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Why has community-based care been chosen as the preferred model?

Evidence shows that many people with severe and persistent mental illness can enjoy an improved quality of life by living in the community.

Mental health systems nationally and internationally are developing their community-based services in order to better support people in the community. Inpatient services are also improving to provide more contemporary, recovery-oriented models of care that ensure people can move back to the community as soon as possible.

How does PCLI assist long-stay patients to live in the community?

The initiative is a 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 in mental health inpatient units.

PCLI focuses on developing world class accommodation support services for the people who have been in hospital with very complex mental health issues for more than 12 months or more. PCLI clinicians work with individuals to understand their strengths, wishes and needs, investigate best practice care pathways and identify the right models of care to help meet a person’s needs.

PCLI is designing new community residential and other service options for people currently receiving long-term hospital care in NSW. These transitions are being guided and supported with tailored accommodation, clinical care and psychosocial support.

How are the decisions made?

Each person is being supported to move into the community setting only if and when it is right for them. They are invited to participate in a supportive and comprehensive assessment to help determine their appropriate level of care.

Staff are working with each and every person, their families and carers to create a plan, based on their individual strengths, needs, vulnerabilities and wishes (as well as those of their families), to help find suitable community care.

When does the transition to the community take place?

Each person moves into a community setting only if and when it is right for them. For some people this may take some time.

Staff work with the person, their carer and family to create a plan tailored to their individual needs, strengths and wishes.

This plan includes, but is not limited to, planning and preparing the move, visions and goals for the future home, developing or maintaining skills to build a meaningful life at home, making the move, settling in the new home and participating in community activities.

How is the transition into the community being managed to ensure the safety of patients and the wider community?

NSW Health takes the safety of people in its care, and the community very seriously. Mental health clinicians will work with long-stay patients, their carers and non-government partners to ensure they can be safely supported in the community through integrated programs and services.

Comprehensive assessments help determine how each person may safely transition to a community setting or appropriate inpatient setting. They are being provided with the ongoing care that they need, as long as they require it.

How are consumers who have had long-stays in hospital, adjusting to the community based care?

Each person’s experience on this journey and the transition to the community process is different and unique. And this often includes forward and backward movement, while the person and their carer are supported to make their decisions.

Clinicians are working with the person to determine how they may safely transition the person into a community setting based on their strengths, needs and preferences. Once the plan is developed and possible community based care identified, the clinicians discuss this with the person, carer and family to actively involve them in the decision.

The person is also able to visit the accommodation where they will be transitioning and meet with the staff from the partnering organisation. The clinical staff work along with, and provide support to the person to identify the best strategies for the move (ie. gradual transition or single move).

Carers and the families are being included in these discussions and are offered the opportunity to support a person’s decisions as they move into the appropriate community based care.

Are families expected to provide care if their loved ones are moved into the community?

Families are not being expected to be the primary care givers for their loved ones. The support provided to those in hospital will continue when they move into the community.

Many people who have stayed in the hospital for a long time have remained in contact with their loved ones, to some extent. But many more have lost contact over the years. If a person has lost contact with their family, reconciliation is being investigated and families are offered the opportunity to be involved with the person to make the decision. Regardless of the outcome of the transition, carers are included in communication about the person’s plans and are given the chance to provide feedback.

Consumers, their carers and families will be supported during this process.

Is this a way to reduce beds in the mental health hospitals?

Mental health care in hospitals will always be available for people who require hospital level clinical treatment and rehabilitation where community-based care does not meet their needs.

National and international studies show that community based accommodation with high-level support reduces hospital admission/ re-admissions and significantly improves the functioning and psychosocial outcomes. Evidence also show that people with severe and persistent mental illness can experience better quality of life by living in the community.

PCLI forms key part of the NSW Government’s 2014-2024 mental health reform agenda, which has a greater focus on community-based care by helping people to live in the community and provide new community-based alternatives to long hospital stays. Hospitals are not Homes.

Current as at: Wednesday 29 September 2021
Contact page owner: Mental Health Branch