PLAN Western Sydney Integrated
     Regional Mental Health and Suicide
     Prevention Plan
     The Western Sydney Integrated            3. Developing, integrating
     Regional Mental Health and Suicide       and utilising eHealth systems
     Prevention Plan (the Regional Plan)      to improve self-directed care,
     is an agreement about what has           connectivity and collaboration
     to change, by when, how, and who         between service providers.
     will be responsible for leading the
     change. The Regional Plan has a          4. Improving the access to and the
     three-year focus (2020-2022) to align    quality of perinatal, infant, and child
     with the planning cycles of state        mental health services.
     health organisations and that of
                                              5. Ensuring adolescents and young
     WentWest, Western Sydney Primary
                                              people are supported through
     Health Network (WSPHN).
                                              the school years and during the
     The Regional Plan will guide             transition to adulthood.
     collaborative governance, planning,
                                              6. Implementing suicide and
     commissioning and monitoring
                                              self-harm prevention and crisis
     by the Western Sydney LHD and
                                              interventions tailored to the needs
     WentWest (WSPHN) as the lead
                                              of the community.
                                              7. Attracting and retaining a
     The seven priority areas for
                                              committed and culturally competent
     action are:
                                              and accredited workforce.
     1. Strengthening collaborative
                                              These priorities are consistent with
     governance and information sharing
                                              the Fifth National Mental Health
     for planning, commissioning and
                                              and Suicide Prevention Plan, the
     evaluating services.
                                              reforms outlined in the NSW State
     2. Forging partnerships within and       Health Plan, with a focus on a value
     beyond the health and social care        based healthcare, the Living Well
     sectors that deliver better mental       Mental Health Plan, the Western
     health outcomes for the Western          Sydney LHD Services Plan, and the
     Sydney community across the life span.   WentWest (WSPHN) Strategic Plan.

    The Western Sydney region (WSPHN            residents or nearly 32,000 per year.
    and WSLHD) encompasses four Local
    Government Areas (LGAs) - Blacktown,        Over 17,000 people identify as
    The Hills Shire, Parramatta and             Indigenous with the largest numbers
    Cumberland - and is located in the          residing in the Blacktown LGA (3.4% of
    outer western suburbs of Sydney.            the total population).

    Covering an area of 790 km2, the            The region is one of the most culturally
    boundaries of the catchment extend          diverse in Australia with nearly 40
    from Auburn in the East to Blacktown        percent of the population born overseas
    in the West, and to the Hills in the        in a predominately non-English
    North, encompassing an urban, outer         speaking country. Nearly 7 percent of the
    urban and semi-rural population that        population report speaking languages
    is now over 1,000,000 people.               other than English, and many speak
                                                either little or no English. The highest
    The population is predicted to grow         proportion of residents (13 percent) with
    by 67 percent in the 20 years 2016-         low proficiency or use of English reside in
    2036 - or an additional 635,000             the LGA of Cumberland.

        DEMOGRAPHICS                                             AGE
                 (ERP 2016)                                    (ERP 2016)

     50.47%                   MALE                                                 0-4
     49.53%                   FEMALE                                               5-18
     478,750                  MALE                                                 19-64
     469,843                  FEMALE                                               65+

    * ERP refers to the 2016 ABS Census data.

This Regional Plan builds on the       and undertaken by the Centre for        national and data policy context, of
foundations provided by the Western    Mental Health Research at ANU           the existing and current planning
Sydney Health Partnership between      and the revised WSPHN Needs             documents, and actions identified by
WSPHN, WSLHD and Sydney                Assessment 2019-2022.                   governments relevant to the Western
Children’s Hospitals Network (SCHN),                                           Sydney region.
                                       The Steering Committee has
operating under the auspices of the
                                       examined a range of population and      This Regional Plan is the first time
Partnership Advisory Council with
                                       service data to identify existing and   that a formalised plan has been
a Memorandum of Understanding
                                       emerging needs and gaps in the          developed by this State-funded
and longstanding shared priorities,
                                       current spectrum of care. Through       Local Health District and the
including mental health. It has been
                                       consultations with consumers,           Commonwealth-funded Primary
developed more intensively over a 12
                                       carers, primary care providers,
month period commencing in early                                               Health Network. This is an important
                                       the community managed mental
2019 and involved stakeholders in                                              precedent in that it demonstrates
                                       health sector social care providers,
a range of consultative processes.                                             a commitment by both State and
                                       and state wide services and
The Plan has taken into account                                                Federal governments to empower
                                       academic partners, we have a better
the consultations undertaken by                                                regional governance and service
                                       understanding of what is working
NSW Mental Health Commission in                                                development. This Plan therefore does
                                       well, what needs improving, and what
the mid-term review of the Living                                              not displace existing plans approved
                                       needs to commence.
Well Plan in 2019, the re-analysis                                             by these two lead authorities but
of psychosocial care services          The Steering Committee has also         seeks to define the critical areas of
commissioned by WentWest (WSPHN)       undertaken extensive reviews of the     collaboration over the medium term.

                                       Figure 1: Inputs to the Western Sydney
                                       Integrated Regional Plan for Mental
                                       Health and Suicide Prevention

                                                National and State                   Population Needs and
                                                 Policy Guidance                         Services Data

                                                                     Western Sydney
                                                                     REGIONAL PLAN

                                           Stakeholder Consultations                   Best Practice and
                                          (interviews, forums, surveys)                    Innovation

     The development of this Regional Plan   • NSW Strategic Framework and
     has been informed and guided by:        Workforce Plan in Mental Health
     • The Fifth National Mental Health
     & Suicide Prevention Plan and           • Gaya Dhuwi (Proud Spirit)
     Implementation Plan                     Declaration Implementation Guide

     • The NSW Value Based                   • WentWest (WSPHN) Strategic Plan
     Healthcare Framework                    (2016-2019)

     • Living Well – A Strategic Plan for    • Western Sydney Local Health
     Mental Health in NSW (2014-2024)        District Health Services Plan to 2026.
     and the July 2019 Mid-term Review

     • Strategic Framework for Suicide
     Prevention in NSW (2018-2023)

     Ten Common Strategic Mental
     Health Policy Issues:
     1. Regional – collaborative             7. Engage and address the needs of
     governance – co commissioning           special populations

     2. Integrated, person centred,          8. Whole of community resilience
     stepped care – quality                  building

     3. Recovery focused, trauma             9. Data – applied to decision
     informed                                making, shared and outcomes focus
     4. Consumer, carer/family
                                             10. Suicide prevention – alternatives
                                             to ED and aftercare
     5. Community care capacity
                                             …. All underpinned by a culturally
     6. Improving physical health            competent and networked workforce.

