Information paper 1 - Partners in Recovery

Information about Partners in Recovery - coordinated support and flexible funding for people with severe and persistent mental illness with complex needs.

Page last updated: July 2012

PDF version: Partners in Recovery: information paper 1 (PDF 221 KB)

What is Partners in Recovery?

How will Partners in Recovery work in practice?


Around one in three Australians experience mental illness at some stage in their life. Mental illness accounts for 13 per cent of the total burden of disease in Australia, and is the largest single cause of disability, comprising 24 per cent of the burden of non‐fatal disease. Around 600,000 Australians experience severe mental illness and some 60,000 have enduring and disabling symptoms with complex, multi‐agency support needs.

Addressing severe and persistent mental illness requires a complex system of treatment, care and support, requiring the engagement of multiple areas of government, including health, housing, income support, disability, education and employment. The Australian and state/ territory governments as well as the non-government sector, all deliver programs for people with mental illness and their carers. Building a connected and coherent system of care is a challenging task.

Over recent years, all levels of government have been increasing their investment in mental health. The Commonwealth's Better Access, Access to Allied Psychological Services, Mental Health Services in Rural and Remote Australia and Mental Health Nurse Incentive programs have brought treatment to many who previously missed out. The significant increase in community mental health services, including the Personal Helpers and Mentors program and respite services for mental health carers, has also been widely welcomed by consumers and their carers and families.

One of the most consistent themes fed back to the Australian Government is that care for the most vulnerable people with severe and persistent mental illness is not adequately integrated or coordinated, and these people often continue to fall through the resulting gaps.Top of page

What is Partners in Recovery?

Partners in Recovery (PIR) aims to better support people with severe and persistent mental illness with complex needs (the 'target group') and their carers and families, by getting multiple sectors, services and supports they may come into contact with (and could benefit from) to work in a more collaborative, coordinated, and integrated way.

PIR will support the multi‐service integration needed to ensure services and supports are matched to people's need. PIR will facilitate better coordination of and more streamlined access to the clinical and other services and supports needed by people in the target group who require a response from multiple agencies.

Suitably placed and experienced non‐government organisations will be engaged (as PIR organisations) in Medicare Local geographic regions, and will be the mechanism that 'glues' together all the supports and services the individual requires.

PIR organisations will have access to a limited amount of flexible funding which can be used to purchase services and appropriate supports when needs are identified but are not immediately able to be met through normal channels. The flexible funding pool will enable the PIR organisation to buy‐in these services and supports, and is intended to be used to build system capacity and meet immediate and short‐term priority needs of the client.Top of page

Key objectives

The ultimate objective of the PIR initiative is to improve the system response to, and outcomes for, people with severe and persistent mental illness who have complex needs by:
  • facilitating better coordination of clinical and other supports and services to deliver 'wrap around' care individually tailored to the person's needs
  • strengthening partnerships and building better links between various clinical and community support organisations responsible for delivering services to the PIR target group
  • improving referral pathways that facilitate access to the range of services and supports needed by the PIR target group and
  • promoting a community based recovery model to underpin all clinical and community support services delivered to people experiencing severe and persistent mental illness with complex needs.
Through system collaboration, PIR will promote collective ownership and encourage innovative solutions to ensure effective and timely access to the services and supports required by people with severe and persistent mental illness with complex needs to sustain optimal health and wellbeing.Top of page


Implementation of PIR will be governed by the following key principles:
  • Recovery oriented and client focused: PIR will operate under a recovery framework using a personalised approach tailored to address the specific support requirements of an individual and assisting them to maximise their capabilities through social and environmental opportunities.
  • Flexibility in roll out: how PIR operates from one region to the next may look different, as a result of PIR organisations tailoring their model to best meet the needs of the target group and existing service delivery systems in the region.
  • Complementary to existing service systems: PIR organisations will assist with, rather than complicate or duplicate, system navigation. PIR does not seek to fully address issues of service availability but focuses on multi‐service integration and coordination to drive better outcomes for the most vulnerable clients.
  • Better coordination of systems: PIR is not intended to offer a new 'service' in the traditional sense. Rather, it will assist in better coordinating existing services and supports. PIR will provide a 'support facilitation' service focusing on building pathways and networks between the sectors, services and supports needed by the target group.Top of page

Target group

The initiative will focus on 24,000 people who have a severe and persistent mental illness with complex support needs that require a response from multiple agencies. These individuals have persistent symptoms, significant functional impairment and psychosocial disability, and may have become disconnected from social or family support networks. This can lead to extensive reliance on multiple health and community services for assistance to maintain their lives within community based settings and outside of institutional care. They may have comorbid substance use or physical health issues or both, are likely to experience difficulties maintaining stable accommodation, and experience difficulty in completing basic activities of daily living1. These individuals are reported to often fall through the system gaps and require more intensive support to meet the complexity of their needs.

