Inquiry: The Capability and Culture of the NDIA.

Submitter Details: Personal submission

Re: Functional capacity assessment - hospital discharge

The NDIS has released a Functional Capacity Assessment —hospital discharge template.

Occupational Therapists are the primary profession responsible for the majority of Functional Capacity Assessments. Yet as a profession we have not been consulted about this template and as far as | am aware nor have people with disabilities. In 2021, the NDIS had agreed to:

“work in partnership with people who have a lived experience of disability through the Independent Advisory Council and disability representatives. Together we will work on the co-design of a new person- centred model, consistent with the legislative requirements for assessments as set out under the National Disability Insurance Scheme 2013 Act. “

The development of this template and document do not appear to have followed this process. | am recommending that a Functional Capacity Assessment be developed through a consultative co-design process with people with disabilities and also professional groups such as Occupational Therapists.

The Functional capacity assessment template could be completed by someone quickly who is not observing the participant or does not have training or skills in completing functional capacity assessments. This could result in information on the persons disability not being captured accurately or glossed over. It also lacks headings to obtain information that is relevant for a lot of people with psychosocial and neurodevelopmental disabilities . And it does not identify areas of risk such as pressure sores, financial exploitation, fire risk , falls risk, suicide risk etc

This template does not include the domains of community participation, learning and work and this could result in a reduced plan allocated to an individual.

For example; was admitted to the Mental Health Unit with an exacerbation of her schizophrenia. She has had an increase in paranoia and auditory hallucinations and is currently calling out to the auditory hallucinations at night, disturbing the neighbors. She is being discharged on new medications and remains paranoid. She has been working part time in a supermarket and requires support to negotiate some more time off.

As an OT, | would be recommending that is supported to attend appointments with her psychiatrist, GP and community mental health team, she requires support to pick up medication, take medication and to understand and monitor side effects. She had one episode of swallowing difficulties in hospital (due to medication side effects) and has been referred to a speech pathologist. She requires support to advise her GP of her needs in relation to her job and to liaise with her employer. She will also require support worker support before work (due to executive

dysfunction and motivational difficulties) , transporting to and from work and after work to provide support and problem solve any difficulties.

She requires an OT to assess any possible triggers to her auditory hallucinations in her home and work environment. She may require some AT to assist with reducing sound triggers. Eg if she can hear her neighbors talking it may trigger paranoia. So having a white noise machine and some noise cancelling headphones may assist her to be less paranoid and possibly reducing the auditory hallucinations. When she returns home she may require support to have conversations with the neighbors and also her community housing. During her hospital admission she utilized sensory modulation items for calming and assisting her to sleep. She would benefit from obtaining these items to be used at home.

So we could document this as: Client has had an Increase in difficulties with:

e Swallowing

e Paranoia

e Conflict with others

e Sleep

e Auditory Hallucinations

e Executive dysfunction

e Motivational difficulties

e Medication side effects

Support needs include:

e Increased support worker hours to attend appointments, support to pick up medication

e Medication support

e Medication packing

e Advocacy with Employer and community housing

e Monitoring of side effects at home

e OT assessment of environment and home

e AT to assist her with reducing sound triggers

e Support to converse with neighbors (conflict resolution)

e Support workers to assist with night time routine

e Support workers to assist with work attendance.

e Speech pathologist assessment of dysphagia

e Sensory Modulation items to assist with sleep.

Using the provided hospital discharge template it would be difficult to include this information into the headings due to the absence of:

e AT recommendations

e Allied Health professional recommendations

e Work

• Sleep
• Advocacy
• Specific support workers tasks that have been identified.

Completing Functional Capacity Assessments is an area that requires education, skills and practice. Perhaps the NDIS could fund trained OTs to visit the hospital to complete the assessment. A poorly completed assessment may have negative consequences for the client in terms of funding and yet the person completing it may just be short of time or uneducated re the process.

