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Chapter 11 Section A: Support in the community for people living with mental health conditions

11.A: Introduction

In NSW many services and programs are available to people living with mental health conditions. This includes psychological and psychosocial rehabilitation and support services as well as other types of clinical care. Services and programs are funded in some instances by the Commonwealth and sometimes by the NSW government. In a rapidly changing service delivery environment, particularly in connection with the National Disability Insurance Scheme (NDIS), models of service delivery reflect a much more accessible service delivery approach than was available in the past.

The following information provided in this opening section is more for people working in the sector than people living with mental health conditions who may want to move onto the next section, click here.

Services and programs provided by the community managed mental health service sector, can be loosely described as representing seven core functions. Ideally these should be accessible within each local area, and dependent on population-based needs, however, in some areas, especially rural and remote locations, generally have poorer access to the diversity of services available in metro and more populated regional areas.

Based on an accepted and standardised classification of service types, 18 service type options are identified as follows:

  1. Counselling-face-to-face
  2. Counselling, support, information and referral-telephone
  3. Counselling, support, information and referral-online
  4. Intake/Assessment/Triage for referral to other service
  5. Self-help-online
  6. Group support activities
  7. Mutual support and self-help
  8. Staffed residential services
  9. Personalised support-linked to housing
  10. Personalised support-other
  11. Family and carer support
  12. Individual advocacy
  13. Care coordination
  14. Service integration infrastructure
  15. Education, employment and training
  16. Sector development and representation
  17. Mental health promotion
  18. Mental health prevention

The public and primary health care services available to people living with mental health conditions, more usually fall into the category of clinical care and outreach services, including services for coexisting conditions and physical health care, a vital component of keeping people well in the community. Care coordination is particularly and services are ideally delivered in conjunction with other community-based support services such as those delivered by the community managed mental health sector, allied health care and other human support services.

In this chapter we provide an introduction to important sources of specialist community-based support that may be available to persons living with mental health conditions, coexisting conditions and psychosocial disability.

The following list of services available (in alphabetical order) in the community is by no means exhaustive, and many community managed organisations offer a number of different services as part of the mix of services and programs available under their banner.

Where they do not offer a service, they will generally provide referral/s; and in many local health districts, relationships have built an integrated care approach across services to maximise effective service and care-coordination.

To find out more information and details about services and where they are located, follow this link to the NSW Mental Health Association’s (MHA) “Way Ahead ” directory of mental health services in NSW.

This directory provides information across the following categories (as listed by MHA):

  • accommodation;
  • community organisation;
  • emergency services;
  • education;
  • employment;
  • government assistance;
  • health services;
  • information services;
  • law and justice;
  • leisure activities;
  • organisation types;
  • mental disorders;
  • population groups;
  • support services; and
  • treatments.

To view subcategories under these headings, click here.

Services in NSW operate in an environment that is experiencing great change. MHCC provide information about what is happening in the sector on its webpage.

11.A.1: Access to Allied Psychological Services (ATAPS)

The Access to Allied Psychological Services (ATAPS) is designed to treat people with common mental health conditions (e.g. anxiety and depression) who have difficulty accessing Medicare-subsidised mental health services due to reasons such as the lack of services in some geographical locations, reduced ability to pay fees, and people at-risk of homelessness, children under the age of twelve (12) years, people at risk of suicide, and women with perinatal depression.

A range of health, social welfare and other professionals can refer people who have been assessed as having a mild to moderate mental health condition to a mental health professional to provide short-term focused psychological services. For example, general practitioners (GPs), hospital emergency departments, nurses and school principals can all make referrals. A range of health professionals may deliver ATAPS, including psychologists, social workers, occupational therapists, mental health workers and Aboriginal and Torres Strait Islander health workers with mental health qualifications.

Consumers are eligible for a maximum of ten (10) ATAPS funded sessions per calendar year. In exceptional circumstances, a consumer may be referred for an additional ATAPS sessions.

To find out more please contact your local Primary Health Network, click here.