It is anticipated PIR clients will generally be in their mid twenties and older, reflective of the typical development of severe and persistent mental illness. At younger ages, there are a range of other government programs, such as the Early Psychosis Prevention and Intervention Centre (EPPIC) program and headspace, aimed at early intervention for young people who may be developing a mental illness that aim to reduce the risk of long term disability.Top of page

Operational model

While the PIR roll‐out model may vary across regions depending on need and context, the common feature of all models will be the engagement of suitably placed and experienced non‐government organisations (PIR organisations) to deliver PIR across Medicare Local geographic regions: these will be the mechanism that helps 'glue' together all the supports and services the individual requires. PIR organisations will work at a systems level to drive collaboration, bringing together senior representatives from agencies with key responsibilities for the PIR target group. They will direct the strategies needed to achieve better coordinated services to improve overall outcomes for individuals referred to and accepted into the program.

PIR organisations will undertake a number of tasks, including for instance:

  • as a primary role, engage and join up the range of sectors, services and supports within a region from which individuals may need assistance. They will work to build partnerships, establish (or improve) collaborative ways of working together, and establish the framework to oversee implementation of the initiative at a local level. This could be achieved through:
    • undertaking detailed service mapping and gap analysis to establish a profile of the capacities and gaps inherent within the service delivery systems in the region
    • using the information generated through the service mapping and gap analysis to build capacity in the service delivery systems through invigorating existing and establishing new partnerships between service providers
    • establishing protocols with service providers to formalise partnerships and accountability mechanisms
    • building shared goals; sharing knowledge; mutual respect; frequent, timely and problem-solving/ solution‐focused communication; and fostering connectivity and collective ownership/ responsibility to ensure the needs of PIR clients in the region are met
  • complement, support or influence care coordination activities that may already be underway in the region
  • through development of system‐level partnerships, identify and proactively engage potential PIR clients, support carer and family engagement and reconnection as is appropriate, manage referral pathways, and manage stakeholder relationships and
  • monitor the ongoing effectiveness of the partnerships through use of appropriate resources and tools. Top of page
Appropriately skilled and experienced support facilitators will be engaged by the PIR organisation to undertake day to day tasks to achieve the initiative's objectives. In delivering the benefits of system collaboration to clients, the support facilitator could:
  • receive and review referrals that come to the PIR organisation and assess referred individuals against defined inclusion criteria (this could include facilitating the verification or arranging for the diagnosis of a severe and persistent mental illness if this is not immediately apparent or available through existing records2)
  • following the referral, undertake an assessment of the needs of PIR clients
  • in collaboration and with the commitment of regional PIR partners (and carers and families as is appropriate), develop, monitor and regularly review a PIR action plan that will guide the necessary engagement and integration of required services identified in the needs assessment
  • engage with existing case managers that may have a role in the care of the client. Where sufficient or effective management functions do not exist for the client, support facilitators could undertake the case management role in the interim with a view to establishing this function early in the implementation of the PIR action plan through identification of a new case manager
  • in working to improve the system response to a PIR client, engage with and follow up services and supports, build service pathways and networks of services and supports needed (wherever possible, the support facilitator should try to secure access to existing services and supports, reinforcing the expectation of existing services being available and accessible to assist PIR clients) and
  • be a point of contact for PIR clients, their families and carers when service arrangements are not working or the client becomes disconnected from required supports.Top of page
In undertaking their role effectively, PIR organisations and their staff will need to:
  • build and maintain effective relationships and partnerships and have strong networking ability
  • be confident in the appropriate use of authority (with clients and with the range of service providers within the region)
  • have strong communication and negotiation skills
  • have capacity to: engage with people who have often been difficult to work with; share experiences and information; and analyse and formulate assessment/ plans
  • have experience within and understanding of clinical/ health and/or welfare service and support systems
  • have an understanding of mental health issues and/or experience working with people with severe mental illness
  • encourage a recovery‐oriented culture and possess personal qualities such as humane concern, empathy with both the client issues and service provider experience, imagination, hope and optimism
  • contribute to ongoing monitoring and iterative evaluation processes in order to assess the impact of the initiative and its success in contributing to improved system and client outcomes and
  • access baseline resources and tools to support them in undertaking their roles (for example operational guidelines; standard referral tools; needs assessment frameworks and tools; a PIR action plan; partnership building and governance tools; information sharing protocols; planning, coordination, and communication tools).Top of page

