This fact sheet is intended to guide ACATs and mental health service providers to understand their roles and responsibilities in assisting the transitions of long term customers in NSW public hospitals to community living.

Last updated: 16 February 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 receiving long-term (i.e. over 365 days) hospital care in non-acute and acute 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 inpatients. 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 in NSW.

Under the PCLI, staff from mental health inpatient facilities in NSW will 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 to be 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*. Further information can be obtained from NDIS

Under the PCLI, people experiencing long-stays in hospital will be offered a comprehensive psychosocial assessment. Mental health staff will work with each person and their carers and family to create a plan based on their individual needs. The LHD mental health service, informed by an Expert Reference Group, and supported by the Mental Health Branch of the Ministry (as required) will manage the assessment process. Mental health services are committed to moving people into community settings only when these are the most appropriate settings and the time is right for each person. Results of the mental health assessment will inform the ACAT eligibility assessment.

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 a competitive tender process by NSW Health, a number of new, specialist residential aged care facility-based services for these people are now being established. Specialist clinical services have also been expanded to provide enhanced in-reach to consumers of mental health services who live in residential aged care facilities.

The information in this fact sheet draws on the Australian Government Aged Care Assessment Program Guidelines, May 2015 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, as per verbal advice from Commonwealth Department of Health. The Fact Sheet has been updated from the first version in September 2015. It will be updated as further advice is provided, and in line with changing national and state wide legislation, policies and practices.


ACAT assessors:

  • are familiar with the Pathways to Community Living Initiative
  • 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
    • written confirmation from the mental health team that alternative accommodation facilities have been considered and none found which are more appropriate to meet the person’s needs AND
    • there is evidence of a prior or parallel referral to NDIS.

Mental health service providers:

  •  will refer long-stay consumers directly to ACAT (not through My Aged Care) and indicate at referral that the person comes under the 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 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, will provide written confirmation that there are no other care facilities or services more appropriate to meet the person’s needs, as well as evidence of a referral to NDIS. 

The assessment: Initial client 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 and planning process, where possible
  • with the person’s consent, conduct their assessment in collaboration with a nominated mental health professional.

Mental health service providers:

  • will be present at the ACAT assessment, if appropriate, as a “representative” of the person
  • will inform the ACAT assessor of current comprehensive assessment plans and outcomes
  • understand that the ACAT assessor operates under the Aged Care Act 1997 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:

  • 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 Pathways to Community Living 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 multidisciplinary case review process involving key people from mental health inpatient team, the community mental health team and the receiving facility
  • 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 care coordination of clients under PCLI who are residing in a RACF, as necessary.

 Mental health service providers:

  • 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: Tuesday 16 February 2021
Contact page owner: Mental Health Branch