Showcasing: Integrated Sub-specialty Clinic in Tahmoor

Region
South Western Sydney

Lead agency
South Western Primary Health Network

Living Well domain

  • Providing the right type of care

Program Overview

The South Western Sydney Primary Health Network (SWSPHN) has commissioned South Western Sydney Local Health District (SWSLHD) to recruit to a mental health care coordinator position based at Tahmoor Medical Centre. 
Together the partners integrate a range of mental health, physical health and community-based services across different levels of care. 
The Integrated Subspecialty Clinic provides coordinated, wrap around care for people with severe and persistent mental illness. Key aspects of the program and model include:

  • care coordination provided through a SWSLHD care coordinator based full time in the general practice
  • improved physical health outcomes for people with a severe mental illness through access to additional (gap free) chronic disease sessions above the five sessions provided by Medicare, as well as access to physical health groups
     
  • improved health outcomes through needs assessment and care planning, resulting in the person receiving the right care based on their needs
  • access to a range of mental health, physical health and social support services through co-location in a general practice
  • streamlined transfer of care between SWSLHD and Tahmoor Medical Centre
  • increased capacity of general practitioners and other practice staff to support people with severe and enduring mental illness
  • development of a proof of concept for an integrated mental health service model targeting people with severe mental illness within a general practice setting, which could be replicated in other regions.

The program’s Steering Committee is a key driver providing leadership and oversight.

Challenge

People living with a severe mental illness can have a life expectancy of 20 years less than the average person.  This is often a result of poorer physical health outcomes such as high rates of chronic disease. Social determinants of health, such as homelessness, unemployment and poor access to education, can also impact a person’s mental health and wellbeing.
A Partners in Recovery consultation in South Western Sydney found over one third of 255 service users indicated psychological distress as a significant unmet need. This finding is supported by 2017 data which showed that South Western Sydney has the second highest percentage of people experiencing high to very high psychological distress in NSW. 
 

Issues raised in the consultation included:

  • ongoing difficulty in sourcing and maintaining appropriate clinical support from general practitioners, psychologists and psychiatrists
  • lack of psychologists that have capacity, skills and/or willingness to work with people with lived experience of severe and persistent mental health issues
  • difficulty in finding appropriate services for people with a range of complex needs
  • barriers in accessing affordable psychiatrists
  • long waiting times (e.g. often over eight weeks for psychiatrists)
  • people with lived experience being unable to receive care coordination or clinical support from community mental health unless they are in crisis or acutely unwell.

Solution

Two rounds of consultation between 2014 – 2016, led to a co-design phase in 2017. This phase resulted in a proposed model for integrated and coordinated mental health service delivery.
The SWSPHN commissioned a proof of concept trial for the Integrated Subspecialty Clinic model in Wollondilly in September 2018. Service delivery started in 2019.
The Integrated Subspecialty Clinic at Tahmoor Medical Centre provides coordinated, wrap around care for people with severe and persistent mental health issues, thereby addressing not only the person’s mental health needs, but also their physical health and psychosocial support needs.

Outcome

The Integrated Subspecialty Clinic has supported people living with severe and persistent mental health issues to address their mental health, physical health and psychosocial needs through access to services coordinated by a dedicated Care Coordinator. 

Lawrence D, Hancock K and Kisely S (2013). The gap in life expectancy from preventable physical illness in psychiatric patients in Western Australia: Retrospective analysis of population based registers. British Medical Journal, 346, 1. https://doi.org/10.1136/bmj.f2539