Mental Health - Housing In Reach Service (MH-HIRS) Evaluation 2025

Summary

The Ministry of Health commissioned Health Consulting Collaborative to undertake an 18-month evaluation of the Mental Health-Housing In Reach Service (MH-HIRS) program. The evaluation ran from June 2022 to December 2023.

​The evaluation results indicate that the program is working to provide MH-HIRS participants with greater continuity of care and accommodation in the community, while enhancing cross-agency partnerships.

• The evaluation highlighted the viability of an integrated health and housing approach in improving participant outcomes. It demonstrated that participants at risk of being discharged to homelessness could be identified during a mental health inpatient admission and could be successfully supported to transition from hospital to stable accommodation.
• The program reaffirmed the need for strong collaboration and partnerships between government and non government organisations (NGOs) to support participants with complex needs. The focus group findings revealed effective LHD, DCJ, and NGO partnerships built a sense of enhanced collaboration and resource utilisation amongst staff to support participant outcomes.
• Qualitative insights from the evaluation suggest that consistent pre and post discharge case management support increased participant engagement with community mental health care and housing services. This is represented as a decrease in the rate of mental health unit separations and emergency department presentations by MH-HIRS participants, which contributes to the quality of life for participants and relieves pressure on hospital resources and spending.
• Qualitative feedback indicates that the program is well-received by participants and stakeholders, as demonstrated in case studies and focus groups used throughout the evaluation.
• Stakeholders reported that consistent communication through the program fosters participant comfort and community integration, while tailored support enhances housing prioritisation and recovery. This is reflected in increased participant involvement in collaborative discharge planning, continuity of mental health care in the community, and ongoing accommodation support.
• Nearly all the participants accessing the MH-HIRS program reported increased engagement with specialist homelessness services (SHS) and other referrals to support their needs. The program also identified and supported consumers who existed outside of the service system to access SHS services which they otherwise may have not known about during their hospital admission.​​

​About MH-HIRS

The Mental Health-Housing In Reach Service pilot program is a joint initiative between NSW Health and Homes NSW/Department of Communities and Justice (DCJ).

MH-HIRS provides targeted support to individuals who are at risk of homelessness on discharge from mental health inpatient services through pre and post discharge case management support. The program aims to prevent homelessness by establishing and maintaining continuity of care in the community using a holistic and person-centred approach to identifying pathways to stable accommodation.

The program operates in 3 local health districts (LHD): Sydney and South Eastern Sydney (delivered by Wesley Mission) and Central Coast (delivered by Uniting NSW.ACT).

MH-HIRS promotes cross-agency collaboration and strategically aligns with key NSW Government policy frameworks, including the Housing and Mental Health Agreement 2022 (HMHA 22) and No Exits from Government Services into Homelessness: A framework for multi-agency action.