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About the Pathways to Community Living Initiative (PCLI)

The Pathways to Community Living Initiative (PCLI) helps people with severe and persistent mental illness (SPMI) transition back to community living. 

PCLI adopts a recovery-oriented approach that places the quality of life and unique needs and wishes of the consumer at the forefront with the individual, their family or carer. 

By developing effective community-based residential care and support options for people experiencing long stays (more than 365 days) in mental health inpatient units, evidence shows there is better quality of life and improved social and health outcomes by living in the community. 

The initiative is a statewide approach established in mid-2015. It is led and funded by the NSW Ministry of Health in cooperation with Local Health Districts (LHDs) and involves many organisations and care providers.

What is my role in the PCLI?

Your role as a health professional is to help long-term patients go back to living in the community. 

There are a range of published resources and guides available for clinicians and teams to: 

  • assist with the discussion you will have with the patient 
  • conduct their assessments 
  • and develop a plan for the transition to ensure a smooth and seamless process.

Working with families and carers

Families are not expected to be the primary caregivers for their loved ones who are moving back into the community. But you will need to work with families and carers to discuss and support their loved one’s decisions. 

Be aware that some people may no longer be in contact with their families. Reconciliation with families will be investigated.

How will PCLI affect employees in mental health facilities?

Staff will be consulted and kept informed as the initiative is implemented. 

New models of integrated care will be implemented and continue to expand, delivered by a combination of public mental health services, public health services, community managed organisations and the private sector. 

As community models of care are enhanced there may be some changes to staff requirements. Affected staff and unions will be consulted prior to any changes being made. 

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

Evidence checks

The NSW Ministry of Health commissioned the Sax Institute to conduct two evidence checks on models of care for people with severe and persistent mental illness:

  1. Matheson SL, Carr VJ. Transitioning long-stay psychiatric inpatients to the community: an Evidence Check rapid review brokered by the Sax Institute for the NSW Ministry of Health, 2014. Transitioning long-stay psychiatric inpatients to the community
  2. Kakuma R, Hamilton B, Brophy L, Minas H, Harvey C. Models of Care for people with severe and enduring mental illness: an Evidence Check rapid rev iew brokered by the Sax Institute for the NSW Ministry of Health, 2017. Models of care for people with severe and enduring mental illness

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Evaluation reports

Communities of practice

For both Stage One and Stage Two cohorts the addition of PCLI clinicians and peer workers have been funded across most LHDs, including the St Vincent's Hospital Network. There is also a PCLI position located in a rural LHD to help coordinate staff from rural and regional LHDs.

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.

Resources

There are fact sheets, FAQs, guides, reports, symposiums and videos available. 

For further information and other resources please contact PCLI Manager Robyn Murray at the NSW Ministry of Health, by emailing: Robyn.Murray3@health.nsw.gov.au

Some non-published resources are also available for the LHD clinicians and senior staff through the Mental Health Branch, NSW Ministry of Health, email: moh-mentalhealthbranch@health.nsw.gov.au

Factsheets and FAQs

Guides

Symposiums

The goal of rehabilitation psychiatry is to help individuals develop the emotional, social and intellectual skills needed to live, learn and work in the community.

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has established a special interest group in this speciality area.

RANZCP NSW Branch and the NSW Ministry of Health (MoH), through Pathways to Community Living Initiative (PCLI), have been working together to support the development of Rehabilitation Psychiatry, focused on the care and treatment of people with severe and persistent mental illness (SPMI) and complex care needs. The NSW Sub Committee of the Binational Section of Social, Cultural and Rehabilitation Psychiatry has been formed, chaired by Dr Nick Burns.

PCLI supports and assists the facilitation of this work as a key strategy to strengthen medical leadership in Rehabilitation Psychiatry.

March 2022

The third NSW Rehabilitation Psychiatry Network Forum was held 29 March 2022 partly face-to-face and partly online. It was chaired by Dr Nick Burns with keynote presentations from Associate Professor Stephen Parker and Professor Carol Harvey.
 
Associate Professor Stephen Parker Griffith University, School of Medicine, University of Queensland, School of Medicine presented on Evaluation of a community residential program in Brisbane - Bridging the research paradigm into clinical practice.
 
Professor Carol Harvey, Department of Psychiatry, University of Melbourne and NorthWestern Mental Health gave two presentations:

November 2020

The second NSW Rehabilitation Psychiatry Network Forum chaired by Dr Nick Burns, was held 24 November 2020 as a fully virtual event.

The purpose of the day was to bring together psychiatrists working in rehabilitation services across the state so they could get to know each other, exchange ideas and build a culture of shared learning. The aim being to form a cohesive network with a strong unified voice.

The Report of the Forum includes all slides presented during the NSW Rehabilitation Psychiatry Network Forum, as well as a sample of responses received in the online polls, Zoom chat, and evaluation survey. You can click on the section of the report that you would like to access.

The program included a presentation by Professor Helen Killaspy, University College London, Implementing the NICE Guideline Recommendations on Rehabilitation for Adults with Complex Psychosis in the Australian Context.

NICE Guideline for Adults with Complex Psychosis

March 2020

The inaugural NSW Rehabilitation Psychiatry Forum – In Conversation with Professor Helen Killaspy, was held in Sydney.

The NSW MoH and the RANZCP brought together Rehabilitation Psychiatrists from across NSW and other psychiatry leaders for a medical dialogue on care for people with severe mental illness.

Professor Helen Killaspy, Professor and Honorary Consultant in Rehabilitation Psychiatry, University College London and Camden & Islington NHS Foundation Trust London was the keynote speaker.

The following video features Professor Killaspy, who presented on addressing the international marginalisation of people with complex mental illness.

 
The following video features Professor Carol Harvey, Professor, Department of Psychiatry, University of Melbourne and North Western Mental Health, Melbourne, who presented on Australian Perspectives on psychosocial rehabilitation – evidence and realities.

 
[1] Rossler, W, Psychiatric rehabilitation today: an overview, World Psychiatry v.5(3) 2006
 

2017 - Embedding Change: A Distributive Leadership Model – Pathways to Community Living Initiative

The importance of embedding change through leadership at many levels is a key element of the PCLI.  
In a breakout session at the 2017 NSW Health Symposium the following guests talked about how a distributive leadership model can empower consumers, families and health staff and bring about major system change:
 
  • Dr Karin Lines, former Executive Director, Mental Health Branch
  • Bec Davis, mental health consumer
  • Acting Professor Peter McGeorge, former Clinical Lead, PCLI
  • Deb Hoban, Senior Project Officer, PCLI

The following video presents the importance of hope for people with severe mental illness and how major system change can be brought about through distributing leadership at all levels and empowering consumers, families and health staff.

 

Pathways to Community Living - Moving Forward

 
Current as at: Friday 18 November 2022
Contact page owner: Mental Health Branch