The Pathways to Community Living Initiative is a coordinated state-wide approach to supporting people with enduring and serious mental illness who have been in hospital for more than twelve months to, wherever possible, re-establish their lives in the community.​

Last updated: 16 February 2021

Assisting long-term patients to live in the community

The Initiative was established as part of the Government’s commitment to strengthen mental health care in NSW by developing effective community-based residential care and support options for people experiencing long stays in mental health inpatient units.

Existing models of care are being reviewed to provide improved support in the community and prevent unnecessarily long inpatient admissions.

Everyone has the right to live in a community setting. Evidence shows that people with enduring and severe mental illness can experience better quality of life and improved social and health outcomes by living in the community.

Mental health care in hospital will always be available for people who require hospital level clinical and disability support.

Each person will participate in a supportive and comprehensive assessment to help determine their appropriate level of care. They will be supported to move into a community setting only when it is right for them. Over the coming years, staff will be working with each and every person, their families and carers (as appropriate) to create a plan based on their individual strengths, needs and wishes, as well as those of their families.

Transition to community living will be guided by each person’s particular strengths and needs and will be supported with tailored housing, clinical care and psychosocial support. This work will be undertaken over the next three to five years.

New community residential and other service options will be designed for people currently receiving long-term hospital care in non-acute and acute units in NSW.

Pathways to Community Living Initiative

The Pathways to Community Living Initiative will assist long​-term patients to live in the community. Work to date has focused on understanding the complex needs of people experiencing long stays in hospital, investigating best practice care pathways, and identifying new models of care to help meet their needs.

Implementation will occur in four phases:

  1. Agree care needs and required model of care
  2. Develop individual plans for each person based on comprehensive assessments
  3. Establish services in the community
  4. Support agreed transition to community living

New evidence-based service models are being developed to ensure people with enduring mental illness have access to care and services that meet their needs.

Further work, in line with the four phases of the Initiative will involve:

  • communication about the Initiative to people who are long-term patients, to families and carers and to staff and the community
  • detailed discussions with individuals who are currently experiencing a long stay in hospital, their families and carers. Every person will participate in an assessment to determine their individual requirements to transition from hospital to community, where possible
  • development of individual plans with people at each hospital site
  • commission of an evaluation of the Initiative through a tender process
  • commission of the first stage of service tenders focussing on older people with ageing issues
  • development of models of care and roll out of tenders for community-based residential care and support services focused on people aged 18 years and over without age-related issues
Current as at: Tuesday 16 February 2021
Contact page owner: Mental Health