Re: Sensory Modulation

The information below was compiled into two blogs and is written here with minor edits. (http://sensory-modulation-brisbane.com/sensory-modulation-blog)

Currently, NDIS providers are struggling to reduce the use of restrictive practices in service delivery. A report by the NDIS quality and safeguards commission showed that there were more than 2 one million incidents of unauthorized restraints in 2020 — 2021, a 240% increase from the previous 12 months. The restraints included use of sedation, strapping down a person or depriving them of their personal belongings. (Henriques-Gomes, 2021 report of NDIS quality and safeguards commission)

An intervention shown to be effective for reducing restrictive practices is Sensory Modulation. Sensory modulation can be defined as “using your senses to change the way you feel” (O’ Sullivan, Fitzgibbon 2017). Sensory Modulation interventions involve:

• identifying problematic, or overwhelming sensory stimuli and developing strategies to reduce the input or promote self-regulation, with the goal of supporting the individual to continue to be able to engage in occupations.

• Identifying calming and soothing sensory strategies-as to prevent the use of and/or be an alternative strategies to restrictive practices.

Sensory Modulation can incorporate individual and group interventions and changing sensory spaces including lowered stimulus, increased sensory stimulation and specifically designed rooms known as sensory or comfort rooms. Snoezelen rooms provide a multisensory environmental therapy for people with autism and other developmental disabilities, dementia or brain injury. Sensory Modulation can occur in Snoezelen rooms (or multisensory environments) if the person has control over the sensory input to accommodate their unique sensory preferences.

The NDIS inconsistently fund Sensory Modulation strategies, with communications indicating that the NDIS does not fund ‘Sensory items’. In this 2 part blog, we will provide policy support (part 1) and evidence (part 2) for Sensory Modulation interventions and two fictional case studies to highlight these issues. Note: Trigger warning for this article as behaviours of concern are discussed, such as self harm and restrictive practices.

• has been in a mental health unit for 3 months.
• While she was in hospital she had access and learnt to use Sensory Modulation strategies when she had urges to self harm. found these much more useful than taking medication. had previously experienced episodes where she had been chemically restrained by her support workers, and felt access to sensory modulation strategies would offer a better alternative in the future. As part of her discharge planning, stated that it would be helpful for her to purchase a weighted blanket for calming, as well as some scents. had identified that one of the triggers for an urge to self harm was the smell of tobacco, as this reminded her of a traumatic situation in her past. had learnt that if she regularly applied a scent to her handkerchief and held it up to her nose, she could tolerate being around the tobacco without urges to self harm and even wait at the bus stop for her bus to TAFE.

plan manager explained that the NDIS do not fund sensory items and was unable to purchase the weighted blanket and scents.

In this case study was using Sensory Modulation interventions on a Mental Health Unit. Sensory Modulation is a common intervention in Australian Mental Health Services and has policy support as a strategy to reduce Seclusion and Restraint in Mental Health Units.

The following Australian National Policies, Reports and Frameworks all contain references to Sensory Modulation, Sensory Items, Sensory Rooms or Sensory Approaches:

• NDIS QUALITY & SAFEGUARD COMMISSION (2020) Regulated Restrictive Practices Guide
• National Mental Health Commission
  • National Principals to Support the Goal of Eliminating Mechanical and Physical Restraint in Mental Health Services (Mental Health Commission)
  • Australian National framework for recovery-oriented mental health services: Guide for practitioners and providers (2013)

State Policies, Reports and Frameworks that contain references to Sensory Modulation, Sensory Items, Sensory Rooms or Sensory Approaches:

• Mental Health Act 2016 Chief Psychiatrist Policy Mechanical Restraint, QLD (2020):
• Mental Health Act 2016 Chief Psychiatrist Policy Physical Restraint, QLD (2020):
• Admission of children and adolescents to acute mental health inpatient units - Queensland Health Guideline(2021)
• Suicide Prevention Health Taskforce — Phase 1 Action Plan(2017) Qld Health
• Mental Health Safety and Quality NSW
• Chief Psychiatrist Restraint and Seclusion Standard A standard to reduce and eliminate where possible the use of restraint and seclusion applied under the Mental Health Act 2009 (2021) South Australia.

The NDIS QUALITY & SAFEGUARD COMMISSION (2020) Regulated Restrictive Practices Guide documents support for sensory interventions directly such as sensory rooms and sensory items, as well as indirect

Sensory Modulation

support such as recommending identifying and removing potential triggers and identifying environmental changes which could include changes to the sensory aspect of the environment. Examples of sensory references from this report include:

Page 28: Consideration should be given to the physical environment of the seclusion area and any items that can be offered to ensure the person has appropriate sensory input, subject to a risk assessment (Mckenna et al, 2014 cited in NDIS commission report).

