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-establishing their lives in the community.​

Last updated: 30 July 2019

Pathways to Community Living Initiative - Fact SheetAssisting 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 will be 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, needs and wishes and will be supported with tailored housing, clinical care and psychosocial support. This work will be undertaken over the next five to eight 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.

The World Health Organization has noted that community care achieves better outcomes than institutional treatment, and mental health systems nationally and internationally are increasingly focusing on using community-based care.

Adjusting to community-based care

Mental health clinicians will work with people to determine how they may be safely transitioned into care in a community setting (or appropriate inpatient setting) based on their strengths, needs and wishes. The international experience and the experience from other jurisdictions is that people who have been in long-term inpatient care can be supported to make the decision to transition to community-based care.

Working with families and carers

Many people in long-term care have remained in contact to some extent with their families but many more have lost contact with loved ones. Part of the preparations for transition will be to identify where there are family members or carers who would wish to become reengaged with the person – these relationships can have a crucial and positive impact on successful transition to community based living.

Where possible, specific effort will be directed to facilitating reconciliation with families and families will be involved in supporting decision-making for the person. Families will receive support in this process.​​​​

Page Updated: Tuesday 30 July 2019
Contact page owner: Mental Health Branch