11.A.2: Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) Initiative

Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) Initiative is a Commonwealth Government program funded through Medicare. The initiative aims to provide coordinated care to people with mental health conditions and disorders. Medicare rebates are available to patients for selected mental health services provided by general practitioners, psychiatrists, psychologists and eligible social workers and occupational therapists.

On 9 October 2020 until 30 June 2022, the 10 sessions already available are further enhanced by 10 additional individual psychological therapy sessions, now available each calendar year to all eligible patients under the existing Better Access program. These additional sessions are available nationally to eligible people whose mental health has been adversely impacted by COVID-19.

To read more, click here

Access to the Better Access Initiative is available via general practitioners. The general practitioner may either prepare the Mental Health Treatment Plan or refer the patient to a psychiatrist to prepare a psychiatrist assessment and management plan. Alternatively, the general practitioner may refer the patient to a psychiatrist or paediatrician who can directly refer the patient to allied mental health services. These services may be accessible via Tele-health.

You can learn more about Better Access by following this link.

11.A.3: Brighter Futures

The Brighter Futures program can help parents give their children a good start in life. Services include home visiting, parent groups, playgroups and child-care. Delivering Brighter Futures provides information for parents, about community referrals and updated Brighter Futures service provision guidelines. Resources for Brighter Futures includes working with fathers.

The NSW Department of Communities and Justice Brighter Futures program includes early intervention programs that support children’s age-appropriate development before they become involved with the child protection system.

Brighter Futures support services are for children, young people and their families experiencing issues such as domestic violence, parental drug and alcohol misuse and/or mental health issues, as well as child behaviour management problems.

For more information click here.

The Early Intervention and Placement Prevention (EIPP) program provides appropriately targeted child, youth and family support services to reduce the likelihood of children and young people entering or remaining in the child protection and out-of-home care systems.

For more information about these programs follow this link.

11.A.4: Psychosocial support for people with severe mental health conditions

People with severe mental health conditions who are not funded through the National Disability Insurance Scheme (NDIS) can still access supports and services to increase their ability to do everyday activities. These supports and services provide a range of non-clinical community-based support, and include:

  • National Psychosocial Support Transition (NPS-T);
  • National Psychosocial Support Measure (NPS-M); and
  • Continuity of Support (CoS).

Primary Health Networks (PHNs) will support community mental health clients to transition to the NDIS or one of the three programs above.

Contact information for the PHNs can be found at PHN Contacts.

The National Psychosocial Support Measure

The purpose of the NPS-M is to provide psychosocial support services to assist people with severe mental illness who are not more appropriately supported through the NDIS and/or who are yet to test their eligibility for the NDIS.

For more information go to the National Psychosocial Support Measure.

Continuity of Support

Continuity of Support provides older clients who were previously supported under various different programs who are found ineligible for supports under the NDIS, with similar supports to those they received from their previous programs.

For more information, click here

11.A.5: Family Mental Health Support Service (FMHSS)

Family Mental Health Support Service (FMHSS) aims to improve mental health outcomes for children and young people. FMHSS provide early intervention support to children and young people who are showing early signs of, or are at risk of developing, mental illness. FMHSS also
supports their families and carers.

FMHSS provides these flexible, responsive services:

  • intensive, long-term, early intervention support for children, young people and their families which may include: assessment and identification of needs; practical assistance and home-b sed support; linking with other relevant services; and, targeted therapeutic groups;
  • short-term immediate assistance for families which may include assessment of needs, information or referrals, and limited support; and
  • community outreach, mental health education and community development activities which may include: organisation of and participation in community events; and, general group work in the community.

Highest priority is given to vulnerable children, young people and their families. These groups include people from Aboriginal or culturally and linguistically diverse backgrounds, children and families in contact with the child protection system, and young people transitioning from out-of-home care.

FMHSS will accept referrals of children and young people from any source, including self-referrals. FMHSS conducts an initial brief screening process to ensure the services are appropriate. A formal diagnosis of mental illness is not required to access FMHSS. For more information, click here.

For Family Mental Health Support Services locations and contact details, click here.

