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What is the Pathways to Community Living Initiative (PCLI)

The Pathways to Community Living Initiative (PCLI) was established to support the transition of long-stay mental health patients (12 months or more) into appropriate community-based living and services.

Evidence shows there is better quality of life and improved social and health outcomes by living in the community.

It is led, funded and coordinated by the NSW Ministry of Health in collaboration with Local Health Districts (LHDs), and involves multiple organisations and care providers.

The PCLI has two aims:

  1. Transitioning long-stay patients - or those at risk of long stays – who experience very complex mental health issues back into the community. And where possible, developing new service models for appropriate care.
  2. Creating practice change in inpatient and community services across NSW to decrease the number and length of long stay admissions.

Why was it established?

The PCLI was established in mid-2015 as part of the NSW Government’s commitment to strengthen mental health care in NSW and to provide a better balance of acute and community-based service.

It is a key program under the government’s Mental Health Reform 2014-2024. The Pathways to Community Living Initiative is focused on ensuring people with mental illness can lead the most fulfilling lives possible.

Who are PCLI consumers?

The PCLI works with two main cohorts of consumers all with SPMI and complex needs which place them at risk of long hospital stays.

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
  • physical health problems.

What are the objectives for these consumers?

The objectives for Stage One or Cohort 1, people with ageing-related issues are:

  • complete a range of assessments that 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 objectives for Stage Two or Cohort 2, people without ageing-related issues are:

  • complete a range of comprehensive assessments to understand their needs, strengths and wishes
  • consider available existing options in the community
  • where possible, 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:

How does PCLI work?

Each person will participate in a supportive and comprehensive assessment to help determine their appropriate level of care.

Staff will work with each person, their families and carers to create a plan based on their individual strengths, needs and wishes. They will move into a community setting only when it is right for them.

Transition to community living will be supported with tailored housing, clinical care and psychosocial support.

Mental health care in hospitals will always be available for people who require hospital level clinical and disability support.

Families and carers are not expected to be the primary care givers under this initiative. They will, however, be able to discuss their loved one’s decisions to move back into the community.

How will PCLI impact the current mental health care system?

Mental health care in hospitals will continue to be available for people who require high levels of clinical treatment and rehabilitation where community-based care does not meet their needs.

The nature of mental illness means a range of partners providing mental health support for a person, their families and carers needs to exist.

Evidence checks

The Sax Institute has conducted two evidence checks on models of care for people with severe and persistent mental illness. The reports can be found in Evidence checks.

Evaluation of PCLI

A four-year independent evaluation was conducted by the Australian Health Services Research Institute at the University of Wollongong. It noted that the vision, energy and commitment of PCLI’s coordinated approach is ensuring successful transitions with immediate positive outcomes for both consumers, carers and families.

Evidence also indicates that since the start of this program, the overall length of long-stay admissions in NSW has reduced significantly.

In June 2021, six years into the initiative, the initial evaluation by the Australian Health Services Research Institute from the University of Wollongong found that the PCLI:

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

For people with ageing-related issues, the evaluation found that:

  • in 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, with long stays of 15 to 30 years, are now reunited with their families, living near them and enjoying aged care community life
  • "top-up" funding from the NSW Government has resulted in 80 PCLI beds in aged care mental health partnership services and additional new specialist clinicians
  • value-adding is also now occurring for older patients with clinicians supporting them to move more rapidly back to the community.

For people without ageing-related issues, the evaluation found that:

  • additional funding from the NSW government created new specialist positions, which offered support much sooner for people transitioning to community services of their choice
  • more planning is also underway for specific community-based services under the Statewide Mental Health Infrastructure Program.

Evaluation reports

Pathways to Community Living Initiative: Evaluation Report 1: Builing the Foundation for Transformational Change - Published in April 2019, the report 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 Stage One Summary Report - Published in August 2021, it 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.

PCLI Evaluation: Stage One Implementation and Outcomes Report - Published in December 2021, it 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.

Pathways to Community Living I Evaluation Report 6: Organisational case studies of practice change - Published in March 2022, it 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 - Published in April 2022, it 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 consumers and their families

If you are a patient, carer or family member, visit the web page of PCLI for consumers and their families for more information. You will also be able to watch and listen to consumers and their families sharing their stories on the PCLI process and the benefits the program has made to their lives.

Related links

Resources for health professionals and service providers

If you are a health professional or service provider for the initiative, please visit the Pathways to Community Living Initiative (PLCI) web page for health professionals and service providers. The section includes a full list of resources and reports.

More information can also be found on:

For any questions, you can contact Robyn Murray, Manager, PCLI, NSW Ministry of Health, by emailing Robyn.Murray3@health.nsw.gov.au


Current as at: Friday 5 August 2022
Contact page owner: Mental Health Branch