Page 38 Some of the strategies aimed to increase quality of life and help support the medication reduction plan and reduce the incidents of chemical restraint focused on: asveruenaureeaee Having a quiet space in her home with sensory and relaxation items. Page 55, 56

Some of the strategies aimed to increase Emma’s quality of life and help support the reduction and elimination of seclusion focuses ON: ……..:008 A Sensory room was designed for | tailored to her sensory needs. It included different items and activities, some of which were portable and could be used within the community when she needed them. Over time, it was hoped that having a sensory room would replace the use of seclusion. The sensory room was to be used proactively to assist to feel calm when she was beginning to show early signs of distress.

The NDIS commission report indicates that the clinical reasoning and evidence of Sensory Modulation was sufficient to be used as examples of interventions to reduce restrictive practices. We will further discuss the current evidence for using Sensory Modulation.

Sensory Modulation for Self-Regulation

Sensory modulation approaches involve the provision of sensory-based therapy tools and/or the creation of appropriate environments that engage the user’s senses to reduce the build-up of agitation and prevent the escalation of aggression (eg Chalmers et al 2012, Lee et al 2010). (O Sullivan and Fitzgibbon, 2017).

A significant driving force for services to adopt sensory modulation was the need to develop ‘alternative methods for managing distress, agitation and aggressive behaviour’ (O’Hagan, 2006) including to reduce seclusion and restraint practices.

Sensory Modulation is useful when there is a sensory trigger to a behaviour of concern, and then a sensory solution can be applied to reduce or minimise the sensory input. (eg using noise cancelling headphones to reduce overwhelming noise).

A sensation can act as a trigger due to a number of reasons including a past memory or traumatic association, intense dislike of a sensation or due to a person experiencing sensory overload or reaching

Sensory Processing Differences

their tolerance for sensory input as part of a hypersensitivity. In some individuals, the intense need to avoid the sensation can lead to a behaviour of concern (eg running away from the sensation, pushing a person away to avoid a sensation).

Verhulst et al (2022) found that “Visual, auditory and olfactory hyper reactivity, such as difficulties with bright, or flickering lights, sudden loud noises, and intense scents, have been commonly reported by autistic individuals and are associated with distress, overwhelm, and anxious responses.” (MacLennan, et al 2021, Tavasolli et al 2016 cited in Verhulst et al 2022)

Sensory sensitivities are recognised in the Autism Spectrum Disorder diagnostic criteria and have also been found to be atypical in adults with schizophrenia, for example auditory sensitivities (eg Adler, Waldo and Freedman,1985,cited in Soto et al ) and visual and somatosensory sensitivities (Andrade, Butler, Peters, Molholm and Foxe 2016 cited in Soto et al). Other mental illness’ shown to have sensory processing differences include Bipolar, Depression, Post Traumatic Stress Disorder (PTSD) and Obsessive Compulsive Disorder (OCD) (Brown et al, 2011). Other disabilities with sensory processing dysfunction include Intellectual Disabilities (Werkmen et al 2022) and Dementia (Champagne, 2018).

It is also important to note that for those people who do not have sensory processing dysfunction normally, when acutely distressed may become oversensitive to input such as noise and bright light or under responsive to other input such as visual cues. (Andersson et al 2021).

Wright et al (2020), stated that “Evidence suggests that the use of sensory modulation approaches can reduce a person’s emotional distress and agitation (Adams-Leask et a/. 2018; Chalmers et al. 2012; Cummings et a/. 2010; Lloyd et al. 2014 cited in Wright et al 2020)

Unwin et al (2021) described benefits for controlling sensory stimulation for autistic children and adults:

Interventions to control sensory stimulation in everyday environments have shown benefits for autistic children and adults, including the use of headphones (e.g. Ikuta et al., 2016; Pfeiffer et al., 2019; Rowe et al., 2011) and modification in lighting (e.g. Kinnealey et al., 2012). Across the studies, these adaptations led to a range of improvements in attention (Kinnealey et al., 2012; Pfeiffer et al., 2019; Rowe et al., 2011), meeting individualised goals (Ikuta et al., 2016), mood and classroom performance (Kinnealey et al., 2012), and reductions in anxiety and challenging behaviours (Pfeiffer et al., 2019). Kinnealey et al. (2012) also report some improvement in social interaction, although only after several weeks of intervention. These findings are consistent with teacher reports that increasing autistic children’s control over the classroom environment helps them control unwanted sensory experiences, and that it is the uncontrollable and unpredictable nature of sensory stimuli that causes the most difficulty for their learning (Jones et al., 2020).

