Showcasing: My Choice - Pathways to Community Living Initiative


Hunter New England and Central Coast

Lead agency

NSW Ministry of Health statewide; Hunter New England Local Health District

Living Well domain

Providing the right kind of care

Program overview

The Pathways to Community Living Initiative (PCLI) is a major program under the NSW Government’s Mental Health Reform 2014-2024. It is a coordinated state-wide approach to supporting people with lived experience of severe and enduring mental health issues, who have been in hospital for more than 12 months to re-establish their lives in the community. 

The initiative was established to strengthen mental health care in NSW by developing effective community-based residential care and support options for people experiencing long stays (over 365 days) in mental health inpatient units. 


Since PCLI began in Hunter New England, and with the introduction of the NDIS, it was identified that a large cohort of people had been in hospital for a mental health admission for more than 12 months, some having stayed up to 30 years. The majority of these people were cared for at the Morisset Hospital. 


The aims of the program are to:

  • improve recovery-oriented care in hospital that facilitates transition to community living
  • create well designed community clinical and residential services to support people with complex and severe mental health issues to live in the community
  • decrease the number and duration of long-stay admissions in mental health facilities.

The program has rolled out in two stages in Hunter New England.  Stage one focused on people with issues of ageing. A multidisciplinary team of community transition clinicians was established in the Older Peoples Mental Health Service, and a new 10 bed Mental Health Aged Care Partnership Initiative (MHACPI) unit was established at Charles O’Neill Court, a residential aged care facility in Mayfield. 

The community transition clinicians worked with the clinical team at Morisset Hospital, to transition 10 older people who had long hospital stays to the MHACPI unit. They continue to work with aged care staff to provide ongoing recovery-oriented care and support to residents after transition.


Stage two focuses on people with long stays in mental health facilities aged 18 years and over without issues of ageing. Success has already occurred in transitioning people with long admissions to community care due to opportunities arising out of the National Disability Insurance Scheme (NDIS). A second clinical community transition team was established in early 2018 to work with consumers, families, clinical teams from inpatient and community mental health settings and community managed organisations to assist with further transitions. 

Stage 2 residential services called Specialist Living Supports (SLS) are being modelled and costed by the NSW Government, and are scheduled for roll-out over the coming two years. These services are being envisaged as “new generation” services that will offer a high level of clinical support that will reduce long-stay admissions. A significant number of Hunter New England clinical staff have participated in modelling these services.  


In Hunter New England, the program is now in its third year. Due to the NDIS and aged care partnership initiatives, 92 people with lived experience of severe and enduring mental health issues have transitioned out of long term mental health inpatient care.

A key part of PCLI is a thorough planning, assessment and follow-up process for individuals to live in the community. This involves a comprehensive, tailored assessment designed to guide a person’s transition, and structured follow-up for two years after the person has moved into the community.  

PCLI is being independently evaluated by the Centre for Health Service Development, University of Wollongong to examine the implementation and impact of the program on people with lived experience, service providers and the broader system of mental health service delivery. 

Next steps

A further aim of PCLI is to shift service culture to allow for a more preventative and recovery-oriented focus, and to avert a build-up of unnecessarily long inpatient admissions. 

Inpatient models of care are being reviewed to embed recovery-oriented clinical processes introduced by PCLI. Likewise, community models of care are being reviewed to ensure we have the right level and type of care in place to support people with severe and enduring mental health issues to remain out of hospital.  PCLI will be embedded into our system as everyday practice to sustain this much needed service reform.

For more information, contact Kim Lane, Executive Leader Innovation, Partnerships and Engagement at HNE Mental Health,