This fact sheet is intended to guide ACATs and mental health service providers to understand their roles and responsibilities in assisting the transition of people who have had a long stay in mental health facilities to the community.

Last updated: 01 December 2021

What you need to know about the ACAT assessment process

The Pathways to Community Living Initiative (PCLI) is a key component of the NSW Government’s Mental Health Reform 2014 – 2024. People currently experiencing long hospital stays (over 365 days) or at risk of long hospital stays in non-acute and acute mental health units in NSW are being offered comprehensive assessment to determine their long-term care and support needs for community living.

Older adults and some younger people (under 65 years with ageing-related issues) form part of this group of long-stay consumers. The older group are likely to have complex needs due to ageing, disability and / or mental illness.

The younger group may be ageing prematurely: physically and/or cognitively, due to their mental illness, treatment and/or hospitalisation for long periods of time. ‘Ageing-related issues’ in this younger group can include (but are not limited to) the presence of frailty, multiple complex problems, complex disease, reduced mobility, continence problems, and / or progressive cognitive impairment).

For some of these people, ACAT assessments will be required to determine eligibility for Commonwealth subsidised aged care services. Currently most of the people receiving long-term care are located in six major mental health hospital sites in NSW: Cumberland, Macquarie, Morisset, Orange, Liverpool and Concord. The remainder are situated in about 15 other mental health inpatient facilities across NSW.

An important component of PCLI has been the development of residential aged care facility-based accommodation models. These facilities specialise in care for older people (and younger people with ageing- related issues) who have severe and persistent mental illness, including severe behavioural disturbance related to dementia and/or mental illness. Such people often have prolonged stays in mental health inpatient facilities due to lack of appropriate accommodation and community care options.

Following competitive tender processes by NSW Health, a number of specialist residential aged care facility-based services for these people have been established. Specialist clinical services have also been expanded to provide enhanced in-reach specialist mental health care to people living within these specialist mental healthresidential aged care partnership services.

Under the PCLI, staff from mental health inpatient facilities in NSW – can directly refer people to Aged Care Assessment Teams (ACATs) for assessment to determine their eligibility for accommodation in a Commonwealth-subsidised residential aged care facility (RACF). This will bypass the national My Aged Care contact centre.

Referrals will be made when the mental health team considers the condition of the person as stable and there is time for a well-planned and individualised transition process. Care planning and transition to community living will depend on the particular needs of each person and may include identifying suitable residential
accommodation, clinical care and psychosocial support.

For people under 65 years, NDIS is the primary pathway to access community support. However, where they have high-level care needs and accommodation in a RACF is the only available option, a parallel referral to both NDIS and ACAT should occur*. For further information see Younger people in residential aged care on the NDIS website.

Under PCLI, mental health staff work with each person and their carers and family to create a plan based on individual needs. The LHD mental health service will manage the assessment process and seek support from the Mental Health Branch, Ministry of Health where required.

Mental health services are committed to transitioning people into the community only when these are the most appropriate environments and the time is right for each person. Results of the mental health and physical health assessment will inform the ACAT eligibility assessment.

The information in this fact sheet draws on the My Aged Care Assessment Manual June 2018; Aged Care Supplementary Guidelines for Younger People January 2020 and specific information relating to people who come under the NSW Health My Choice: Pathways to Community Living Initiative.

*Information correct at time of writing. The July 2017 Fact Sheet has been updated and will be updated as further advice is provided from national and statewide legislation, policies and practices.


ACAT assessors:

  • are familiar with PCLI processes
  • understand that a person who is under the Mental Health Act is eligible for an ACAT assessment
  • accept and note the advice of a mental health medical professional that the person is medically stable
  • accept the referral of a person under 65 years of age on:
    1. written confirmation from the mental health team that alternative accommodation has
      been considered and none found which are more appropriate to meet the person’s needs
      AND evidence of a prior or parallel referral to NDIS if eligible for NDIS
    2. Receipt of completed ACAT younger people check form and evidence that all other more
      age-appropriate options have been exhausted
    3. Complete NDIA urgent circumstances form sent by secure file transfer
    4. ACAT will not be able to proceed if NDIA claim responsibility but can reapply if NDIS Complex Support Needs (CSN) Pathway cannot resolve.