Abbreviation   DEFINITION                                             Abbreviation   DEFINITION

AIHW           Australian Institute of Health and Welfare             NGO            Non Government Organisation

ABS            Australian Bureau of Statistics                        NMHC           National Mental Health Commission

AOD            Alcohol and Other Drugs                                NSMHWB         National Survey of Mental Health and Wellbeing (ABS)

ASR            Age Standardised Rate                                  np             Data not available for publication

CALD           Culturally and Linguistically Diverse                  PAGES          Providers of Australian Government Employment Services

CMO            Community Managed Organisations                        PBS            Pharmaceutical Benefits Scheme

COAG           Council of Australian Governments                      PCLI           Pathways to Community Living Initiative

DCJ            Department of Communities and Justice (NSW)            PCMH           Patient Centre Medical Homes

GP             General Practitioner                                   PHIDU          Public Health Information Development Unit

GOT IT         Getting on Track In Time                               PMHC           Primary Mental Health Care Services

HCH            Health Care Homes                                      PHN            Primary Health Network

IAMHWS         Integrated Atlas of Mental Health for Western Sydney   SDH or SDOH    Social Determinants of Health

IRSD           Index of Relative Socio-Economic Disadvantage          SDR            Service Delivery Reform

LGA            Local Government Areas                                 SLA            Statistical Local Area

LHD            Local Health District                                  SA3            Statistical Area Level 3

MASH           Making a Safe Home                                     WFT            Whole Family Team

MBS            Medicare Benefits Schedule                             WSLHD          Western Sydney Local Health District

MECSH          Maternal Early Childhood Sustained Home-visiting       WSPHN          Western Sydney Primary Health Network (WentWest)

MNAT           Mental Health Ambulance Team                           VBHC           Value Based Health Care

MHC NSW        Mental Health Commission of NSW

 Carer                                    Person-centred                            Trauma Informed
 A person with lived experience of        Care                                      Care
 caring for someone with a mental
 health problem. This can be a family     Person-centred care places the person     Trauma Informed Care (TIC) is a
 member or friend – paid or unpaid.       in context, over and above bodily         treatment framework supported by an
                                          systems or diseases, and places this      organisational structure that involves

 Community                                concept at the centre of healthcare.
                                          Person-centred care respects
                                                                                    understanding, recognising, and
                                                                                    responding to the effects of all types of
 Managed                                  individual diversity and enables
                                          personal control of healthcare.
                                                                                    damaging life events and experiences.
                                                                                    TIC is an approach to service delivery
 Organisations                                                                      based on an understanding of the

 Community managed organisations
                                          Special                                   ways trauma affects people’s lives,
                                                                                    their service needs and service
 (CMOs) are private, not-for-profit
 organisations that may be managed
                                          Populations                               usage. It incorporates principles of
                                                                                    safety, choice, collaboration, trust and
 by a board of representatives and/or     Populations which are either              empowerment.
 elected community members.               underrepresented in accessing

                                          care or have higher risk or poorer
                                          health outcomes than the general
                                                                                    Value Based
 Referring to a person with a lived
                                          population. It includes some
                                          Culturally and Linguistically Diverse
 experience of mental illness and/or      communities, Aboriginal and Torres        (VBHC)
 recovery who has used or uses            Strait Islander people, children and
 treatment, rehabilitation and/or         young people, people with chronic         VBHC means continually striving to
 support services.                        health conditions and veterans.           deliver care that improves:

                                                                                    1. health outcomes that matter to
 Integrated Care                          Social                                    patients,

 Integrated care is a way of working      Determinants of                           2. experiences of receiving care,
 that enables care to be provided in
 a way that reflects the whole of a       Health                                    3. experiences of providing care, and
 person’s health needs; from prevention                                             4. effectiveness and efficiency of care.
                                          Social, environmental and economic
 through to end of life, across both
                                          factors that play a significant role in
 physical and mental health, and in
                                          shaping the health and wellbeing of
 partnership with the individual, their
                                          individuals and populations.
 carers and family. The individual
 experiences care as though provided
 by a single unified health system. The
 aim is to have care centred around the
 person, rather than organisations, to
 help people with complex needs get
 the care they need. To transform to a
 more person-centred model of care,
 changes are required at organisation,
 service and care delivery levels.

                                                         What gets measured, how and by whom
                                                         A critical factor in achieving the             The KPIs listed here are, in the majority
                                                         intentions set out in this Regional            of cases, required for reporting
                                                         Plan, will be our commitment to what           against national data sets and are
                                                         gets measured, how we measure,                 expected to be available at a regional
                                                         and who has a lead responsibility              level during the timeframe of this
                                                         for each measure. In addition to               Plan. Some additional indicators have
                                                         reporting to Commonwealth and                  been added to ensure measurement
                                                         State governments, the WSLHD,                  against regional priorities is routinely
                                                         WSPHN and SCHN Boards, we                      undertaken. Details on the methods
                                                         will routinely report to the Western           and tools used for measuring progress
                                                         Sydney community to ensure we are              will be available from the WentWest
                                                         transparent and accountable to them,           (WSPHN) website following a co-
                                                         and we help to build a community               design process with community and
                                                         of support for better mental health            stakeholders to determine the priority
                                                         outcomes across the region.                    measures / KPIs.

  DOMAIN & INDICATOR                                                                          LEAD                            REPORTED
  Proportion of consumers & carers with positive experiences of service                       WSPHN                           Bi-annual
		                                                                                            (all commissioned services)
  Proportion of consumers & carers with positive experiences of service                       WSLHD (all public MHS)          Bi-annual
  Rate of involuntary hospital treatment                                                      WSLHD                           Annually
  Rate of seclusion & restraint in acute units                                                WSLHD                           Annually
  Life expectancy & mortality gap for people with mental illness                              WSPHN                           Annual
  Proportion of children developmentally vulnerable in the Australian Early
  Development Census (AEDC)                                                  WSLHD                                            Three-yearly
  Proportion demonstrating a positive change over time
  Percentage of population with very high psychological distress                              WSPHN                           Annual
  Population access to mental health care                                                     WSPHN                           Annually
  Mental health related ED presentations                                                      WSLHD                           Annually
  Referral Wait Time for Primary Mental Health Care services                                  WSPHN                           Bi-annually
  Readmission rate to hospital                                                                WSLHD                           Annually
  Percentage of new clients to Primary Mental Health Care services                            WSPHN                           Bi-annually
  Post hospital discharge community care                                                      WSLHD                           Annually
  Measurement of Integrated care across Western Sydney ^                                      WSPHN                           Annually
  Planned vs actual FTE/vacancy rate                                                          WSPHN                           Annually
  Competency in team-based care & collaboration*                                              WSPHN                           Annually
  Workforce satisfaction                                                                      WSPHN                           Annually

