Showcasing: The Peer Supported Transfer of Care initiative

Region

South Western Sydney 

Lead agency

South Western Sydney Local Health District

Living Well Domain

  • Making it local
  • Getting in earlier
  • Providing the right type of care
     

Program Overview

The Peer Supported Transfer of Care (Peer-STOC) initiative offers hope to people leaving acute mental health care by connecting them with peer support workers who have lived experience of recovery and experience in managing their wellbeing.

Peer-STOC workers draw upon their own lived experience of mental health challenges and recovery to support the personal recovery of people with lived experience of mental Peer Supported Transfer of Care initiativehealth issues. Peer-STOC workers provide assertive support during transfer of care from inpatient hospital stays through to the community, helping people to connect to the information, knowledge, resources and services they need to live well in the community.

 

Recurrent funding is provided by the NSW Ministry of Health, with the initiative delivered by Bankstown Community Mental Health Service in collaboration with the Banks House team. 

Peer-STOC workers started delivering the program in 2019. Peer-STOC contributes to the growth of the lived experience workforce in the South Western Sydney Local Health District. 

Solution

The Peer-STOC initiative provides additional supports to people transferring between Banks House and Community Mental Health to improve their health outcomes. Peer-STOC workers provide assertive and flexible support and post-discharge follow-up.

Peer-STOC support focuses on: 

  • meeting people while they are receiving care at Banks House
  • safe and purposeful sharing of lived experience knowledge and personal wellness strategies 
  • providing individual advocacy and support to people with lived experience of mental health issues to be involved in their care planning and discharge planning, by working collaboratively to identify their recovery goals to live well in the community
  • working collaboratively with the person, their health care team, and support network, to identify supports and services needed for a smooth transition into the community for the person and their carers/family. 

 

The Peer-STOC workers attend inpatient and community multi-disciplinary team meetings to advocate for the needs and preferences of the people they are supporting regarding care planning, discharge planning and ongoing support needs. 

Peer support workers with lived experience of mental health issues have been involved in the design, delivery and evaluation of the Peer-STOC Model of care in Bankstown Mental Health Service. 

Two Peer-STOC worker positions are supported by the Senior Peer Support worker and the community mental health and inpatient team managers and staff.

Outcomes

Peer-STOC contributes to individuals’ recovery by connecting them to a peer support worker during the difficult transition between inpatient care in the hospital and community-based care. The peer support workers act as beacons of hope for service users and their carers/families as they are a true reflection that recovery and living well with a mental health issue is possible. Peer-STOC workers empower and give people with lived experience opportunities to be active participants in their own recovery journey.

Next steps

Future plans involve evaluating and enhancing the service by continuing to gather feedback from people supported by Peer-STOC workers about their experience of the program. 

For further informaiton contact: Ashley Reynolds, Senior Peer Support Worker, SWS LHD,

T: 9616 4065 E: ashley.reynolds@health.nsw.gov.au