2. What I am going to talk about National overview of the program How SWS PIR is organised What SWS PIR has achieved to date What is the role of carers in PIR

3. Aims Partners in Recovery (PIR) is a national initiative to improve mental health systems and coordination for:  people experiencing severe and persistent mental illness  with complex needs  requiring a multi-agency response

4. Research underpinning PIR  600,000 Australian experience severe mental illness  60,000 with enduring and disabling symptoms with complex, multi-agency support needs  PIR targets 40% nationally (24,000 people) * ‘Operational Guidelines for PIR Organisations’, Department of Health, May 2013

5. Research underpinning PIR  “... growing evidence that suggests that collaborative and coordinated care delivers the best mental health services” *  Need more research about how care coordination actually works  Recommended a model that will “provide person- directed and centred, systematic, responsive and supportive services that promote recovery.” * ‘Care Coordination Literature Review and Discussion Paper’, MHCC, July 2011

6. Objectives PIR will work to:  coordinate local health, clinical, community and social services, to deliver “wrap around” care;  build partnerships between local services, communities, families, and carers;  improve referral pathways and information networks;  promote community based recovery from mental illness.

7. Eligibility Criteria  Consumer has a diagnosed or undiagnosed mental illness that is severe in degree and persistent in duration  Multiple agencies needed  Pressing concern about their mental health  Existing service coordination lacking  Consumer consent  Age – mid twenties and older

8. Where does SWS PIR operate? Nationally  61 PIR Organisations  Assisting 24,000 people Wingecarribee Wollondilly Campbelltown Camden Liverpool Fairfield Bankstown SWS PIR covers 7 LGAs  Same boundaries as local health district  SWS is 4 th largest region

9. 2 STREAMS We are trying to ensure that: People with severe and persistent mental illness with multiple and complex needs Service System OutcomesClient Outcomes coordinated and integrated service system that meets their recovery needs have access to

10. How will PIR Operate in 2 Streams?  Access 939 clients over 3 years  Partner agencies will employ 30 Support Facilitators and 6 Support Facilitator Team Leaders covering SWS  Access to Flexible Funding  SWS Medicare Local will employ 3 system reform staff working across region  Support facilitators will work toward system reform locally System ReformConsumer Care Coord.

11. Governance  Governance Committee chaired by former Police Commissioner Ken Moroney  Consumer and carer representation  State Government agency representation  Partnership and service agency representation

12. WOLLONDILLY – to be appointed WINGECARRIBEE – to be appointed FAIRFIELD – to be appointed CAMPBELLTOWN/CAMDEN – Macarthur Disability Serv BANKSTOWN – Richmond PRA, Care Connect LIVERPOOL – Aftercare, ROAM, Gandangara Who are Partners in Recovery in SWS? Medicare Local Partner Agency SWS PIR Governance Committee Manager Admin Officer Intake Officer Development Officer OFFICE TEAM 3 System Reform Officers OFFICE TEAMSUPPORT FACILITATION CONTRACTED AGENCIES CONSORTIUM AGENCIES  Aftercare  Anglicare  Benevolent Society  Care Connect  Catholic Care  Community Links  Gandagarra HS  Illawarra Dis. Trust  Lifeline  MDS  MDSI  MAX Employment  Mission Australia  Neami  New Horizons  Odyssey House  Richmond PRA  ROAM Communities  Wise Employment  and others We also consider PIR to be in partnership with consumers, carers, families, private and public health services, police, justice system, and many other services, programs, etc. Schizophrenia Fellowship Lead agency

13. Regional Service Mapping and Gap Analysis  First step in developing an understanding of the complex and multiple health and support needs of people with mental illness.  Identified barriers faced in accessing a range of clinical and non-clinical services. Consultations with range of stakeholders: Consumers Carers Local Health District clinicians & staff General Practitioners Non-Government Organisations Government Organisations

14. Analysis Findings  2-3% of population experience severe mental illness  Co-morbid substance abuse in 48% clients  Higher rates of smoking and metabolic syndrome  Lower life expectancy  Severe mental health disorders in homeless populations is high

15. Referrals to Date Total of 182 since January 2014 Self referral 36 Family/friend9 GP9 Other medical practitioner4 Hospital 16 Public sector clinical MH service17 Non government MH service10 Alcohol/drug treatment5 Other community/health26 Corrections/justice/court5 Disability support7 Housing/homelessness20 Other18

16. Gender

17. Age

18. Residency

19. Carer Involvement in PIR A fundamental principle of PIR Commonwealth DoH policy states: “....there is a need to optimise genuine carer involvement in the support of people with mental illness. This includes participation in service planning and delivery.”

20. Key principles Families and carers should be recognised, respected and supported as partners in the support of clients Should be engaged as early as possible through clear and open communication and sharing of information Right to information about MH Act, privacy/confidentiality/consent issues Cultural and language issues should be taken into account

21. Carer Involvement in SWS PIR Governance Committee representation Consumer and Carer Committee Involvement in the consumer/client PIR journey: Assessment Action Planning Review of progress Meeting the needs of families and carers

22. PIR Organisations across NSW Central Coast NSW (02) 4365 2294 Eastern Sydney1800 035 626 Hunter1300 656 608 Illawarra – Shoalhaven(02) 4220 7688 Inner West Sydney1800 501 858 Murrumbidgee(02) 6923 3193 Nepean - Blue Mountains(02) 4721 1150 New England (02) 9393 9000 North Coast NSW (02) 6658 5437 Northern Sydney(02) 9477 8700 South Eastern Sydney(02) 9330 9900 Southern NSW (02) 4475 0800 Sydney North Shore and Beaches1300 000 747 Western NSW(02) 6884 0197 Western Sydney(02) 8811 7100

23. Referral & Intake for SWS PIR 1300 747 797 1300 PIR SWS GENERAL ENQUIRIES Campbelltown Office Team 1300 179 765 INTAKE NUMBER