^ This is based on the Rainbow Model of Integrated Care Measurement Tool (Valentijn, 2016). See Appendix 1.
* This would be based on a standard set of agreed competencies for team-based care and collaboration.
Appendix 2 contains the National Indicators as set out in the Fifth National Mental Health and Suicide Prevention Plan.                             P9
                                            Underway and core to our way of working
WentWest (WSPHN), Western Sydney            professionals work together. The health      • Scaling collaborative efforts to
Local Health District (WSLHD) and           system needs to pursue right care, right     realise system wide impacts - We plan
Sydney Children’s Hospitals Network         time, right place with the consumer as       to reform the Western Sydney health
(SCHN) have jointly commissioned            an active member of the care team.           system, by thinking as ‘one system’
services into areas of need for more                                                     and working accordingly. We will work
than eight years.                           We are proposing that over the coming        within a shared regional framework
                                            years, to combine our efforts and seek       of objectives, principles and strategies
Currently there are several joint           State and Commonwealth support to            applied flexibly in and with local
collaboratives including:                   further scale this work. Rather than         communities, creating diverse place
                                            focus on one model of care, the Boards       based and sustainable developments.
• Partnership Advisory Council (PAC)        and Executives of WentWest (WSPHN)
- supports collaboration and integration,   and WSLHD will focus on whole system         • Strategically focus on the levers
and focuses on shared strategic priority    reforms to the health system.                of change - Our approach considers
areas for the SCHN, WSPHN and                                                            macro, meso and micro reforms
WSLHD, effectively demonstrating the        THE AIMS OF COLLABORATIVE                    required to realise short, medium and
virtual ‘pooling’ of resources to deliver   COMMISSIONING                                long term impacts, but also represents
specific models of integration.                                                          the next step toward our mutual long
                                            1. Collectively deliver ‘one Western
• Service Delivery Reform (SDR) cross       Sydney health system’ which is value-        term aims with a specific focus on
sector initiative which aims to improve     based and patient-centred.                   change management and ‘changing
service delivery to vulnerable families/                                                 hearts and minds’, orienting the system
populations.                                2. Deliver right care, at the right time,    toward our new operating paradigm.
                                            and in the right place – in community        This will necessarily involve trialling
• Integrated Chronic Care and Health        and primary care wherever possible.          and evaluation of changes to financing
Care Homes - supports communication                                                      – notably general practice financing, to
and integration between the hospital,       3. Improve equity in health, reducing
                                                                                         build capability and enhance recognition
GPs and patients.                           health risks, promote healthy lifestyles
                                                                                         of value-based care provision.
                                            and respond to social determinants.
• After Hours Programs, Aboriginal                                                       • Being realistic about what can be
Health Promotion, Students as               KEY FEATURES OF OUR PROPOSED
                                                                                         achieved but being scalable to other
Lifestyle Activists (SALSA), and the        APPROACH:
                                                                                         cohorts - Our initial plans cover two
implementation of Thrive@5 (first 2,000     • Moving from input and activity             specific cohorts – patients requiring
days) within the suburb of Doonside.        to outcome-based commissioning               value-based urgent care and patients
                                            - Reforming Western Sydney’s ‘joint          at risk showing symptoms of chronic
Although joint commissioning is
                                            commissioning’ of service models             heart conditions. This will include
well embedded into the way of doing
                                            and funding of inputs/activities to          mental health consumers and we
things in Western Sydney, WentWest
                                            collaborative commissioning of activity      have begun scoping additional cohorts
(WSPHN) and WSLHD recognise a more
                                            and incentivising outcomes and value         which could benefit from a collaborative
cohesive and systematically coordinated
                                            across providers. This would include joint   commissioning approach including
approach is necessary to enable
                                            accountability for outcomes and agreed       Aboriginal health, diabetes, mental
collaboration and deliver care that is
                                            mechanisms for sharing benefits.             health, frailty and vulnerable families.
consistently value-based, person-
centred, and can be delivered at scale      • Consolidating and enhancing                • Engagement of consumers and
across the region.                          governance - Our Person Centred              clinicians - A co-design approach was
                                            Co-commissioning Group (PCCG)                applied with consumer and clinical
WSLHD, the SCHN and WentWest
                                            governance includes a consolidated           councils over many years to develop
(WSPHN) want to remove organisational
                                            and enhanced governance model for            these models, however, much of the
and professional barriers, alleviate the
                                            broader Western Sydney collaboration.        thinking needs further development
siloed, fragmented nature of care and
                                            While these efforts will initially focus     to be updated and customised to the
pursue our mutually shared vision of
                                            on collaborative commissioning               current Western Sydney context. We
‘one Western Sydney health system’ in
                                            within the health system, we will be         plan to test more extensively during
order to provide true value-based and
                                            looking to build on Western Sydney’s         a joint development phase, including
person-centred care. This requires us
                                            Service Delivery Reform program,             working with local community providers
to reimagine how primary, community,
                                            which already includes the Stronger          – linking Community Health, General
acute and social care is delivered.
                                            Communities Cluster (Justice and             Practice and NGO services to build
Health system pressures have never          ‘Their Futures Matter’), Treasury, Police    Patient Centred Medical Home (PCMH)
been greater, and we need to think          and Education Clusters, to address the       clusters in connected Health Care
differently about how providers and         social determinants of health.               Neighbourhoods (HCNs).

GOVERNANCE          Delivering this Regional Plan will
                    be a joint effort, with commitment
                    from partners across our region.
                    Our commitment to a One Western
                    Sydney Health System has already
                    commenced. The Patient Centred Co-
                    Commissioning Group (PCCG) Executive
                    is established and the first two sub-
                    committees (Value-Based Urgent
                    Care and Cardiology in Community)
                    are evolving. A sub-committee for
                    progression of our Mental Health &
                    Suicide Prevention Regional Plan
                    will be developed as part of our
                    implementation and delivery plan.


   WESTERN                      SYDNEY
    SYDNEY                    CHILDREN’S                          WENTWEST
 LOCAL HEALTH                 HOSPITALS                            (WSPHN)
   DISTRICT                    NETWORK                              BOARD
    BOARD                       BOARD



                      The Patient Centred Co-commissioning
                      Group (PCCG) will report into the
                      Partnership Advisory Council, which in
                      turn, reports into the three local health
                      system Boards.                                         P11

                                                          HEAD AGREEMENT
                                                         MOH – WSPHN / WSLHD

                                               WSLHD Director                                                        WSLHD        WSPHN Director
WSLHD CE     WSPHN CEO                         Medical Services     Consumer/        WSPHN           WSPHN          Executive      Primary Care
                             Director Allied
(Co-Chair)    (Co-Chair)                        or Emergency          Patient       GP Leader       GP Leader       Director of   Transformation
                                                  Physician                                                         Operations     & Integration

                                                         Workstreams / Enablers

                Value Based Urgent Care (sub-committee)                         Cardiology in Community (sub-committee)

                  Project Management                              Commissioning                 Data, Analytics & eHealth

