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.
Delivering quality healthcare in the community is essential to a person’s wellbeing. Healthcare in the community is central to the health system now
and into the future.
Evidence shows that people with severe and persistent mental illness experience better quality of life and improved social outcomes if they have the right levels of support to live in the community.
In 2015 the NSW Government established the Pathways to Community Living Initiative (PCLI) to support people who had long–stays (over a year) in mental health inpatient units in NSW to be supported to live in the community.
In 2021 over 60% of the initial group of these people, many of whom had been in hospital for years are living successfully in the community.
The PCLI is also now working with treating teams to ensure newer groups of people with complex illness can move through hospital more rapidly to appropriate accommodation with clinical support services in their local areas.
A strong acute mental health service is important and inpatient care in NSW will continue to address community needs.
Mental health care in hospital is available for people who require high levels of clinical treatment and support where community-based care does not meet their needs. People with severe and persistent mental illness may still also require periods of rehabilitation in non-acute hospital units, returning to their community supports when ready.
Each person will move into a community setting at the right time.
Transition to community living will always depend on each persons’ particular needs and wishes as well as tailored housing, clinical care and available psychosocial support.
Person-centred assessment and planning and a range of community options are key to the PCLI.
Each person who has had a long hospital stay or who is at risk of a long-stay, takes part in assessments to understand their strengths, clinical issues and support needs and also their hopes and dreams. Staff then work with each person and their family to create a plan based on the person’s individual needs.
Transition takes place in stages to ensure that a variety of accommodation options are available to meet the person’s individual needs and preferences.
Services have been designed for now and for the future.
New community-based partnership services have been developed and further services are planned.
Detailed information on the PCLI and the findings from its evaluation is available on