11.A.6: GROW Program

Grow is a community-based organisation that has helped thousands of Australians recover from mental illness through mutual support and personal development. Grow was established in Sydney in 1957. The founders were drawn together by their first-hand lived experience of mental health conditions. The wisdom they gained in helping each other to overcome life’s challenges and recover forms the basis of the unique Grow Program.

Grow Groups meet weekly and vary in size from 3-10 members. They are run by seasoned ‘Growers’, who have taken a voluntary leadership role within the Group. Over the course of each meeting, the group engages in a series of group discussions, interactions, and readings that follow a structure and timetable to ensure everyone has an opportunity to participate, and meetings finish on time.

There are also opportunities to develop new friends and interests and support each other in practical ways.

It is free to participate in Grow programs. There are no assessments, no need for a diagnosis and no strict eligibility criteria.

There are over 250 Grow Groups throughout Australia. Some programs are now available online.

To find out more about GROW programs, call 1800 558 268* or visit the website by following this link.

*Mobile phone calls to freecall numbers (numbers starting with 1800) are charged to the caller at the usual mobile rate.

11.A.7: Housing and Support Program (HASI)

The Housing and Support Program (HASI) provides housing linked to clinical and psychological rehabilitation services for over the age of sixteen (16) with a range of levels of psychosocial disability. HASI is now available to persons over the age of sixty- five (65).

HASI is a partnership program between NSW Health, Housing NSW and the NSW non-government sector. A lot of HASI participants live in social housing, but a person is not automatically eligible for public or community housing just because they are a HASI participant. The normal application process and eligibility criteria for social housing apply.

HASI support helps people to achieve their own goals. The types of support people receive depends on their individual needs and what they want to achieve. As some examples, people in the program often get help with:

  • daily living skills like shopping, looking after finances, cooking or catching public transport;
  • remembering mental and physical health appointments, medications and other treatments;
  • meeting people in the local community and participating in social, leisure or sporting activities;
  • learning new skills;
  • accessing education or help to get a job;
  • moving from a hospital or a prison back to home; and/or
  • accessing other supports like drug or alcohol services and the National Disability Insurance Scheme (NDIS).

The amount of HASI support you can receive is flexible. Some people might need only a few hours of support a week while some HASI consumers might get more than five (5) hours support a day. The amount of support can change to meet your needs. When things are going well, you might only need a few hours of support a week but there might also be times when you are finding things difficult or distressing and it would be helpful to get more support.

You may be eligible for HASI support if you:

  • are sixteen (16) years or older;
  • have a diagnosis of a mental illness which causes you some difficulties in your day to day life;
  • live, or are staying in a local area for some time so you can meet regularly with your support provider; and
  • want to access this sort of program where you receive help to develop and achieve your goals.

There are priority groups for HASI Plus. People referred to HASI are assessed according to their need and, when there are limited vacancies, priority will be given to people who meet the eligibility criteria and:

  • are having to stay in hospital for longer than they need to because of their high support needs;
  • are putting their social housing at risk because they need more support to manage their severe mental illness;
  • are coming out of a prison or in contact with the community justice system (like a person on parole or someone who is serving a community-based detention order)
  • are living in a boarding house; and/or
  • are Aboriginal.

Your local HASI provider can provide you with more information about HASI, including how to access or refer someone into the program.

You can contact your local HASI provider using the below contact information. If you are unsure about which local health district you are in, further information can be found at the Local Health Districts and Specialty Networks.

11.A.7.1: Housing and Support Program (HASI) Plus

Housing Accommodation Support Initiative Plus is a residential program that aims to assist people with a severe mental illness leaving long-term psychiatric facilities. HASI Plus facilitates consumers to participate in their community, maintain a successful tenancy, reduce hospitalisation rates and improve their quality of life.

The program includes the provision of sixteen (16) and twenty-four (24) hour per day coordinated housing, clinical and accommodation support services for people with severe or persistent mental illness. The aim is to support people transition to living in the community from long term institutional care, such as mental health facilities, correctional facilities or long-term care in hospitals.

HASI Plus is located in Northern Sydney, Hunter New England and Western Sydney Local Health Districts. The program is a state-wide service and takes referrals to support people from all NSW Local Health Districts.

To read a fact sheet and find out more, click here.