                                                             PCCG Change Lead

                                                   Provider Agreements (examples)

              Single Point
                                          General                    WSLHD                 WSPHN                Evaluation
                                          Practices                                                              Provider

                                                 Key features of the PCCG Executive             patient representation to ensure a
                                                 includes:                                      co-design approach and continual
                                                                                                validation that the services are
                                                 • Co-Chairs: CE, WSLHD and CEO,
                                                                                                delivering on consumer/patient
                                                                                                expectations. Sub-committees are
                                                 • Members: WSLHD clinicians (2),               responsible for driving the design and
                                                 WSPHN GP Leaders (2), consumer,                implementation of their respective
                                                 WSLHD Executive and WSPHN                      model utilising PCCG enablers.
                                                                                                The following diagram demonstrates
                                                 Sub-committee will be co-chaired               expected membership of each
                                                 by a WSLHD clinician and a                     sub-committee, including key
                                                 WSPHN GP Leader. Each sub-                     partners which will be integral to the
                                                 committee will have consumer/                  realisation of benefits.


                                                          VALUE BASED URGENT CARE
                                                               WSPHN / WSLHD

     WSLHD                                                                           WSLHD
                                    WSPHN                                                                                                      WSLHD
 General Manager                                           Western Sydney        Network Director                  WSPHN
                                   GP Leader                                                                                             Divisional Medical
   Westmead &                                                                     of Emergency                    GP Leader
                                                             Consumer                                                                     Director - Acute
 Auburn Hospitals                  (Co-Chair)                                    Medical Training                                             Medicine

                     WSPHN                       WSLHD                                            WSPHN                          Key PCCG
                Director Primary           Director Integration                                Medical Director               Implementation
                      Care                     & Enablers,                                     Immediate Care                       staff
                Transformation &               Integrated &                                       (Partner                     (as required)
                   Integration             Community Health                                     Organisation)


                                                           CARDIOLOGY IN COMMUNITY
                                                               WSPHN / WSLHD

      WSLHD                                               Digital Health CRC         WSLHD                                                     WSLHD
Professor of Medicine               WSPHN                     Director of        Executive Director                                        Director HITH,
& Academic Director                GP Leader                                                                       WSPHN                   Integration &
                                                            Research and           Nursing and
 Westmead Applied                  (Co-Chair)                                                                     GP Leader                   Enablers,
                                                          Director of Digital   Midwifery & Clinical
 Research Centred                                                                   Governance                                              Integrated &
                                                         Capacity | Consumer
     (Co-Chair)                                                                                                                          Community Health

                     WSPHN                       WSLHD                                                                           Key PCCG
                Director Primary           Director Integration                                   WSPHN
                      Care                     & Enablers,                                     General Practice
                Transformation &               Integrated &                                      Pharmacist
                                                                                                                               (as required)
                   Integration             Community Health

                                                     WSLHD and WentWest (WSPHN) have                     There will also be ongoing regular
                                                     agreed on the Lead of each enabler                  consultations with key stakeholders
                                                     including: Program Management                       including WentWest Clinical Advisory
                                                     led by WSLHD; Commissioning led                     Council, WSLHD Clinical Governance
                                                     by WSPHN; and Data, Analytics and                   Committee, and WentWest and
                                                     eHealth led by WSPHN.                               WSLHD Consumer Advisory Councils.
                                                                                                         Communication plans (internal, public
                                                     We expect that each enabler will include            and through media channels), with key
                                                     at least one seconded person from the               messages and consideration of “when
                                                     non-lead organisation to enable the                 people need to know what” and “for
                                                     free flow of information between the                what purpose” will be vital to success.
                                                                                                         The project will also build in key points
                                                     The PCCG Change Lead will drive                     where feedback can be received from
                                                     program and change management                       stakeholders, whether that be through
                                                     and, in consultation with the Co-Chairs,            follow up surveys (post accessing the
                                                     assign clear accountabilities for tasks.            model of care) or public surveys to
                                                     Current or new working groups and                   gauge public awareness of the Value
                                                     focus groups will be created as required            Based Urgent Care service and the
                                                     to drive actions and outcomes.                      Cardiology in Community service.

                                                     Clinical leadership will be a core                  WHAT THIS MEANS FOR MENTAL
                                                     element of each sub-committee,                      HEALTH IN WESTERN SYDNEY
                                                     with primary care and acute care
                                                                                                         In simple terms moving to a Person
                                                                                                         Centred Co-commissioning Group
                                                     COMMUNITY AND CONSUMER                              in mental health will see shared
                                                     ENGAGEMENT                                          investments to build a more
                                                                                                         integrated service system that is
                                                     Each sub-committee will include                     easier for consumers and carers to
                                                     consumers with direct links to                      navigate and get the suite of services
                                                     community.                                          they need to live well.
     Bonding the health sector
     In pursuing the vision of a mentally        provider of mental health, community
     healthy and inclusive Western Sydney        support and disability support
     community, it is essential that a broad     services to people with a lived
     coalition of health and non-health          experience. Services include supported
     organisations are brought together. In      accommodation, daily living support,
     the health sector WentWest (WSPHN)          recovery programs, community
     and Western Sydney LHD will work to         connection and suicide prevention or
     build robust bonds across the partners      postvention (aftercare). Families and
     in health care to ensure pathways to and    carers of people with a lived experience
     from health care for those with mental      are supported through the family and
     health needs are clear, well known and      carer programs run by community
     effective. Tackling the root causes of      managed organisations.
     mental distress and many mood and
     substance disorders requires that we        • Private providers including
     build bridges to partners beyond health     psychiatrists, psychologists and
     care to tackle the social determinants of   allied health professionals, such
     ill-health and that we sustain coalitions   as dieticians, physiotherapists or
     to ensure those families and individuals    counsellors, may also be part of the
     with complex needs get the hand up          care team.
     they need.
                                                 • Private hospitals, some
     In the health care sector we need           specialising in mental health treatment,
     strong bonds between Consumers,             supplement services for people who
     their carers and families, those with a     need hospital admission.
     lived experience of mental illness and/
     or suicidal behaviour - key partners in     • Health promotion, prevention
     the design, implementation, operation,      and early intervention programs
     and monitoring of services, and:            may be offered in different sectors,
                                                 by local governments and public and
     • State Hospital, Mental Health and         national, state and/or local community
     Community Health services providing         organisations (e.g. beyondblue, R U OK?
     a wide spectrum of mental health care       and NSW Cancer Council).
     services from early prevention through
     to acute hospital based care.               • Alcohol and other Drug services
                                                 may be offered by Health as well as
     • General Practitioners funded by           CMOs. These include some residential
     the Australian government through           rehabilitation services, some of which
     Medicare and consumer co-payments,          offer targeted support to Aboriginal and
     provide comprehensive primary health        Torres Strait Islander people.
     care, a high proportion of total mental
     health care, and will be involved in        • Peak bodies play a role in
     shared care of people with a lived          community managed sector
     experience of mental ill-health.            development, capacity building in
                                                 community managed organisations,
     • Community Managed                         and in advocacy for consumers
     Organisations (CMOs) are a key              and carers.

