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, or are at risk of a long-stay 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 mental health significant ageing-related issues.
  • Cohort 2: people aged 18 years upwards, who are long-stay inpatients, 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/ 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 with them 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 ageing-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 to transition with assistance from PCLI clinicians to these services.

Where is PCLI now?

At June 2020, five years into this initiative, the initial evaluation findings by the Australian Health Services Research Institute from the University of Wollongong are that this is a major reform program that is transforming people's lives and 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.

Transitions to the community of the initial long-stay cohort July 2015 are on target. During 2019 there was a substantial increase in the transitions of the original cohort of patients with age-related issues, with now over 68 per cent successfully transitioning 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 with specialist support funded by the NSW Government. Funding has enabled the development of 85 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.

For both cohorts additional new complex care PCLI clinicians and peer workers are funded across most LHDs with a specific PCLI position in a rural LHD to assist staff from all rural and remote LHDs to work with people who are long-stay patients. These new staff form a complex care PCLI community of practice across the state.
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.
PCLI consumers and their families have shared their stories on the PCLI process and the benefits the PCLI program has made to their lives More information for consumers, carers and families.
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.

The importance of embedding change through leadership at many levels is a key element of the PCLI. In a presentation to the 2017 NSW Health Symposium, 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. Embedding change
Current as at: Wednesday 11 November 2020
Contact page owner: Mental Health Branch