Policy Project Archive

Service Coordination Strategy

This work relates to progressing recommendations 3 & 5 of MHCC's 2010 Sector Mapping Project around continuity of care and pathways and linkages between services and implementation of the new Partners in Recovery (PIR) initiative.

Recent work undertaken by MHCC that is relevant to the Service Coordination Strategy includes:

Service Coordination Workforce Competencies: An investigation into service user and provider perspectives (October 2012)

During 2011/12, MHCC has undertaken considerable research to better understand the nature of care/service coordination. This has most recently included consultations with consumers, carers and service providers to close an identified literature gap regarding service coordination as a recovery oriented practice skill set. Most discussions about PIR to date have focused on care coordination at the service/systems level. This new knowledge about individual worker and Support Facilitator service coordination skills, and the nine recommendations to improve sector and workforce development directions to achieve them, is now being made available to you towards informing discussions about Partners in Recovery (PIR) implementation and planning. 

Service Coordination: True Partners in Recovery or Just More Medical Model Approaches

MHCC made a presentation at the 2012 TheMHS Conference presenting on activities undertaken to progress the Service Coordination Strategy and presenting the initial findings from the recent consultations with people affected by mental distress and service providers to better understand the worker competencies required for effective coordinated care. 

MHCC Consumer, Carer and Service Provider Consultations - 'Work Competencies: Providing continuity of care and supporting self-directed care - An Education and Training Skills Needs Analysis' (June-July 2012)

MHCC will use report describing these consultation findings, and related recommendations, in our continuing advocacy regarding the rollout of the Partners in Recovery and National Disability Insurance Scheme initiatives. Previous activites related to these important initiatives include:

The consultations are another step in progressing the Service Coordination Strategy, and responding to the priority areas for action identified by service providers at MHCC's 2011. The consultations investigated consumer, carer and service provider perspectives on the workforce competencies required to deliver effective continuity of care and support self-directed care. The background paper was developed to stimulate ideas as a starting point for discussion. The final report - including recommendations to better embed service coordination competencies in education/training programs and for next steps in the Service Coordination Strategy - will be available in October.

"MHCC Care Coordination Literature Review and Discussion Paper: Mental health service coordination and the community managed mental health sector in the context of national health and hospital reform (July 2011)"

MHCC - in partnership with Dr Leanne Craze - conducted an international research and practice literature review on the concept of best practice in service/care coordination. The literature review findings resulted in a proposed model for thinking about and evaluating service coordination activity. MHCC consulted with MHCC members and other interested people regarding the content of the Discussion Paper and subsequent directions for theService Coordination Strategy at six Regional Forums during August 2011.

The Regional Forums provided rich information on service provider perspectives of service coordination. Actions required to progress a Service Coordination Strategy were identified including the need to: 

  • Consult with consumers and carers about their views on good care coordination practice and service delivery
  • Conduct a training needs analysis to identify the knowledge, skills and attitudes required to deliver continuity of care (including workers from CMO, public, primary health/private and AOD services)
  • Determine what units already exist in the Health and Community Service Training Package related to care coordination.

MHCC Scoping Report - NSW GP Divisions (April 2011)

"Scoping Report of NSW Divisions of General Practice: Their activities and networks with Community Managed Organisations"

MHCC undertook this scoping activity in recognition of new primary mental health care structures and services that are to be developed through sector development related to National Health and Hospital Reform (i.e., the proposed role of Medicare Locals). The report highlights mental health programs and partnerships underway in NSW GP Divisions and makes recommendations for strengthening partnerships and service coordination between GP Divisions/Medicare Locals and the community sector. This work has also been made available to Local Health District (former Area Health Service) mental health services for comments toward achieving improved service coordination.

MHCC Discussion Paper - Team Care Model (October 2010)

Review of Hunter New England Mental Health (HNEMH) "Team Care Model" - Clinical and NGO Non-Clinical Roles: A guide to working together to more efficiently and effectively coordinate care for consumers"

MHCC has asked international mental health consumer consultant, Mary O'Hagan, to independently review this role delineation/service coordination document from community sector, consumer, human rights and recovery perspectives. This task was prompted by sector concern about this document being adopted at a state-wide level in the absence of broad sector consultation (see "Briefing Paper for February 2009 MHCC Board Meeting: Role delineation between government and non-government service providers"). The review was provided to HNEMH and is being considered for the next version of the Team Care Model document which is undergoing evaluation.