Sensory Modulation can also be used to support an individual’s self regulation and increase coping strategies, even when there is not a sensory trigger or sensory aspect. Sensory Modulation may include using sensory input to provide regulation, distraction, calming, grounding or to achieve a lower or higher sensory stimulation.

Sensory Modulation

Altering the environment by using calming features or moving to a less overwhelming context was the most common strategy reported for managing sensory overstimulation in Andersson et al 2021 study. However, for many people including frail, aged, and those living with disabilities, it can be difficult to move themselves to a different/more suitable environment due to a range of factors. Such factors may include mobility issues, comprehension or communication difficulties, socio-economic constraints, environmental constraints, dependence on others to meet personal care needs

e Sensory Modulation for Reducing Seclusion and Restraint

e Sensory Modulation is a common practice intervention in Australian Mental Health Services and has policy support as a strategy to reduce Seclusion and Restraint in Mental Health Units (refer to blog 1 for further information).

e In the United States in 2006, the National Association of State Mental Health Program Directors (NASMHPD) developed six core strategies to reduce seclusion and restraint. These strategies have been implemented by many other countries including Australia, New Zealand, the United Kingdom and a number of European countries. One of the core strategies recommends the use of ‘de-escalation surveys or safety plans, use of person-first language, environmental changes to include comfort and sensory rooms; sensory modulation experiences and other meaningful treatment activities. These tools actively support people to develop emotional self-management skills’ (Huckshorn, et al 2006 cited in O’Sullivan and Fitzgibbon (2017)).

e The role of Sensory Modulation in reducing seclusion and restraint has been most researched within Mental Health Units and there are multiple studies to demonstrate its effectiveness. Studies include Andersen et al. 2017; Barton et a/. 2009; Champagne & Stromberg 2004; Lloyd et a/. 2014; Maguire et al. 2012; Sivak 2012; Yakov et a/. 2017 cited in Wright et al , (2021) and Seckman et al (2017) Bobier et al (2015). More recently, Zimmerman’s 2020 study on the implementation of a serenity/comfort room for sensory modulation found a decrease in chemical restraint, seclusion and mechanical restraint. Azuela, (2019) found that service users in a psychiatric unit reported that sensory modulation was preferred over in situ medication (PRN) as a calming strategy.

e In a study by Van den Boogert (2021) autistic adults with higher scores in sensory sensitivity had the highest risk of aggressive behaviour and thus applying detailed diagnostics on sensory processing difficulties when treating aggressive behaviour was recommended.

e Sensory Modulation has also been used to decrease self harm. In one study (Matson et al (2021) participants found that they were able to use sensory input to experience a sense of release that they would normally achieve from self harming, but without any different. This depended on the usual method of self harm and was different for each individual

e Im (2021) reviewed treatment of Aggression in Adults with Autism Spectrum Disorder and found that both multisensory interventions and behavioural interventions had similar levels of evidence.

e “Lower levels of evidence (e.g., nonrandomized N of 1 trials, prospective open trials, retrospective reviews) point to possible benefits, in adults with ASD and aggression, of behavioral

Interventions

table-of-contents: interventions,56,57,67,85—88,91—95,99 multisensory environments,96,109 yokukansan,58,110 clomipramine,104 sertraline,46,103 clozapine,115,117 and aripiprazole.76,77,82,116 Among these interventions, multisensory environments and yokukansan are slightly more supported based on risk-of-bias assessments. While the level of evidence for these approaches is less robust than for controlled trials, the adverse effects and long-term risks associated with many of these treatments (in particular, behavioral interventions and multisensory environments) are significantly more favourable.” (Im, 2021)

In the area of dementia, there have been studies reporting a decrease in the number of behavioural and psychological symptoms with the use of multi sensory environments (Maseda et al., 2014a; Minner et al., 2004; Riley-Doucet & Dunn, 2013; Staal et al., 2007; Ward-Smith et al., 2009), cited in Unwin et al (2020).