     Building bridges beyond health
     • Early childhood, children and          • Police have a role in protecting
     young people’s services, child           the community and preventing and
     protection and out of home care          responding to crime. In the mental
     services led by the Department of        health context, police may be first
     Communities and Justice (DCJ)            responders during a mental health
     address the needs of children and        crisis being experienced by a person
     families. They may identify concerns     in the community.
     that require mental health support
     and partner in providing a holistic      • Legal, statutory and/or advocacy
     response to the child and/or family.     services – government agencies,
                                              courts and tribunals may be involved
     • Education NSW and non-public           in supporting and advocating for the
     education providers. School years        rights of people with a lived experience
     are key periods when developmental,      on an individual or systemic level. This
     conduct and mental health disorders      includes Mental Health Commission
     first appear. Ensuring schools are       NSW, the Mental Health Review
     equipped to support the social and       Tribunal, Legal Aid Commission, NSW
     emotional learning of every child and    Civil and Administrative Tribunal,
     are able to support those that are at    Juvenile Justice, and Public Guardian.
     risk and have need for care
     is important.                            • Volunteer community
                                              organisations help to undertake
     • Post-secondary education and           local community capacity building
     employment services may assist           activities. Groups such as Rotary,
     people with a lived experience to        Lions and LandCare groups can play
     access education, vocational training    a prominent role in supporting better
     and work. This includes TAFE, Western    mental health for the community.
     Sydney University, private vocational
     training providers, Providers of         • Local government plays a
     Australian Government Employment         critical role in urban space design,
     Services (PAGES) and others.             environmental protection and
                                              community services, and facilities like
     • Aged Care services, funded by the      libraries, parks and playgrounds, and
     Australian government and user fees,     supporting community events that
     are able to provide support to people    celebrate living in Western Sydney.
     aged 65 and over or Indigenous people
     aged 50 and over in their own homes      • Business sector of Western
     or in aged care facilities.              Sydney wants a mentally healthy
                                              workforce for now and the future.
     • Ambulance services, as first           Business is increasingly aware
     responders, play a vital role in field   that mental illness is a real threat
     assessment, screening and treatment      to business continuity and offers
     for those experiencing a mental          partnership opportunities for both
     health crisis.                           WSLHD and WentWest (WSPHN).

WESTERN SYDNEY                                          In mid 2019 the NSW Mental Health        priorities’ are summarised here.
                                                        Commission, in collaboration with
                                                        WSLHD and WentWest (WSPHN),              A series of ‘graphic scribes’ were
                                                        undertook community consultations        produced to capture the interactions
                                                        to review the progress made in           and feedback gathering through a
                                                        the region on the implementation         workshop held at Homebush in July
                                                        of the Living Well Strategic Plan.       2019. These are available at https://
                                                        The key messages in relation to          nswmentalhealthcommission.com.
                                                        ‘what’s working well’, ‘what are         au/living-well-agenda/living-well-
                                                        the challenges’ and ‘what are the        mid-term-review/western-sydney.



Awareness: Awareness of mental health, and diverse communities;            Visibility of services: Variation between services, same service but
People are more aware of services                                          different maze, lack of linkage; Mental health sector is a maze

Co-design and peer workforce: Greater number of consumer led               Access: Young people who need high levels of care and can’t get it;
programs and the peer workforce                                            NDIS long waiting times

Diversity: Culturally linguistically diverse programs                      Workforce: Workforce to meet demands; Student development;
			                                                                        Quality of employees; Workforce gaps

Outreach: More assertive outreach in the community and less                Funding: Length of funding, limited contracts

Community engagement: More authentic engagement of carers and
families in service design and planning


Early intervention: Invest in good community care that has demonstrated success in early intervention; Early invention in the education system

Funding: Funded service to point people towards help; Simplified tendering process – system standardised questions; 10-year funding priority

Accessibility: Navigation of services

Community based services: Accessible community based services to avoid hospital, respite and rehab; Stable housing

Workforce: Training and remuneration for workers; Training for non-mental health services; Training for mental health police

Co-design: Access across each government area

      WentWest (WSPHN) and WSLHD                   • Collaborative Commissioning –
      undertook further consultations with         an emerging process.
      consumers and carers, and a range
      of commissioned service providers            • Improved interagency
      and stakeholders, in late 2019 and           cooperation; improved relationships
      early 2020 to provide input into the         now embedding.
      finalisation of the Regional Plan. The
                                                   • Early adoption of innovation – e.g.
      workshops and online survey used an
                                                   youth navigator model.
      appreciative enquiry method to capture
      views of the strengths and what has          • Collaboration between General
      changed and improved in recent               Practice and Allied Health.
      years through the reform efforts. The
      emerging opportunities, the policy and       •   Sharing of information.
      systems issues placing constraints and
      challenges on the community and then         • Improved psychosocial services in
      finally the data and information gaps        the community.
      were identified. From this, a set of eight
      issues were seen as the priorities for       OPPORTUNITIES
      reform under the Regional Plan. Using
                                                   • Address the unmet needs of
      their words, we have summarised the
                                                   special populations.
      feedback here.
      STRENGTHS OF WESTERN SYDNEY                  • LHD reform agenda and progress
      REGION                                       – communication and collaboration
                                                   to be strengthened.
      • WentWest (WSPHN) and WSLHD
      working together as agents for change.       • Teacher and school community
      • Service Delivery Reform (SDR) –
      involves all human services. Regular         • Expand the GP-psychiatry liaison
      meetings of the Mental Health                service.
      Working Group.
                                                   • Greater cohesion and cooperation
      • The Integrated Care Management
                                                   between housing and health – need
      Group convened by DCJ, with a
                                                   to work together to keep consumers
      designated lead agency for every client.
                                                   in public housing.
      • The MASH Program – 28 families
      with savings of $2.3m.                       •   Suicide prevention programs.

Themes from the consultations with
our stakeholders for the Regional Plan
POLICY AND SYSTEM ISSUES                    • High density living – need to see
                                            more ‘5 Star Green Community’
• The link between service planning         developments (see Fairwater).
and delivery, using data to inform. Data
not yet fully driving service planning at   • Clear referral pathways – schools to
local level.                                community and to health services. Youth
                                            navigation program a positive step.
• There is a fundamental disconnect
in the rhetoric of ‘integration’ and        •   Safe & Well for all schools.
‘regional’ and the way many programs
are funded. Shared care still dependent     • Clear signposts for the community
on individual provider/HCP; payment         – who to reach out to/go to if you need
systems divide not connect.                 support.

