January 20, 2026What do consumers and carers need from their mental health services to make their lives better? This is one of the questions we’re always asking as we work towards building stronger relationships and improving outcomes for everyone that accesses our services. In line with the recommendations from the Royal Commission into Victoria’s Mental Health system and guided by the principals of the Mental Health & Wellbeing Act of 2022, Northern Health has redesigned the model of care for adult community services.
We’ve been listening to our consumers and carers and recognise that episodic care can result in disjointed and protracted recovery journeys, with consumers finding it difficult to re-enter the service at a time that suits them. In response to this need, we have changed our community services to an ongoing model of care. The aim is to provide better access and timely specialist mental health services, with a focus on consumers’ recovery and prevention of relapse. Services are designed to provide the right level of support and flexibility that meets the consumer’s care needs, with the focus of keeping people well in the community.
Within the four community teams, care is offered in streams, with options for enhanced clinical services and outpatient streams, in addition to the traditional case management which we call the clinical recovery stream. This model, which has been built on codesign at every step, provides increased supports to consumers whose needs are more complex in the enhanced stream and also provides consumers who would have traditionally been discharged to the care of their GP, the option to transition to an outpatient stream of care, with less intensive ongoing support for as long as they choose to engage. Early warning signs of relapse can be picked up, with an easy transition to more intensive treatment and care in the community setting. Consumers in all streams continue to have access to a suite of specialist interventions and group programs to support their wellbeing.
From its inception, the model of care was developed with codesign by Lived Experience and clinical staff within the community teams. Peer workers and the Consumer and Carer Advisory Group provided valuable input through the lens of consumers and carers. Prior to implementing the enhanced stream, a consumer journey exercise was undertaken to test the transition points between streams and communication processes from the viewpoint of consumers and carers. In this exercise, the peer workers assumed the perspective of the consumer and carer to provide valuable insights to inform processes and education and training for our clinical teams. Also critical to the new model is the development of the Peer Support Opt Out model, where consumers and carers are offered the support of a peer worker to “walk alongside” them throughout their journey.
Phase one of the model of care has been operational for 18 months and early analysis of data indicates very promising reductions in Emergency Department presentations and admissions for the consumer who have chosen to continue in the outpatient stream rather than being discharged to their GP. With the enhanced stream being implemented soon, we are excited to see the positive impact the codesigned model will make in the lives of our consumers and their families.