Case Study:

was visiting the shops to buy groceries for dinner. He enjoyed cooking and was looking forward to preparing his favourite meal — chicken nuggets. When was walking through the shops, a nearby child starting having a tantrum, which involved screaming and lying on the shop floor. and his support worker quickly moved further away, but could still hear the noise and it was driving him crazy! He held his hands over his ears and started rocking on the floor. His support worker wanted to support to leave the shops and started pulling on his arm to go. Unfortunately the situation quickly deteriorated, with the support worker physically restraining in an attempt to stop him from running away from the shops. When got home he started banging his head, and rocking back and forth into the wall. discussed this incident with his treating team and it was identified that the sound of the child screaming was a trigger for him. They identified the strategy of using noise cancelling headphones if was out and heard an overwhelming sound. had always enjoyed using his Aunty’s rocking chair and it was identified that this could be a useful calming strategy at home as an alternative to head banging.’s Occupational Therapist wrote a supporting letter addressing reasonable and necessary criteria to enable Bruce to use his NDIS funds to purchase noise cancelling headphones and a rocking chair. Staff training was also completed on using sensory modulation interventions.felt positive regarding his new strategy and found that it worked well for him, both at the shops and at home, thus preventing the need for further restraint.

Sensory Modulation is one of a suite of interventions to reduce seclusion and restraint. As this case study highlights, it needs to be tailored to the individual and accompanied by staff training and verbal de-escalation strategies. The NDIS could increase their support of Sensory Modulation items and interventions

References:

Helene Andersson, Daniel Sutton, Ulrika Bejerholm & Elisabeth Argentzell (2021) Experiences of sensory input in daily occupations for people with serious mental illness, Scandinavian Journal of Occupational therapy, 28:6, 446-456, DOI: 10.1080/11038128.2020.1778784

Azuela, Gilbert (2019). The implementation and impact of sensory modulation in Aotearoa New Zealand adult acute mental health services: Two organisational case studies

Brown, C., Stoffel, V., & Munoz, J. P. (2011). Occupational therapy in mental health: A vision for participation. Philadelphia: F.A. Davis Co. Chapter 22 Catana Brown, Patricia Steffen-Sanchez and Rebecca Nicholson

Champagne,T (2018) Sensory Modulation in Dementia Care: Assessment and Activities for Sensory-enriched Care, Jessica Kingsley Publishers, London, 2018, 168 pp., pbk £15.99, ISBN 13: 9781785927331. Volume 39 Issue 8

Dorn, Emma, Hitch, Danielle and Stevenson, Christopher 2020, An evaluation of a sensory room within an adult mental health rehabilitation unit, Occupational therapy in mental health, vol. 36, no. 2, bp. 105-118, doi: 10.1080/0164212X.2019.1666770.

Im D. S. (2021). Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review. Harvard review of psychiatry, 29(1), 35-80. https://doi.org/10.1097/HRP.0000000000000282

Henriques-Gomes, L. 10 Nov, 2021 Guardian Australia

MacLennan, K., O” Brien, S., and Tavassoli, T (2021) In our Own Words: The Complex Sensory Experiences of Autistic Adults. Journal of Autism and Developmental Disorders. https://doi.org/10.1007/s10803-021- 5186-3

O’Sullivan, J and Fitzgibbon, C. (2017) Sensory Modulation Resource Manual.

Matson, R., Kriakous, S and Stinson, M (2021) The Experiences of Women with a Diagnosis of Borderline Personality Disorder (BPD) Using Sensory Modulation Approaches in an Inpatient Mental Health Rehabilitation Setting, Occupational Therapy in Mental Health, 37:4, 311-

331, DOI: 10.1080/0164212xX.2021.1933674

NDIS Quality and Safeguards Commission

(2020) Regulated Restrictive Practices Guide. Pentrith. Australia: NDIS Quality and Safegards Commission.

