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