Project Background

This work relates to progressing recommendations 3 & 5 of MHCC's 2010  Sector Mapping Project:



The mental health sector in Australia consists of a complex and increasingly fragmented mix of public/government, private for-profit and not-for-profit non-government community-managed organization (NGO/CMO) service providers with multiple layers of commonwealth and state/territory government policy, planning, and funding levers. This mental health service delivery environment requires that close attention be paid to the knowledge and skills needed to achieve effective and integrated service coordination. This concern is also reflected in Action 18 of the Fourth National Mental Health Plan to:

Improve communication and the flow of information between primary care and specialist providers, and between clinical and community support services, through the development of new systems and processes that promote continuity of care and the development of cooperative service models.

The evidence for service linkages in primary mental health care was recently reviewed and clinical, service and economic efficiencies demonstrated for working with people with depression ("Effectiveness of service linkages in primary mental health care: a narrative review part 1", Fuller et. al., 2011). The need for health services to have strengthened collaborative partnerships with the community sector is noted (e.g., housing, employment etc.) as is the need for more research about collaborative approaches when working with people with psychosis.

The Service Coordination Strategy will consult with MHCC members, people affected by mental illness, communities and other stakeholders to develop best practice guidelines for achieving service coordination that facilitates recovery. MHCC promotes service coordination approaches that support consumer self-directed care (see Care Planning Processes: From Managed Care to Self Directed Care", Helen Glover 2006).


For more information about the 
Service Coordination Strategy please contact Tina Smith, Senior Policy Officer, or Ph 9555 8388 Ext 111


Consumer Participation Position Statement

As part of its NGO workforce development strategy, MHCC worked with NSW CAG regarding the development of a joint position statement on remuneration and support for consumer representatives in NGOs. Consultations were undertaken to develop the position statement including funding bodies to ensure their buy in / ownership to the process. Work in this area also tied in with work being undertaken for the development of an accredited course for Consumer Advocacy (possibly a partnership between MHCC, IOP, and consumer groups).


Forensic Consumer Representative Model Development Reference Group

MHCC has long highlighted the need for consumer participation, representation and advocacy on behalf of forensic patients. 

Forensic patients have access to official visitors 'at their request,' but this is limited due to time constraints. 

Numerous meetings took place during 2006 - 2007 between MHCC and the Deputy Director General of NSW Health, Justice Health senior executives and the NSW Director of Forensic Mental Health, and the NSW Chief Psychiatrist to discuss how to proceed with this concept. Justice Health proposed that MHCC establish a reference group in order to make recommendations for the development of a model / policy for the establishment of forensic consumer advocacy roles in the new forensic hospital under construction on the Long Bay site. The reference group met bi-monthly for the entire year. MHCC consulted experts in the sector and researched models in Australia and Internationally. The submission was completed by June 2007, to be presented to Justice Health and the Executive in August 2007.


Social Inclusion Platform

The MHCC paper, Social Inclusion: its importance to mental health, was discussed in more detail earlier in this report, but is mentioned here as an example of MHCC's research work, as it draws extensively on the strong research supporting the link between social inclusion and mental health.

This paper has been prepared with the aim of articulating the work of the mental health NGO sector under the banner of NGOs' work to support social inclusion, and the benefits this work provides for improved mental health. The paper was disseminated at the NGO conference in March to enable broad consultation and comment. The final version has just been released, incorporating stakeholders' comments. 

The document contains a list of recommendations that draw from the large body of evidence supporting the positive links between social inclusion and good mental health.

We have also prepared an action plan, aligned with the strategic plan, which includes activities to inform and educate members about social inclusion and how to bring it into their work, bring good practice social inclusion principles into submissions and position papers, and promote positive stories of consumer recovery to the community.

Experiences of Welfare to Work Legislation

The Federal Government's Welfare to Work legislation came into effect on 1 July 2006. Since this legislation was first proposed by the Government, disability advocates were concerned about its potential adverse effects on people with disabilities. Within the first few months of its implementation, it appeared that many of the concerns were indeed eventuating. There are clear links between meaningful employment and mental health, and evidence has shown that for many people with a mental illness, meaningful and fulfilling work can aid recovery and help reconnect people with society.

Whilst the purported aim of the Welfare to Work legislation is to promote employment, including for those with disabilities, it does little to actually enable the placement of people into meaningful roles, and instead takes a big stick approach to ensuring compliance with requirements. The project comprised a series of facilitated focus groups/consultations with: a) consumers, b) carers, and c) mental health and disability employment staff, to find out their experience of the employment and welfare environment during the first 12 months of the legislation, as well as recommendations for MHCC action in the area.