Referral pathways, inclusion and exit criteria

Referrals to PIR organisations will be assessed by support facilitators. Early and thorough communication by PIR organisations across each region will assist in maximising appropriate referrals and ensuring inappropriate referrals are kept to a minimum. To become 'registered' with a PIR organisation, individuals referred need to meet the following inclusion criteria:
  • the client has complex needs that require substantial services and supports from multiple agencies (this is the main inclusion criteria as PIR is about coordination of services and supports across sectors)
  • the client has a diagnosed mental illness that is severe in degree and persistent in duration, and is willing to be referred for ongoing clinical treatment
  • the client has had recent engagement with services where there is a pressing concern about their mental health and/or related issues (this could include for instance, a hospital admission related to their mental illness)
  • existing service arrangements and coordination between services have failed, have contributed to the problems experienced by the client, and are likely to be addressed by acceptance into PIR and
  • the client consents to being involved in PIR.
PIR organisations will need to establish appropriate processes to handle referrals that are not accepted, to ensure the individual receives the supports they require outside of PIR. For instance, the client is referred back to the referrer with advice of other supports and services available in the region, or referred directly to more appropriate supports in the community.

A PIR client may 'exit' a PIR organisation when stable arrangements are in place, and they are accessing the required services and supports to meet their needs with no need for additional coordination or flexible funding support. PIR organisations could consider registering PIR clients as 'active' or 'non‐active' recognising that some clients may need support periodically and at different levels of intensity. Non‐active clients could access the PIR organisation as the need arises and as they are able to benefit from it. PIR organisations will be required to determine how best to manage clients in the longer term, following the provision of more intensive support received as 'active' clients.Top of page

PIR flexible funding

The aim of PIR is to utilise the existing service delivery system and make its integration more effective, rather than to establish new service delivery functions. However, where required services are not directly or immediately available, a flexible funding pool managed by the PIR organisation will enable the short term buy‐in of these services. The PIR flexible funding is intended to be used to build system capacity rather than divert responsibility from existing service providers.

PIR flexible funding may not necessarily be attached to individual PIR clients but will provide a pool for the PIR organisation to draw upon to best meet the needs of PIR clients within the region. PIR flexible funding could be combined to address essential regional service gaps, or it could be used to cover a range of short term expenses to meet the priority needs of a PIR client such as access to clinical care (e.g. physical health checks or dental care), urgent accommodation support, vocational skills, peer support, counselling/ behavioural management, connection to social activities and recreation, support to get to services (e.g. taxi and bus fares), respite, assistance with financial management, or parenting support and skills development.

Clear parameters will be established to ensure consistency in the use of PIR flexible funding across PIR regions, while still allowing flexibility so that the funds can be used in a way that enables tailored support and provides maximum benefit to the PIR organisation and PIR clients within the region.

It is important that in the main, PIR clients access services available within the existing network of service providers, rather than build a reliance on PIR flexible funding. PIR flexible funding will not be sufficient to meet the acute health care and intensive social support and housing needs of PIR clients on an ongoing basis. PIR organisations will need to establish an expectation that PIR clients will be serviced by the existing network of providers.Top of page

How will Partners in Recovery work in practice?

The following case study is presented to highlight the complex and multi‐agency needs of the clients targeted under this initiative, and how PIR might operate to ensure the full range of an individual's needs are met and to support the integration and coordination of service provision at a systems/ cross‐sectoral level. Actual models may vary from one region to the next depending on population and service delivery system contexts.

