About Pathways to Community Living Initiative

The Pathways to Community Living Initiative (PCLI) is a coordinated statewide approach to supporting people with severe and persistent mental illness (SPMI) and:

• who have had a long stay in hospital for more than 12months
• or are at risk of a long-stay to re-establish their lives in the community.

PCLI works:

• by adopting a rights-based, recovery-oriented approach that places the quality of life and unique needs and wishes of the consumer at the forefront 
• with the individual, and their family or carer to find the best option for community-based living.

Why was PCLI established?

This initiative is part of the NSW 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 (more than 365 days) in mental health inpatient units. It is a key program under the government’s Mental Health Reform 2014-2024.

Aims of PCLI

• Transitioning people who are long-stay patients or people at risk of long stays, who experience SPMI into the community, where possible, including developing new service models for appropriate care.
• Creating practice change in inpatient and community services across NSW to decrease the number and length of long stay admissions.

Who are PCLI consumers?

• Stage One or Cohort 1: older people who also have significant ageing-related issues.
• Stage Two or Cohort 2: people aged 18 and older, without significant ageing-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 or vulnerability, trauma related issues, intellectual disability and physical health problems.

What are the objectives for these consumers?

The objective for people with ageing-related issues is:

• to complete a range of assessments that will help identify their needs and issues
• work with the person's choice and their family's support
• help them transition from the inpatient setting to an agreed and appropriate generalist or specialist residential aged care facility
• ensure follow-up from the PCLI and the NSW Older Person's Mental Health services.

The objective for those people without ageing-related issues is:

• to work with them on a range of comprehensive assessments to understand their needs, strengths and wishes
• to consider available existing options in the community and where possible
• to support the person to transition with help from PCLI clinicians to these services.

The PCLI has developed two guides to work with people through their journey:

• Planning, Assessment and Follow-up Guide
• Journey to Home Guide

Where is PCLI now?

At June 2021, six years into this initiative, the initial evaluation findings by the Australian Health Services Research Institute from the University of Wollongong are:

• it is a major reform program that is transforming people's lives and
• it is contributing to practice change in mental health hospitals. 

PCLI Evaluation Report 1 details the significant work by Local Health Districts (LHDs) to ensure person-centred and successful transitions are making a difference to the lives of patients and their families.

PCLI Evaluation Report 6: Organisational case studies of practice change presents the findings of a qualitative organisational case study of mental health service reform processes and the resulting practice change in two local health districts. The report presents evidence that the PCLI has contributed to establishing contemporary care pathways across settings and sectors, as well as ensuring  the principles of person-centred, recovery-oriented care are embedded in practice.

PCLI Final Evaluation Report is the final report of an independent evaluation conducted between January 2017 and October 2021 by the Centre for Health Service Development, University of Wollongong. The report, endorsed by the PCLI Steering Committee in December 2021, presents the summative findings of the mixed methods evaluation activities and formative information to guide continuing reform within mental health services. The report concludes that the PCLI is successfully transitioning consumers with complex care needs to the community.

For Stage One cohorts:

• At December 2020 more than 70% of the initial ageing group have successfully transitioned to high-quality aged care mental health partnership services.
• Many of these individuals had lengths of stay of 15-30 years. They are now reunited with their families, living near them and enjoying normal aged care community life.
• "Top-up" funding from the NSW Government has enabled the development of 80 PCLI beds in aged care mental health partnership services and additional new specialist clinicians for LHDs.
• Value-adding is also now occurring for newer cohorts of older patients with clinicians supporting them to move more rapidly back to the community.
• The PCLI Stage One Summary Report describes the implementation of partnerships across hospital and community settings that are delivering sustainable, co-designed value based health care to meet the needs of people with very complex mental illness and significant issues of ageing who have had very long hospital stays. 
• The PCLI Evaluation: Stage One Implementation and Outcomes Report  is a qualitative and quantitative evaluation of the work of the PCLI with  people with SPMI and significant issues of ageing. Many of these people had experienced hospital stays of over five years, some much longer. The report provides detailed analysis and findings that are referenced in the PCLI Stage One Summary Report.
  

For Stage Two cohorts:

• Additional funding from the state government has enabled new specialist positions in LHDs to work across hospital and community and more rapidly support people to transition to community services of their choice. 
• Planning is also underway for specific community-based Stage Two services under the Statewide Mental Health Infrastructure Program. 

Communities of practice

For both Stage One and Stage Two cohorts the additional new complex care PCLI clinicians and peer workers have been funded across most LHDs including St Vincent's Hospital network.

There is also  a specific PCLI position in a rural LHD to assist staff from all rural and remote LHDs to work with people who have recurring hospitalisations or are long-stay patients.

These new staff form a complex care PCLI community of practice across the state working with other specialist staff and peer workers.

In March 2020, PCLI the NSW Ministry of Health and the Royal Australian and New Zealand College of Psychiatrists brought together Rehabilitation Psychiatrists from across NSW and other psychiatry leaders for a medical dialogue on care for people with severe mental illness and complex needs.

Professor Helen Killaspy and Professor Carol Harvey gave presentations on Rehabilitation Psychiatry. Throughout 2021 this leadership group has continued to meet under the auspice of the College and the Ministry.

Further resources

• Dr Karin Lines (former Executive Director, Mental Health Branch
• Bec Davis (Mental Health Consumer),
• A/Prof Peter McGeorge (former Clinical Lead, PCLI)
• and Deb Hoban (Senior Project Officer, PCLI)

talk about how a distributive leadership model can empower consumers, families and health staff and bring about major system change.