service fatigue, the inability of services to manage presenting risks, and service refusal or avoidance. Through assertive outreach and tailored case management, AOS aims to connect participants with the resources needed to improve mental health, secure housing, address substance use, strengthen community ties, enhance work readiness, and build healthier relationships.
Each participant receives an Individual Support Plan, based on their unique needs and goals. The plan outlines specific support strategies to help them achieve these goals, reducing participants’ risk of harm and increasing their chances of making positive changes in their lives. Participants also have an engagement plan developed to explore the best methodology of engagement, how to maintain engagement and what measures to put in place to re-engage participants who have previously had barriers to ongoing service engagement. Engagement plans have had strategies like going to the local plaza for Korean food, and that is just fine with the AOS team, we will meet participants where they are at.
The AOS team is committed to empowering participants through a strengths-based, trauma-informed, participant-centred, and non-judgemental approach. The AOS team also focus heavily on risk management and workplace health and safety through ACSO’s risk governance and risk framework structures and contributes to the broader goal of safer communities.
ACSO’s experience in developing and running services tailored to participants with complex needs was recognised by DFFH in March 2024, when they extended the AOS pilot until June 2025.
“The team have been working really hard to support marginalised and disadvantaged members of our community and should be congratulated on their endeavours so far, well done team. It takes a community to operate a service like AOS and the ACSO community has been an enormous support to AOS.”
– Tim Stevenson, AOS Program Manager
Collaboration for better outcomes
ACSO highly values collaborations with other service providers to deliver better participant outcomes. Collaboration is central to AOS’s success. One notable partnership has been with the Lived Experience Advisory Panel, which played a key role in recruiting outreach workers and continues to provide valuable feedback on the service.
In November 2023, AOS also announced the Risk Assessment and Management Partnership (RAMP), an innovative collaboration with the Clinical Services at ACSO. RAMP is a partnership established to enhance risk management practices, ensuring staff safety and providing the best and most robust participant support.
“The RAMP adopts a collaborative and solution-focused approach to assessing and managing risk and safety, whilst maintaining a focus on addressing the systemic barriers that impede a participant’s access to services and supports.”
– Stan Pappos, General Manager Forensic Practice
Making an impact
The AOS pilot aligns with ACSO’s strategic focus on delivering impactful client services. To date the AOS pilot has received 35 referrals and supported participants to achieve 77 individual goals and participants have accessed 92 outbound referrals supported by the AOS team.
Participants frequently face crisis situations, particularly related to housing and mental health. The AOS team has consistently provided support during these critical times, helping nearly half of the participants access emergency accommodation. They have also facilitated access to emergency services on multiple occasions, ensuring that individuals receive the necessary support during crises. This proactive approach aims to prevent participants from reaching the same level of crisis in the future by addressing urgent needs and providing timely interventions.
Every individual we work with brings their own unique strengths and needs, and success can look different for each person. For example, one participant who had been living in crisis accommodation was supported by the AOS team in achieving a monumental goal — purchasing his own home. This was made possible through funds he received as compensation for past childhood abuse at a Christian Boys’ Home, and with close collaboration between AOS and the Fund in Court.
Securing his own home not only provided him with long-term stability but also helped divert him from homelessness and reduced the demand on an already strained housing system. After moving into his new home, he completed his second Client Outcomes Survey, which showed significant improvements in engagement and overall well-being. This positive result is especially commendable given the complexity of his initial circumstances.
There are numerous examples of the team supporting participants to access appropriate services, such as secure mental health facilities, diverting them away from the community mental health system, which are not always equipped to support clients with complex needs.
“Working to support people who have varying complex needs and presentations that also pose significant risk to themselves and others, requires a tailored response that is safe and often creative. People we work with often present in very precarious situations, experiencing significant disadvantage, co-morbidities and issues accessing required services. It’s great to work with the AOS team who are dedicated to achieving the best possible outcomes for the people we work with, utilising innovative thinking.”
– Anthea Neyland, Assertive Outreach Worker
The AOS pilot exemplifies the transformative power of dedicated support and innovative collaboration. By addressing the unique needs of participants with complex challenges, AOS has made significant strides in improving lives and fostering safer communities. The service’s success is a testament to the unwavering commitment of the AOS team and their partners, who have worked tirelessly to empower individuals and reduce risks.
In partnership with ermha365 and DFFH, we will be co-hosting the Complex Needs Conference, which will focus on the challenges and solutions in providing support to clients with diverse and complex needs, aiming to bridge gaps in community safety and share inspiring examples of overcoming obstacles. Complex needs often stem from mental health issues, substance abuse, trauma, poverty, homelessness, disability, and social isolation, making service provision both rewarding and demanding. The conference will seek practical solutions, foster connections among service providers, and exchange innovative ideas to enhance support for participants with complex needs.