Case study #1: Andrew – a consumer perspective

Andrew is a 48 year old man who was admitted to a local hospital after presenting with serious physical injuries and acute auditory hallucinations following an assault. Hospital staff ascertained Andrew had engaged sporadically with crisis services over several years in three different states. Andrew said he had been diagnosed with schizophrenia and that he tended to lapse into "old ways" of drinking binges when he felt down or when the hallucinations were strong. When things "went bad" he would try to escape in the hope of a new life. Consequently, he had difficulties sustaining housing, and community mental health services had experienced difficulty with sustaining engagement with Andrew due to his transient lifestyle. Services were often only engaged after his discharge from hospital following alcohol or psychosis‐related crisis interventions. It appeared Andrew had been in contact with clinical mental health services, homeless services, police, Centrelink and drug and alcohol services but when he moved interstate, contact would be lost. Andrew said he was tired of living like this and wanted a more sustainable solution, but that he intended to move back to a larger metropolitan area following discharge.

The hospital social worker, Sally, contacted the regional PIR organisation and local state clinical mental health team within days of Andrew's admission, noting that discharge planning could be complex and involvement of the PIR organisation may be beneficial. Sally completed the PIR referral form.Top of page

Upon review of the referral from Sally, the PIR support facilitator, Miriam, met with Andrew and Sally while he was in hospital to talk about how the PIR initiative may assist. Andrew agreed participation in PIR may be of benefit to him, and agreed for Miriam to gain information (assessments and management plans) from services he had been in contact with to gain a better understanding of his history. Through this process, Miriam was able to confirm Andrew had been diagnosed with schizophrenia.

Following consideration of the information gained, Miriam met with Andrew to assess his full range of needs. Based on this assessment, Miriam worked with Andrew to develop a PIR action plan which identified the clinical and other support services he required, and outlined a step by step plan to access the services. These included:

  • community mental health to re‐engage clinical case management (including any necessary clinical assessments and medication reviews)
  • a GP to monitor Andrew's physical health and assessment of readiness to engage with alcohol rehabilitation services
  • drug and alcohol services to provide support to manage his alcohol and drug concerns and refer to drug and alcohol rehabilitation
  • the local Personal Helpers and Mentors (PHaMS) service to support Andrew's recovery
  • a local supported accommodation service (for short term housing solutions)
  • public housing (for long term housing solutions) and
  • Centrelink to ensure Andrew receives the correct payment and entitlements and to ensure nominee and Centrepay arrangements were in place where appropriate.Top of page
The PIR organisation had previously established Memoranda of Understanding (MOU) with all of these agencies within which they had agreed on principles they would each adopt to work in partnership to best support the PIR clients in their region.

Using the partnership arrangements the PIR organisation had in place (including the MOU), Miriam took Andrew's case and the draft PIR action plan to the PIR working group, which included representatives from a range of services within the region. The working group reviewed Andrew's history and the draft PIR action plan, discussed options to support Andrew upon discharge, and also discussed ways to ensure Andrew could receive the services and supports he needed when he needed them. The working group refined the PIR action plan to ensure the delivery of services was scheduled in a prioritised and coherent way for maximum benefit to Andrew. All services involved in the working group signed the PIR action plan, formally committing to their identified role in supporting Andrew. A copy of the PIR action plan was provided to Andrew and the relevant services.

The working group agreed the local community mental health worker, Shane, was best placed to be Andrew's lead clinical case manager and Shane agreed to work closely with Miriam to make sure the required clinical and other supports were available to Andrew in a coordinated and seamless way.

Miriam and Shane met with Andrew and Sally at the hospital to discuss his discharge planning. Andrew agreed to work with Shane on a daily basis following discharge. Upon discharge, Andrew moved into supported accommodation which Miriam had organised through the PIR working group.

The PIR working group had identified a case coordination team was available within the local Centrelink service centre. Miriam connected Andrew to the Centrelink case coordinator, Pat. Pat was able to meet with Andrew at the supported accommodation to review his Disability Support Pension (DSP) arrangements. Andrew's DSP status and payments were all up to date, however, Andrew advised he had not actually accessed his bank account for over six weeks as he had lost his ATM card and had not gone into the bank to get a new one. Pat supported Andrew in contacting the bank and in working through what needed to be done to obtain a new card.Top of page

Pat also discussed nominee arrangements with Andrew. Andrew agreed having a correspondence nominee would be a good idea and Pam helped Andrew establish his brother as his nominee. Pat also explained that when Andrew was ready, she could help him access supported employment through a Disability Employment Service. Pat arranged to meet with Andrew after one month to make sure all arrangements were still working for him. An overview of this meeting and its outcome was sent to Miriam.