• Needs to have greater emphasis on         • Cultural support and knowledge
technology – the need to have systems       – updated, accessible, relevant; CALD
to allow sharing of client data/care        groups using specific Facebook sites.
plans (with consent); shared metrics on
outcomes; My Health Record not proving      • Auburn – Healthy Communities
to be fully useful at this point.           initiative.

• Early childhood is not seen as            • Workforce component – emphasis
a priority. Need to have whole of life      on Multi-Disciplinary Teams; more
approach. Day care services are             capacity to partner.
overwhelmed with demand.
                                            • Data must move to focus on
• Funding – this is THE elephant in         outcomes, in all settings.
the room. Funding based on the needs
                                            • NDIS: lack of sustainable funding
of Western Sydney for community
                                            for mental health providers; huge risks
managed funds.
                                            for clients transitioning and those now
• Social determinants are absent            needing to access NDIS packages.
– housing, education, employment,
environment.                                • High rates of non-engagement
                                            of young people not in education,
• Inadequate focus on prevention            employment training – one in seven
– universal social and emotional            young people 16-21 years.
wellbeing missing.
                                            • Absence of employment services
• Whole of community resilience – no        with health care; some linkage with
one is addressing this.                     headspace but it’s small.

Themes from the consultations with
our stakeholders for the Regional Plan
DATA AND SERVICE GAPS                      • Continuing issues around stigma
                                           among service providers – cultural
Data Gaps                                  and toward AOD and Mental Health
• Health issues – HIV+ and Hepatitis       consumers.
C infection numbers and growth.            • Stable public housing - provision
• Socio-economic issues – data not         & access.
linked to health data (enough) nor at      • Inadequate knowledge of what
‘granular level’ (i.e. SA 2).              services are available for the community
• Data on domestic violence; child         from GPs and medical staff.
protection; children in out of home care   PRIORITY NEEDS - WHAT MATTERS
(including the levels of trauma and        MOST
poor health outcomes).
                                           • Developing alternative sources of
• Struggling and vulnerable families       funding – the need to look for strategic
– need for data on non-attendances at      partners beyond government and
school, numbers of families using crisis   reduce ‘silos of funding’.
food banks and housing, number of
families under extreme financial stress,   • Children – prior to schooling;
where and who can offer support.           the early schooling with Social
                                           and Emotional Learning K-12 plus
• Multicultural community data             specialist programs for children with
- including separating refugee data        higher needs like GOT It!
– actual migration – planned vs
non-planned and numbers impacted           • The need to tackle social
by trauma; plus, the number of             determinants and risk factors – 5 Star
temporary visitors.                        Green Communities: Healthy Eating,
                                           Healthy Action.
• On self-harm – when GPs do the
treating, there won’t be data captured     • The need to ensure young people
by the ED presentation data.               have access to employment, education
                                           and/or training.
•   Drug-related hospital presentations.
                                           • Youth in out of home care – lack
Service Gaps                               of flexibility with CAMHS; greater
• Gap in comorbid services – AOD-          access (timely) to MH services needed;
MH (complex) treatment.                    ‘Intensive Community Care for Youth’
                                           (DCJ coordination).
• Prevention, early intervention
targeted services.                         • Under 18 yo homeless - not funded
                                           to support these clients; complexity not
•   CALD / refugee service provision.      addressed in funding at present.

• Impact of high density living – poor     • Workforce development and
health outcomes, lack of community         training – must mirror the community
space, alienation of community.            it serves.

• Tailored programs to address high        • Research and evaluation – better
rates of smoking among some groups         data to inform service planning and
including mental health consumers.         monitoring of outcomes.

     STRUCTURAL AND SYSTEMS                   WSHIU portal to monitor the health
                                              status of the community, identify health
     Collaborative Governance                 needs, develop programs to reduce
                                              risk, foster policies which promote
     WentWest (WSPHN), Western Sydney
                                              health, plan and evaluate the provision
     Local Health District (WSLHD) and
                                              of healthcare and manage and
     Sydney Children’s Hospitals Network
                                              implement change.
     (SCHN) have jointly commissioned
     services into areas of need for more     Integrated Mental Health Atlases of
     than eight years. Currently there are    Western Sydney, 2014 and 2019
     several joint collaboratives including
     the Service Delivery Reform (SDR),       WentWest (WSPHN) was the first
     Partnership Advisory Council (PAC)       regional health authority in Australia to
     and Integrated Chronic Care and          apply an internationally validated tool to
     Health Care Homes.                       the geo-mapping population of mental
                                              health needs and available services.
     Collaborative Commissioning also
                                              This Atlas uses a standard classification
     underpins a number of specific
                                              system, the “Description and Evaluation
     programs including Western Sydney
                                              of Services and Directories in Europe
     After Hours Programs, Aboriginal
                                              for long-term care” model (DESDE-
     Health Promotion, Students as
                                              LTC), to map the services. The use
     Lifestyle Activists (SALSA), and
                                              of a common language has allowed
     the implementation of Thrive@5
                                              us to compare the pattern of mental
     in Doonside.
                                              health care provided in Western Sydney,
     Western Sydney Health Intelligence       other regions across Australia and
     Unit (WSHIU)                             with regions in Europe and elsewhere.
                                              We continue to develop and use the
     The WSHIU supports and contributes       ‘Mental Health Atlas’ to enhance our
     to the new shared services in the        understanding of the functional mix of
     region providing an agreed and           capacity (or spectrum and capacity of
     expanding range of services, including   services) in the region and compare this
     information production, knowledge        to international benchmarks using a
     management, web-based reporting          standard taxonomy.
     and capacity building.
                                              The 2019 Integrated Atlas of
     The WSHIU works to support health        Psychosocial Mental Health services
     professionals and system partners        showed significant changes to the
     to make informed decisions towards       capacity and location of these services
     better health and social care outcomes   from 2014 and showed a closer
     by using the evidence base of health.    alignment between needs and
     A wide variety of stakeholders use the   service provision.

