The Pathways to Community Living Initiative (PCLI) is a coordinated state-wide approach to supporting people with severe and persistent mental illness, who have had a long stay in hospital for more than twelve months, to re-establish their lives in the community.

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

Why was PCLI established?

This 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 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 long-stay patients with severe and persistent mental illness  into the community, where possible, including developing new service models for appropriate care, and
  • Creating practice change in inpatient and community services to decrease the number and length of long stay admissions.

Who are PCLI consumers?

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

  • Cohort 1: older people who are inpatients with long admissions and who have age-related issues.
  • Cohort 2: people aged 18 years upwards, 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.

What are the objectives for these consumers?

The objective for people with age-related issues, is to complete a range of assessments that will help indicate their needs and issues. Then, working with the person’s choice and their family’s support, transition them from the inpatient setting to an appropriate specialist residential aged care facility and ensure follow-up from the PCLI Older Person’s Mental Health services.

The objective for those people without age-related issues, is to work with them on a range of comprehensive assessments to understand their needs, strengths and wishes. Then to consider available existing options in the community and where possible, support the person o transition with assistance from PCLI clinicians to these services. 

Page Updated: Tuesday 17 September 2019
Contact page owner: Mental Health Branch