While in supported accommodation, Shane arranged for Andrew to meet with a psychiatrist and GP to review his medication and physical injuries, and discuss his alcohol use. Andrew agreed to attend a residential drug and alcohol rehabilitation service. Shane made all of the arrangements with the rehabilitation service, who were prepared for Andrew's referral given their initial participation in the PIR working group. Shane sent weekly updates to Miriam on clinical activity and progress against the PIR action plan.

During Andrew's time in rehabilitation, the public housing officer who had participated in the PIR working group contacted Miriam to advise that Andrew had been on the public housing waiting list when he had been in this state three years previously and that he had actually missed out on a flat about three months earlier because they were unable to contact him. It was likely accommodation would become available in the local area shortly, and it would be offered to Andrew. Miriam contacted Pat to assist Andrew to set up a Centrepay account to support automatic rental payments from his bank account once he moved into the flat.

The supported accommodation service had also contacted Miriam to advise they would no longer be able to accommodate Andrew when he finished rehabilitation, even if his flat was not available at that time. Miriam confirmed with the public housing officer that the wait for the flat would be no longer than one week from the time Andrew was to finish his rehabilitation. Miriam therefore drew on the flexible funding pool managed by the PIR organisation to purchase accommodation in a private hotel for Andrew for the week prior to the flat becoming available.Top of page

The local PHaMS service had attended the PIR working group meeting and was available to meet with Andrew when he was ready. Andrew decided he would like to meet with PHaMS on completion of the drug and alcohol rehabilitation program. A PHaMs worker, Julie, met with him prior to his discharge from the program. Julie worked with Andrew to develop an individual recovery plan based on his recovery goals. Julie and Andrew worked together to ensure the plan aligned with Andrew's PIR action plan. Andrew's individual recovery plan was provided to Miriam to be incorporated into his PIR action plan. Upon discharge, Julie worked intensively with Andrew and supported him to move into the private hotel for a week and then his new flat, make social connections, and maintain his connection with clinical mental health services and drug and alcohol services. Julie worked with Andrew towards his goal to re‐enter the workforce by connecting him with a peer support worker to increase his confidence, assist him to gain support for skills training, and help him seek employment. Julie and Andrew also worked with Pat (Centrelink case coordinator) to explore supported employment options through a Disability Employment Service.

Prior to his engagement with the PIR organisation, Andrew's contact with the services and supports he required was sporadic and patchy. He had been in contact with all the relevant services in an ad hoc way, but they had not been working together to sequence or coordinate their support to Andrew. In addition, once Andrew's accommodation arrangements changed, most services were unable to find him to sustain their contact. Through the collaborative development of the PIR action plan, each provider was aware of the planned nature and timing of Andrew's contact with other providers and was able to target and tailor their support to Andrew. Miriam's oversight of the collaborative efforts enabled her to keep everyone informed of how things were tracking and advise when variations to the PIR action plan were required.

Miriam was instrumental in gaining agreement by the services to provide intensive support for Andrew. This included sharing assessment of Andrew's concerns and needs, which meant Andrew didn't need to retell his story to each service. The PIR working group agreed Miriam would follow up with them every two weeks for two months and monthly thereafter for another six months to ensure Andrew was gaining the planned support, and make adjustments to the PIR action plan as needed.Top of page

Two years later Andrew decided to travel to a bigger city to explore further work options. This time, however, Andrew agreed to do this in a more planned manner that could allow him a greater chance to remain stable. Through PIR arrangements, Miriam was able to contact the PIR organisation in the city Andrew was moving to, and with Andrew's consent, share information about Andrew, including the PIR action plan. The PIR organisation in the city was able to use its partnership arrangements to connect Andrew with support services on his arrival and support him in the longer term.


For further information about Partners in Recovery, please email Partners in Recovery at
Phone: (02) 6289 9528


1 The target group for PIR is intended to reflect the issues and concepts identified in the Position Statement by the National Mental Health Consumer and Carer Forum (NMHCCF) on Psychosocial Disability Associated with Mental Health Conditions
2 Individuals referred to PIR organisations do not have to have a diagnosed severe and persistent mental illness with complex needs. However, obtaining such a diagnosis should be a priority.

Page last reviewed: 15 March 2013

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