The Pathways to Community Living Initiative (PCLI) helps people with very complex mental health issues to return to living in the community, especially if they have stayed at a hospital mental health unit for more than 12 months.
Evidence shows that people with complex mental illness have better quality of life and better social outcomes if they have the right support to live in the community.
They may still need to stay at non-acute hospital units at times but can return to community living when ready. Where community-based care does not meet a person’s needs, mental health care in hospital is available.
Each person who has had a long hospital stay (12 months or more) or who is at risk of a long stay, takes part in a range of assessments.
This is to understand their strengths, clinical issues and support needs, and to understand their hopes and wishes for a fulfilling life.
Mental health clinicians and peer workers then work with each person, and their family or carer, to create a plan to ensure they can safely transition to community living through coordinated programs and support services.
This plan includes:
Transition to community living takes place in stages and includes tailored housing, clinical care and psychosocial support. Each person will move into a community setting at the right time. Ongoing care will be provided for as long as is required.
Each person’s experience on this journey and the transition to the community process is different and unique. This often includes forward and backward movement, while the person and their carer are supported to make their decisions.
The person is also able to visit the accommodation where they will be going and meet with the staff from the partnering organisation. Staff will provide support and work closely with everyone involved.
Families and carers will not be expected to be the primary care givers for their loved ones.
They will be offered the opportunity to discuss and support the person’s decisions as they move into the community. Families and carers will be helped during this process.
Some people in long-term care have stayed in contact with their families but many have lost contact with loved ones. Reconciliation with families will be explored.
These services operate locally. Please contact the mental health services within your local health district for further information.
The Pathways to Community Living Initiative is a coordinated, state-wide program that was established in 2015 as part of the Government’s commitment to strengthen mental health care in NSW.
The program focusses on developing options for people with severe and persistent mental illnesses to live in the community with the support they need.
PCLI clinicians work with individuals to understand their strengths, wishes and needs, investigate the best care pathways and identify the right models of care to help meet a person’s needs.
By 2021, more than 60% of the initial group of people who took part in the PCLI are living successfully in their communities. Many had been in hospital for many years.