11.A.7.2: Community Living Supports (CLS)

Community Living Supports (CLS) is a state-wide program which supports people with a severe mental illness to live and participate in the community in the way they want to. CLS was established to help more people live in the community with the type of support provided under the Housing and Accommodation Support Initiative (HASI).

Like HASI, people in the CLS program work with a support worker from a community organisation, a clinician from the local mental health service and their family or other important people in their life to develop their own unique support plan.

Everyone’s supports are different and depend on the person’s needs and wants. As examples, the type of things that people in the program often get help with are:

  • daily living skills like shopping, looking after finances, cooking or catching public transport;
  • remembering mental and physical health appointments, medications and other treatments;
  • meeting people in the local community and participating in social, leisure or sporting activities;
  • learning new skills;
  • accessing education or help to get a job;
  • moving from a hospital or a prison back to home; and/or
  • accessing other supports like drug or alcohol services and the National Disability Insurance Scheme (NDIS).

The amount of CLS support you can receive is flexible. Some people might need only a few hours of support a week while some HASI consumers might get more than five (5) hours support a day. The amount of support can change to meet your needs. When things are going well, you may only need a few hours of support a week, but there may be times when you are finding things difficult or distressing and it would be helpful to get more support.

Supported people with a severe mental illness who live in social housing is a priority for the CLS program. But a person is not automatically eligible for social or community housing just because they are a CLS participant. If you need housing, the normal application process and eligibility criteria for social housing apply.

You may be eligible for CLS support if you:

  • are sixteen (16) years or older;
  • have a diagnosis of a mental illness which causes you some difficulties in your day to day life;
  • live or are staying in a local area so you can meet regularly with your support provider;
  • want to access this sort of program help you develop and achieve your goals.

Like with HASI, people referred to CLS are assessed according to their need and, when there are limited vacancies, priority will be given to people who meet the eligibility criteria and:

  • are having to stay in hospital for longer than they need to because of their high support needs;
  • are putting their social housing at risk because they need more support to manage their severe mental illness;
  • are coming out of a prison or in contact with the community justice system (like a person on parole or someone who is serving a community-based detention order);
  • are living in a boarding house; and/or
  • are Aboriginal.

Your local CLS provider is able to provide you with more information about CLS, including how to access or refer someone into the program.

If you are unsure about which local health district you are in, further information can be found at the Local Health Districts and Specialty Networks.

11.A.7.3: Pathways to Community Living Initiative (PCLI)

The Pathways to Community Living Initiative (PCLI) supports people in NSW who have ‘severe and persistent mental illness’, who have had a long stay in hospital for more than twelve (12) months, to re-establish their lives in the community. PCLI works with the consumer, their family or carer to find the best option for community-based living.

The PCLI initiative is part of the Government’s commitment to strengthen mental health care in NSW by developing effective community-based residential care and support options for people experiencing long stays (over a year) in mental health inpatient units. It is a key program under the Government’s Mental Health Reform 2014-2024.

The PCLI works with two main groups of consumers all with severe and persistent mental illness, comprising:

1: older people who are inpatients with long admissions and who have mental health age-related issues. (Generally 65+ and 55+ for people of Aboriginal background, but also based on clinical assessment of functionality).

2: people aged over eighteen (18) years old, who are long-stay inpatients, without significant age-related issues but who have very complex needs due to their mental illness and major co-occurring disorders such as alcohol and other drug use/ vulnerability, trauma related issues, intellectual disability and physical health problems.

If you are a consumer or carer, to read more about PCLI, click here.

To read a fact sheet, click here.

11.A.8: LikeMind

LikeMind brings together existing community services to one accessible and engaging community space or ‘hub’. LikeMind aims to provide support for adults with mental health concerns, as well as their families and carers.

Trained healthcare professionals will work with you to understand your specific needs, listening to your goals, and helping you develop a Coordinated Care Plan to achieve them. You will then be connected to the services you need, such as:

  • mental health care;
  • drug and alcohol services;
  • employment and training support;
  • housing assistance; and
  • access to general practitioners, psychologists, social workers and more.