Improvements in Recent Years
Suicide Prevention Research              Low-intensity services provide public
Collaboration and Systems Mode           information, self-help strategies,
                                         digital and phone-based mental health
The suicide prevention research          services as well as group, peer and
collaboration led by the University      GP support. The services include The
of Western Sydney, Sax Institute,        Shed in Mount Druitt, Western Sydney
and the Brain and Mind Centre at         Recovery College, and the Connections
the University of Sydney developed       Helpline. Medium intensity services
a systems modelling approach             are face-to-face services and include
to community-based suicide               psychological services and clinician-
prevention and suicidality attempts.     assisted, digital mental health services,
The collaboration has developed          and GP support. High intensity services
a Dynamic Modelling approach to          are multi-agency care including
suicide prevention that incorporates     coordinated multi-agency support,
the Lifespan Model from the Black        psychiatric support, mental health
Dog Institute. WentWest (WSPHN)          nurse services, acute care and hospital-
will act as a local implementation       based services.
partner for the research collaborative
enabling the systems modelling           The Principles and Characteristics of
approach to be tested in real            the Stepped Care approach are shown
life scenarios and enable our            in Appendix 3.
commissioning framework to draw          Primary Care – Psychiatry Liaison
on the evidence of effectiveness and     Services Model of Care (PC-PLS)
impact for suicide prevention. This
will address the current fragmented      This service aims to improve both
nature of suicide prevention             physical and mental health outcomes
activities and provide a rigorous        in people with mental health issues,
approach to commissioning of             through better integration of care
suicide prevention services.             and increased access to psychiatric
                                         expertise and psychosocial support
IMPROVED ACCESS TO AND                   within primary care settings. WentWest
QUALITY OF SERVICES                      (WSPHN) has engaged a Lead Agency
                                         to employ two full-time psychiatrists
Stepped Care                             to support up to 20 general practices
                                         across the region to target a range
WentWest (WSPHN) commissions a
                                         of priority population groups. The
number of mental health services
                                         psychiatrists provide consultant liaison
within Western Sydney informed
                                         support to GPs and brief intervention to
through a comprehensive Needs
                                         people accessing PC-PLS, increasing
Assessment. These services are
                                         access to professional mental health
structured within a ‘Stepped Care’
                                         services in the primary care setting.
approach to help a range of people
                                         A unique feature of this PC-PLS
with low to high mental health needs,
                                         model is the layering of support, to
with many of these services being
                                         ensure people with a diverse range
free and easy to access without the
                                         of support needs can be supported
need of a referral from a health
                                         comprehensively. The PC-PLS also
professional. The Stepped Care
                                         place emphasis on providing a
approach connects primary mental
                                         person-centred and recovery-oriented
health care with Western Sydney
community members and helps
health professionals, including GPs,     The preliminary evaluation of the PC-
deliver the right care by determining    PLS has shown significant improved
the service level required.              health outcomes and a good quality

Improvements in Recent Years
Gold Card Clinics                          aims to strengthen integrated
                                           mental health care for pregnant
The Gold Card Clinics (GCCs), are          women, mothers, their infants and
clinical services offered through          families throughout NSW. SwOPS
WSLHD’s Department of Psychology.          provide telephone, telehealth and
They provide a brief psychotherapeutic     online support. Consultations aim to
intervention for people aged 18-65         provide rapid response to support and
years old in the WSLHD catchment           facilitate access to specialist Perinatal
area who have recently experienced a       Mental Health Assessment. SwOPS-
mental health crisis. The intervention     mh is based in Redbank House,
focuses on providing timely, accessible    Westmead Hospital.
and evidence-based psychological
intervention for people who frequently     Specialist Perinatal and Infant Mental
present to EDs or Inpatient Services       Health Services (PIMHS) aare for
in the context of psychosocial crisis      pregnant women and mothers with
with emotion dysregulation, suicidal       severe and complex mental illness
ideation or self-harming behaviour.        with infants up to two years of age.
                                           PIMHS provides coordinated care for
The intervention provides an initial       the mother’s mental health needs,
three sessions that focus on identifying   parenting capacity, and parent-infant
and addressing psychological and           relationship. It also provides hospital
behavioural factors that contributed       in-reach as well as in-home support
to the crisis. An additional session for   to women and their families, reducing
carers, partners and family members        separation of mothers from their
is included in the intervention where      families wherever possible. NSW Health
needed. When nearing the end of the        are planning two new Mother Baby
intervention, referrals to appropriate     inpatient units with one to be based at
services or ongoing psychological          the Westmead Hospital campus.
therapy are discussed between the
GCC team and consumers.                    Child, Adolescent and Youth Services

The GCCs forms part of the Project         ED Navigator
Air for Personality Disorders
implementation in WSLHD Mental             The Child &Youth (C&Y) Mental
Health Services and works in a             Health Emergency Department
recovery oriented, trauma informed         (ED) Navigator program is a
way. There are four Gold Card              Commonwealth funded pilot initiative
Clinics operating across WSLHD at          between WSLHD and WentWest
Cumberland, Parramatta, Merrylands         (WSPHN). It commenced in April 2018
and Blacktown. The GCCs take               at Westmead Hospital and has utilised
referrals from the Parramatta or           a Child and Youth trauma informed
Blacktown Acute Mental Health teams        approach to acute intervention in the
and aim to offer an appointment to         ED for children and young people
suitable clients within 1-3 working        experiencing acute mental health
days of referral.                          crises with complex needs. This
                                           innovative project is aimed at providing
While a relatively new service,            the right care at the right time at the
the clinical outcomes from the             right place and thereby linking young
GCC service indicate that a brief          people to appropriate supports in
psychological intervention has a           the community and preventing non-
significant positive impact on reducing    urgent re-presentations to the ED
self-harming behaviours, suicidality,      whilst attempting to promote suicide
emotion dysregulation, paranoid            prevention and minimise risk of self-
perceptions of others, and negative        harm. The impact of the program
perceptions of self.                       has exceeded expectations and there
                                           has been a significant reduction in
Improved Perinatal and Infant Mental
                                           re-presentation rates. The service has
                                           been extremely well received by young
The Statewide Outreach Perinatal           people, their families/carers and the
Service for mental health (SwOPS-mh)       general community.

Improvements in Recent Years
U12s Community Mental Health               mental disorders. PEIRS is a multi-
Service                                    disciplinary service that encompasses
                                           prevention, mental health promotion,
Emotional and/or behavioural               early identification and intervention,
symptoms can cause significant             relapse prevention, recovery and
disruptions in family life and school.     research initiatives. The PEIRS Team
The U12s Community MHS aims to             covers The Hills, Cumberland and
address these needs. All referrals are     Parramatta LGAs.
triaged, with an individual assessment
of the child and the family context        ENABLE provides assertive intervention
in which that child resides with           for young people aged 12 -24 years
appropriate treatment. The also            who are at risk of hospital admission
provide specialist transition to school    or ED presentation by offering intensive
programs include the ‘Getting Ready        outreach, assertive crisis intervention,
for School’ and The Early Intervention     risk management and short-term
‘Now Ready for School’. The U12s           support (up to 8 weeks).
service is based at Auburn, Redbank
(Westmead) and the Rupertswood             SPECIALIST SERVICES FOR
Hub (Mount Druitt).                        VULNERABLE FAMILIES

Got It!                                    The Whole Family Team (WFT)

