Showcasing: Primary Integrated Care Supports (PICS) Program

Central and Eastern Sydney

Lead agency
One Door Mental Health, One Door Health Care

Living Well domain

Providing the right type of care

PICS Program

Program Overview

Central and Eastern Sydney Primary Health Network (CESPHN) has redesigned the Mental Health Nurse Incentive Program (MHNIP), through a co-design process to develop the Primary Integrated Care Supports (PICS) program. PICS has expanded the number of credentialed mental health nurses and introduced peer workers to work in collaborative care teams. 

One Door Mental Health, as the successful tenderer, has introduced a community-based service model, partnering with local communities and health services. The partnerships include key relationships with the 3Bridges Community, Lebanese Muslim Association, Newtown Traders and many others to deliver services in communities where people live.



PICS credentialed mental health nurses provide clinical care and coordination with peer workers working with people to achieve their recovery goals, to support their transition to primary care. 



Providing the right support for people in the community living day to day with severe mental illnesses can be complex. Ensuring people receive the right information, treatment and support through a primary care GP service is a priority. GPs are challenged in providing effective care with restricted time appointments, complexity of the person’s illness and providing care in a community setting. Specialist appointments with private psychiatrists can also be limited due to large out of pocket costs and lack of availability of bulk billing appointments. The increasing number of referrals and the introduction of the NDIS are challenges facing all services which reduces the capacity to provide timely non-acute care. Other challenges include effectively providing support to people with multiple health conditions such as physical health problems, alcohol and or drug use and chronic diseases. 


The PICS Program aims to reduce the confusion people experience when navigating mental health and other services and provide an entry point to support people living with severe and ongoing mental illness. To achieve this, PICS assists in connecting people to services that support them to live well in the community through primary care. 

PICS delivers person-centred care and support. Each person collaborates with their PICS team to work on their unique support needs. People are linked to GPs, psychiatrists, psychologists and programs to build social connections and engage in community-based wellness activities. Many people referred to PICS have limited support from carers or family actively involved in their lives and can experience social isolation. The PICS team-based approach supports people’s clinical and psychosocial needs.



The PICS program has supported over 1,800 people in total and currently supports 1,000 people. Each month, PICS nurses work with around 500 people and peer workers engage with 125 people. The service has greatly assisted individuals by providing a higher level of mental health and psychosocial support to people accessing primary health care for their mental health needs. The support provided through PICS has also supported people to receive the right care and support in the community avoiding unnecessary emergency department presentations or hospital admissions. Over 53% of people reported that their levels of distress, anxiety and depression has significantly decreased, (as measured through the psychological instrument, K10 scale of mental health and wellbeing). Ninety-three per cent of people have reported positive experiences in their Your Experience of Service (YES) surveys. People supported by the service have reported improved access to physical health care, increased involvement in the community, improved living skills and improvements to overall mental health. 

Next Steps

The PICS program will continue to provide services in the Central and Eastern Sydney Primary Health Network area, building on its strong partnership with the GPs, Local Health Districts and many community partners. 

PICS is supported by funding from the Australian Government through the PHN Program.