Mental Health service providers: Detailed evidence and supporting information can assist the ACAT process

  • will refer long-stay consumers directly to ACAT (not through My Aged Care and indicate at referral that the person comes under PCLI
  • will confirm at referral that the person is medically stable, i.e. a medical professional has determined that their acute condition has stabilised and their ongoing
    care in the community can be managed by a general practitioner and/or a psychiatrist and/or a PCLI clinician or community mental health team as appropriate
  • will provide the name of a mental health professional as the contact for the ACAT assessor
  • will assess the capacity of the person to provide informed consent for the ACAT assessment and will make arrangements for a legal representative/ substitute decision maker to consent if necessary
  • if the person is under 65 years, provide written evidence that there are no other care facilities or services more appropriate to meet the persons’ needs, as well as evidence of a referral to NDIS. Completion of ACAT younger people check list to ensure relevant documentation is provided (this checklist will be completed by local ACAT).

The Assessment: Initial consumer assessment and needs identification

ACAT assessors:

  • understand that the ACAT assessment is part of a larger assessment and planning process
  • obtain informed consent from the person or their legal representative/ substitute decision maker
    prior to undertaking an assessment
  • undertake an ACAT comprehensive assessment to determine eligibility for entry to a
    Commonwealth- subsidised RACF (or for a home care package, if the person is 65 years
    or older)
  • in addition, provide aged health expertise to inform the transition & planning process, where possible
  • with the person’s consent, conduct their assessment in collaboration with a nominated
    mental health professional.

Mental Health service providers: Detailed evidence and supporting information can assist the ACAT process

  • will be present at the ACAT assessment, if appropriate, as a “representative” of the person. See: How to become a representative for someone in My Aged Care
  • will inform the ACAT assessor of current comprehensive assessment plans and outcomes
  • understand that the ACAT assessor operates under the Aged Care Act 1997 and relevant guidelines for the purposes of assessing and approving a person’s eligibility for Commonwealth-subsidised aged care services
  • contribute to gaining an accurate and complete assessment of the person’s age-related needs.

Development of a care plan

ACAT assessors:

  • will be aware of the development of specialist residential aged care facilities and expansion of clinical services under PCLI for people who otherwise cannot be appropriately accommodated in a generalist RACF
  • involve the person, their carer and family as appropriate, and/or their appointed guardian in the care planning process.

Mental Health service providers: Detailed evidence and supporting information can assist the ACAT process

  • will provide ACAT assessors with information about the availability of new specialist residential care age facilities, under PCLI expanded models of residential
    aged care
  • will involve the ACAT assessor in PCLI case conferences as appropriate
  • can access information from My Aged Care to support care planning if formally registered as a “representative”.

Care Coordination to the point of effective referral

ACAT assessors:

  • understand that under PCLI, care coordination is subject to a multidisciplinary case review process involving key people from the mental health inpatient team, the community mental health team, and the residential aged care facility (clinical advisory committee)
  • will take guidance from the case review process on their need to be involved in the care coordination to the point of effective referral
  • understand that the mental health team will continue to provide specialist mental health care to consumers under PCLI who are residing in a RACF, as necessary.

Mental Health service providers: Detailed evidence and supporting information can assist the ACAT process:

  • will involve ACATs in care coordination to the point of effective referral when appropriate and required
  • will take responsibility for care coordination in the RACF where required and refer again to the ACAT should a change in consumer circumstances, such as changed health or functional status warrant re-assessment.
Current as at: Wednesday 1 December 2021
Contact page owner: Mental Health