You can phone them, get a referral from a general practitioner or other healthcare professional, or just come in and see LikeMind. LikeMind services are free but bring your Medicare card when you attend.

To find out where LikeMind Centres are located, click here.

11.A.9: Mental Health Respite: Carer Support (MHR:CS)

Carers NSW has a Mental Health Respite: Carer Support program that supports carers of people living with mental illness. This program provides one on one support and opportunities to take a break from caring. It aims to assist carers to sustain their caring roles and maintain connection with their communities, by increasing access to flexible, innovative carer support services.

Carers might be supporting a son or daughter, partner, parent, sibling, or someone else close to them. Anyone can be a carer; including children and young people. The Carers NSW Mental Health Respite: Carer Support service provides carers of people living with a mental illness with:

  • one on one support;
  • access to counselling;
  • opportunities to take a break from caring and
  • access to respite.

Mental Health Respite: Carer Support can help carers to deal with some of the challenges of their caring role and be better supported in their caring role now and into the future. It is for anyone who supports a family member or friend with a mental illness, whether diagnosed or undiagnosed.

Carer Support and Programs

There are a range of carer support services and programs available to help you get the practical, financial and emotional support you need.

To read about all the different programs and services available, click here.

To find out where Carer Support programs are located, click here.

For more information or to join the program, please call the Carer Line on 1800 242 636*.

Carers who do not live in the areas listed above can also call the Carer Line on 1800 242 636* to find out more about similar supports across NSW and Australia.

You can call the Mental Health Carer Counselling Service from anywhere in Australia on 1800 242 636*.

*Mobile phone calls to freecall numbers (numbers starting with 1800) are charged to the caller at the usual mobile rate.

NDIS Support Coordination

Carers NSW is a registered NDIS provider of Support Coordination. Carers NSW can assist you if the person you are caring for is eligible, or has received, an approved NDIS plan with a budget for Support Coordination.

Through Support Coordination services, Carers NSW staff can work with you to ensure the person you care for gets the most from their NDIS plan.

To read more about NDIS support coordination, click here.

11.A.10: National Disability Insurance Scheme

NDIS gives people who have a permanent and significant disability the reasonable and necessary supports they need to live “an ordinary life”. Chapter 12 of this Manual provides information about many aspects of the NDIS, to read more please, click here.

You can find out more out about the NDIS, and how it can support Carers here.

If you want to visit an NDIS customer service centre, click here.

These centres are open Monday to Friday from 9:00am to 5:00pm.

If you require help or a translator, please contact 1800 800 110*.

If you are a TTY user, phone 1800 555 677, then ask for 1800 800 110*.

If you are a Speak and Listen (speech-to-speech relay) user, phone 1800 555 727* then ask for 1800 800 110*.

If you are an internet relay user, visit the National Relay Service website and ask for 1800 800 110*.

*Mobile phone calls to freecall numbers (numbers starting with 1800) are charged to the caller at the usual mobile rate.

11.A.10.1: Supported Independent Living (SIL)

Supported Independent Living or ‘SIL’ is a program supporting people with disability so that they can live the way they want to, either on their own or with other people. This can include support twenty four (24) hours a day, seven (7) days a week if needed, or more significant day-to-day assistance if required. Funding for Supported Independent Living is available through the National Disability Insurance Scheme (NDIS).

SIL can also provide supports in your own home or in a private rental where you live independently. If you live in shared accommodation, SIL can offer support to a number of people with disability living together. Wherever a person chooses to live, SIL will assist you develop a plan that works towards your goals.

A personalised plan will include supporting you with:

  • moving out for the first time into shared accommodation or your own home;
  • living well with others, or managing the responsibilities of living in your own home; and
  • getting ready for the day, staying healthy, and doing the things you enjoy.

To read more about SIL services, click here.

To speak to someone about SIL, call the National Disability Insurance Scheme on 1800 800 110*.

*Mobile phone calls to freecall numbers (numbers starting with 1800) are charged to the caller at the usual mobile rate.

11A.11: Primary Health Networks (PHNs)

PHNs support general practitioners, nurses and allied health practitioners to improve patient care. PHNs also improve coordination between different parts of the health system for example, between the hospital and general practitioner when a patient is discharged.