Got It! is a school-based specialist       The WFT is a specialist child-focused,
mental health early intervention           family-centred service for children,
program for young children in              young people, families and carers,
Kindergarten to Year Two with              where parental or carer mental health
disruptive behaviour disorders             and/or drug and alcohol issues co-exist
and their families. Got It! teams          with significant child risk of significant
work closely with local school             harm concerns. The WFT primarily
staff, children, parents and other         works with families referred by Family
local service providers to deliver a       and Community Services (FaCS) to
multilevel school-based intervention       address the impact and associated
conducted across two school                trauma of parental mental health and/
terms. An initial parent and teacher       or drug and alcohol concerns and aims
screening for emerging conduct             to enhance family functioning, increase
problems, leads to voluntary               the safety of children and all family
participation in a 10-week targeted        members, and improve health and
clinical program for children with         developmental outcomes for children
identified problems and their              and young people.
parents/carers. It is supported
                                           The Alternate Care Clinic (ACC)
by whole-of-school intervention,
specialist assessment and referral         ACC based at Redbank (Westmead)
for individual needs.                      offers a psychiatric clinic for children
                                           and young people in out-of-home-care
                                           (aged 0-17 years) in the region. The
The Blacktown Early Access Team            clinic seeks to improve connections to
(BEAT) provides specialist clinical        services for these children and youth
mental health services to youth aged       through more direct access for FaCS
12-24 years with severe mental illness.    referrals and to improve the continuity
The team covers the Blacktown Local        of care through individually tailored
Government Area.                           treatment and support plans. The ACC
                                           offers a range of therapeutic options
The Prevention Early Intervention          including individual and group work
Recovery Service (PEIRS) team is           with children and young people, family
a child and adolescent community           work and group training with foster
service offering a range of clinical       carers, and systemic intervention and
interventions to young people aged 12-     training for residential care workers and
25 years affected by the recent onset of   members of FaCS.

Improvements in Recent Years

The Patient Centred Medical Home
(PCMH) model plays a pivotal role
in achieving improved health of
populations, enhanced patient
experiences, health care cost
reductions, and better support for
health professionals – also known
as the Quadruple Aim. The PCMH
model continues to evolve as the
potential future of primary health
care internationally. The principles
that underpin PCMH are universally
relevant and fundamental to strong
primary care.

WentWest launched the first stage in
the PCMH journey in 2014, partnering
with 25 trailblazing local general
practices, to support PCMH principles
applied within the Australian context.
Over the years, local practices continue
to join this journey.

National and local experience
demonstrates that practices with a
quality improvement focus, who adopt
and work through the 10 Building
Blocks of High Performing Primary
Care, develop a greater capacity in both
their business and clinical models, to
sustain transformation, in turn shaping
the practices of the future.

 OBJECTIVE 1. STRENGTHENING                 1.4 Share data across primary,               • Through forums like the Service
 COLLABORATIVE GOVERNANCE                   community and acute sectors to drive         Delivery Reform (SDR), ensure a
 AND INFORMATION SHARING FOR                and inform evidence-based service            coordinated cross sector response
 PLANNING, COMMISSIONING AND                development, monitoring and evaluation.      supports the most vulnerable
 EVALUATING SERVICES                                                                     individuals and families and support
                                            • Establish systems that drive forward       initiatives to improve equity of access to
 1.1 1.1 Develop a whole-of-system          data sharing and move towards shared         services for these groups.
 (regional) approach to incentivise         analysis and interpretation, creating an
 local autonomy and accountability          informed community of providers and          • Strengthen the collaboration with
 for delivering patient-centred and         consumers designing a modern system          Housing, the community housing sector
 outcome-focused mental health care in      built on good evidence and knowledge         and the rental market operators to build
 the community.                             of outcomes.                                 more accommodation capacity and
                                                                                         more stable accommodation for mental
 • Continue with the Living                 OBJECTIVE 2. FORGING PARTNERSHIPS            health consumers and their families.
 Well reforms and leverage the              WITHIN AND BEYOND THE HEALTH
 commissioning of Commonwealth              AND SOCIAL CARE SECTORS THAT                 • Trial a ‘root cause coalition’ focused
 funded mental health services in           DELIVER BETTER MENTAL HEALTH                 on refugee populations to put in place the
 Western Sydney, enabled through            OUTCOMES ACROSS THE LIFESPAN                 pathways to participation and successful
 national mental health reform.                                                          transition to living in Western Sydney.
                                            2.1 Continue to build a One Western
 • Collaborate in service networking        Sydney health and social support and         2.3 Progressively transition care from
 and care arrangements to improve           care service system.                         acute settings to primary/community
 service integration between WSLHD                                                       based settings, wherever appropriate
 mental health inpatient and                • Rebalance investments for an               to do so, through collaborative
 community teams, GPs, primary care         integrated community and inpatient           commissioning arrangements, building
 providers and CMOs.                        mental health service that facilitates       a mentally healthier and more resilient
                                            timely access and recovery.                  Western Sydney community.
 1.2 Across all services, shift the focus
 of non-clinical and clinical support       • Work with the CMOs to ensure               • Support the Auburn Healthy
 services and projects from outputs         in-reach into acute inpatient units is       Communities initiative, exploring
 to outcomes.                               integrated into models of care and           successful themes with potential to
                                            connected to the Multi-Disciplinary          expand across our region.
 • Ensure in all commissioning, service     Team for seamless transitions for
 providers have clearly defined outcome     consumers back to the community.             • Implement mental health
 measures to routinely report against.                                                   promotion and mental health literacy
                                            • Support the ongoing transformation         initiatives that engage and empower
 • Continue to build on our capacity in     of general practice to Patient Centre        the community in self-care, reducing
 evaluation and research, measuring the     Medical Homes (PCMHs) and ensure that        discrimination in all its forms and taking
 impact of everything we do and publish/    the physical health needs of mental health   action to help others experiencing
 share our contribution publicly.           consumers are addressed effectively.         mental distress and mental ill-health.

 1.3 Provide regular, clear communication   • Invest in a stepped-care primary care      • Engage with local government
 on the implementation of this Plan and     model supported by a GP-psychiatry           and urban developers to ‘design in’
 other mental health reforms to the         liaison service and tele-psychiatry.         mental health and wellbeing to new
 Western Sydney community.                                                               developments or redevelopments.
                                            • Develop shared care protocols,
 • Establish a time limited co-design       common functional assessment                 2.4 Strengthen the Patient Centred
 Working Party to develop the priority      tools and processes, defined referral        Medical Home model (PCMH) through
 indicators relevant to the community.      pathways and consumer centred care           an enhanced team-based care model to
                                            plans across primary, community and          prevent, intervene early, support care
 • Ensure through digital and               tertiary health care services.               co-ordination and continuity of care.
 traditional reporting methods, the
 Western Sydney community is kept           2.2 Develop coalitions with partners         • As the PCMH model expands
 informed on the progress of mental         to address root causes of mental             across general practice, ensure team-
 health reform and the performance of       distress, mental illness and suicidal        based care always includes principles of
 the local mental health services.          behaviour.                                   good mental health support.

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