Seckman, Angela ; Paun, Olimpia ; Heipp, Biljana ; Stee, Marie ; Keels-Lowe, Vonda ; Beel, Frank ; Spoon, Cari ; Fogg, Louis ; Delaney, Kathleen R, Evaluation of the use of a sensory room on an adolescent inpatient unit and its impact on restraint and seclusion prevention Journal of child and adolescent psychiatric nursing, 2017-05, Vol.30 (2), p.90-97

Tavassoli, T., Bellesheim, K., P, M,. Wang, A. T., Halpern, D., Gorenstein, M., Grodberg, D., Kolevzon, A., and Buxbaum, J.D. (2016) Measuring Sensory Reactivity in Autism Specrum Disorder: Application and Simplification of a Clinician-Administered Sensory Observation Scale. Journal of Autism and Developmental Disorders, 46 (1), 287 — 293. Hyyps://doi.org/10.1007/s10803-015-2578-3

Van den Boogert F, Sizoo B, Spaan P, Tolstra S, Bouman YHA, Hoogendijk WJG, Roza SJ. (2021) Sensory Processing and Aggressive Behavior in Adults with Autism Spectrum Disorder. Brain Sci. 14;11(1):95. doi: 10.3390/brainsci11010095. PMID: 33466570; PMCID: PMC7828723.

Verhulst, |., MacLennan, K., Haffey, A., & Tavassoli, T. (2022, January 12). The perceived casual relations between sensory reactivity differences and anxiety symptoms in autistic adults.

Unwin, K. L., Powell, G., & Jones, C. R. (2021). The use of Multi-Sensory Environments with autistic children: Exploring the effect of having control of sensory changes. Autism. https://doi.org/10.1177/13623613211050176

Werkman, M.F., Landsman, J.A., Fokkens, A.S. et al. (2022) The Impact of the Presence of Intellectual Disabilities on Sensory Processing and Behavioral Outcomes Among Individuals with Autism Spectrum Disorders: a Systematic Review. Rev J Autism Dev Disord https://doi.org/10.1007/s40489-022-00301-1

Wilson, Haley, “Mental Health Inpatient Hospitalization: What Nursing Can Learn From "Sensory Rooms.”(2020). Honors Theses. 3315. https://scholarworks.wmich.edu/honors_theses/3315

Wright, L. Bennett, S, Meredith, P (2020) ‘Why didn’t you just give them PRN?’: A qualitative study investigating the factors influencing implementation of sensory modulation approaches in inpatient mental health units https://doi-org.ezproxy.library.ug.edu.au/10.1111/inm.12693

Zeanah, C. (2018) Handbook of Infant Mental Health Fourth edition. Chapter 19: Sensory Over-responsivity timothy W Soto, Vivian Ciaramitaro, Alice Carter.

Zimmermann, D. P. S. (2020). Use of a serenity room for sensory modulation (Order No. 28002838). Available from ProQuest Dissertations & Theses Global. (2420652212). hhttps://www.proquest.com/dissertations-theses/use-serenity-room-sensory- mulation/docview/2420652212/se-2?accountid=14723

Australian National Policies, Reports and Frameworks that contain references to Sensory Modulation,

Sensory Items, Sensory Rooms or Sensory Approaches.

NDIS QUALITY & SAFEGUARD COMMISSION (2020)

Regulated Restrictive Practices Guide

National Mental Health Commission

National Principals to Support the Goal of Eliminating Mechanical and Physical Restraint in Mental

Health Services (Mental Health Commission)

Australian National framework for recovery-oriented mental health services: Guide for practitioners

and providers (2013)

State Policies, Reports and Frameworks that contain references to Sensory Modulation, Sensory Items,

Sensory Rooms or Sensory Approaches.

• Mental Health Act 2016 Chief Psychiatrist Policy Mechanical Restraint, QLD (2020) :
• Mental Health Act 2016 Chief Psychiatrist Policy Physical Restraint, QLD (2020) :
• Admission of children and adolescents to acute mental health inpatient units — Queensland Health Guideline (2021)
• Suicide Prevention Health Taskforce — Phase 1 Action Plan (2017) Qid Health
• Mental Health Safety and Quality NSW
• Chief Psychiatrist Restraint and Seclusion Standard A standard to reduce and eliminate where possible the use of restraint and seclusion applied under the Mental Health Act 2009 (2021) South Australia:
• South Australia Policy: Guideline Restraint and Seclusion in Mental Health Services Policy Guideline
• Health framework for reducing restrictive interventions Victoria: Victoria Positive Practice Framework
• Attachment and Trauma in People with an Intellectual Disability (2008), Positive Solutions in Practice, Office of the Senior Practitioner.
• Mental Health Restraint Policy West Australia(2020)
• West Australia Prevention and early intervention strategies