PHNs can commission external healthcare providers to meet the needs in the region. For example, PHNs fund or provide:

  • after-hours services;
  • mental health services;
  • support for people to take up My Health Record;
  • health promotion programs;
  • collection of information about childhood immunisation; and
  • support for primary care (general practitioners), including continuing education.

To find out where the PHNs are situated, follow this link.

11.A.12.1: COPMI Children of Parents with a Mental Illness

As at late 2020, Children of Parents with a Mental Illness (COPMI) is a national initiative which is continuing to merge with Emerging Minds, National Workforce Centre for Child Mental Health. This website is the primary way for information to be accessed. They work with health care providers, community support groups, educators, service organisations and the media. The information is designed to foster better mental health outcomes for children of parents with a mental illness, reduce stigma associated with parental mental illness and help friends, family and workers in a range of settings identify and respond to the needs of the children and their families where parental mental illness exists.

Emerging Minds develops the policy, services, interventions, training, programs and resources in response to the needs of professionals, children and their families.

11.A.12.2: headspace

headspace is the National Youth Mental Health Foundation. Getting help early is the key to resolving mental health problems quickly, and headspace is making a difference where it is needed particularly for young people. headspace provides free online and telephone information, emotional support and referral services for children and young people twelve (12) to twenty five (25) years old who are experiencing mental health problems or who are at risk of self-harm. Young people can log onto the website to email or chat with mental health professionals.

headspace Centres act as a one-stop-shop for young people who need help with mental health, physical health (including sexual health), alcohol and other drugs or work and study support.

The centres are designed not just for young people, but with them, to ensure they are relevant, accessible and highly effective. As a result, no two headspace centres are the same, with each offering unique services that reflect the needs of its local community.

National telehealth service
In regional and rural areas, getting access to expert psychiatrists is difficult. The National Telehealth Service addresses this, by providing twelve (12) – twenty-five (25) year olds in these areas, access to highly skilled psychiatrists via video consultations. The low-cost service ensures young people get high quality mental health care, while continuing their treatment within their local community. To find out more, click here.

eheadspace
eheadspace is a national online and phone support service, staffed by experienced youth mental health professionals. It provides young people and carers with a safe, secure and anonymous place to talk to a professional – wherever they are.
eheadspace was launched to reach regional and remote young people who were unable to access a headspace centre. It has since grown in popularity with all young people – many of whom simply feel more comfortable accessing our services online. To find out more, click here.

headspace vocational Services
headspace recognises the importance of work and study in a young person’s life. headspace Vocational Services support young people to reach their work and study goals– all in a confidential, online and youth-friendly environment. To find out more, click here.

The Work and Study service is clinically integrated and supports young people whose work and study activities have been impacted by mental health. Young people work one-on-one with a Vocational Specialist to find, maintain or re-engage in work and/or study. The Career Mentoring service offers young people the opportunity to work with an industry mentor who acts as an independent sounding board to support their journey into employment. Services are young person led, strengths based and voluntary — helping young people to take control of their work and study.

To find out more about the Work and Study Service, click here.

To find out more about the Career Mentoring Service, click here.

headspace schools
headspace Schools provides mental health education specific to young people and access to mental health specialists for young people in primary and secondary school students across Australia. Through training and education, school staff and parents can better support students experiencing mental health issues. With a focus on early identification and intervention, headspace Schools builds mental health literacy and resilience in the school community while establishing referral pathways to general practitioners and mental health clinicians. To find out more, click here.

headspace early psychosis
headspace Early Psychosis program supports young people experiencing, or at risk of developing psychosis.

Based on evidence developed by Orygen, the National Centre of Excellence in Youth Mental Health, the program focuses on early intervention, providing young people and their families with timely access to specialist support. headspace centres delivering the early psychosis program are equipped with specially trained staff to help young people and their families. To find out more, click here.

Find out how you can get help from headspace and if there is a headspace centre near you by following this link.

Click here for the headspace brochure.

To read more about young people’s services and programs, click here.

Updated December 30, 2020