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Partners in Recovery: question and answer booklet on the engagement of PIR organisations, version 3 (this booklet is being used as an addendum to the invitation to apply)

Coordinated support and flexible funding for people with severe and persistent mental illness with complex needs.

The PIR question and answer booklet provides official responses to all relevant queries received by the department on PIR and its implementation. It acts as an addendum to the invitation to apply for funding to engage PIR organisations and will be updated with new questions as appropriate. All parties who have downloaded the invitation to apply will be notified via email when a new version of the question and answer booklet is uploaded to this website.

Partners in Recovery (PIR) question and answer booklet on the engagement of PIR organisations, version 3 (PDF 453 KB)

• Version 1, 6 September 2012 - all new content
• Version 2, 16 October 2012 - new questions A5, B16 to B29, C16 to C19, and D3 to D5. Amendments to B1 and B2.
• Version 3, 9 November 2012 - new questions A6, B30 to B36, C20 to C23. Amendments to questions B1, B8, B9, B20, C5 and C14.

A. General/background

1. How was PIR developed?
2. What is the difference between care coordination and case management?
3. Where do the estimates of 60,000 people with severe and persistent mental illness with complex needs come from?
4. Why is PIR only helping 24,000 people with severe and persistent mental illness with complex needs when there are 60,000 people in this group that require support?
5. What does 'incorporated' mean?
6. What are the PIR target group estimates?

B. Funding and applying for funding

1. When does the invitation to apply close, and what are the implementation timeframes for PIR?
2. Which organisations are eligible to apply to become PIR organisations?
3. Can state/territory funded services apply for funding to become PIR organisations?
4. How many PIR organisations will be funded in a Medicare Local geographic region?
5. Can PIR funding be used to top-up existing services and programs?
6. If there is no suitable housing service immediately available for a PIR client, can PIR funding be used to purchase it?
7. If a region does not have a specific service available, such as a mental health specialist, can the PIR funding be used to hire one?
8. What proportion of the total funding provided to the PIR organisation can be apportioned to the flexible funding pool?
9. What are the key elements that need to be included in the application for funding, and how much detail can be developed once successful PIR organisations are engaged?
10. What is a lead organisation?
11. If there is already a successful care coordination model operating within the region, can PIR funding be used to improve existing efforts, or is a new model required to be developed?
12. Are there any GST or income tax-related issues involved in receiving funding?
13. When will my organisation receive the funding?
14. Can my organisation be allocated less funding than it applies for?
15. Can my organisation apply for PIR funding for alternative projects?
16. If an organisation did not attend the PIR information sessions can they still apply to become PIR organisations?
17. Should all relevant service providers across different sectors in a Medicare Local geographic region be involved in the regional planning process in determining how PIR could best be implemented within a region, and in determining which organisation is best placed to undertake the role of a PIR organisation?
18. Are local and state and territory governments expected to be part of the PIR organisation consortia or partnership model?
19. What is the role of a member of a PIR collaboration, consortium or other joint arrangement?
20. Can a Medicare Local be a member of a PIR collaboration, consortium or other joint arrangement?
21. Does the funding to PIR organisations compensate for the additional costs associated with delivering PIR in rural and remote communities, such as travel?
22. Can a PIR organisation use cross regional models and/or subcontracting models?
23. Will my organisation have to spend the funding by a particular date?
24. Can assets be purchased with the funding?
25. Can PIR assist with the long term accommodation needs for a PIR client?
26. Can flexible funding be used to support parents and carers of PIR clients, including children who are the primary carers for PIR clients?
27. Can organisations apply for more than one grant under the PIR funding round?
28. Will extensions to the due date of applications for funding be considered?
29. How will applications be assessed?
30. What format should applications be submitted in?
31. What is required to address assessment criterion 7 – client management information system on page 31 of the ITA?
32. Why is the department asking for information on 'other sources of funding' in the ITA?
33. What is an appropriate referee for an application?
34. Will competitive applications delay or prevent the engagement of a PIR organisation in a region? That is, if there is more than one application received from a region and efforts of collaborative planning in developing one application per region have not worked, will a PIR organisation still be funded in that region?
35. Will the department run more than one funding round to establish PIR organisations?
36. Will any organisations be given priority or preference to receive funding?

C. Implementation

1. What are the referral pathways to PIR organisations?
2. How can cross-sectoral engagement and partnerships be developed to support the implementation of PIR within a region?
3. Is PIR intended to be parallel to existing state mental health systems or complementary?
4. In rural and remote areas, what if there are no services to coordinate as part of PIR?
5. Will the same 24,000 clients be accessing PIR over the four years?
6. Are the clients of state-funded mental health services eligible to access PIR?
7. Are people who are incarcerated or exiting a prison system eligible to participate in PIR?
8. Are individuals with a DSM-IV Axis II diagnosis eligible to access PIR?
9. How will the views of carers and families be taken into account in PIR?
10. Will PIR organisations be required to prioritise geographic coverage or target population coverage?
11. What types of skills should a support facilitator have?
12. What is the PIR capacity building project and how will it be established?
13. What training will be provided to PIR organisations and support facilitators?
14. How will PIR be evaluated and monitored?
15. What role are Medicare Locals expected to have in the implementation of PIR within a region?
16. In regions where there are minimal or no formal case managers within the clinical system, can a support facilitator undertake the case management role in the short term and/or long term?
17. Who will be responsible for diagnosing an individual as having severe and persistent mental illness with complex needs?
18. What is the inclusion/eligibility criteria for acceptance to PIR?
19. Is PIR an ongoing or lapsing program?
20. What is the eligible age range for clients to participate in PIR?
21. What is the PIR capacity building project?
22. Will PIR provide financial support for attendance at workshops and meetings?
23. What is the PIR resource development project?

D. How does PIR relate to other initiatives?

1. How does PIR relate to the Flexible Care Packages announced in the 2010/11 Federal budget?
2. How could the Personally Controlled Electronic Health Record (PCEHR) be used by PIR clients and organisations?
3. What is the difference between PIR and the Personal Helpers and Mentors program?
4. What impact will the National Disability Insurance Scheme (NDIS) have on PIR?
5. How can the Mental Health Nurse Incentive Program (MHNIP) be used by PIR clients and organisations?

E. More information

1. Who should I contact if I need more information?

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A. General/background

A1. How was PIR developed?

The department has worked closely with key stakeholders and experts, including mental health consumers and carers, to inform the development of PIR. Consultations have included:

• Stakeholder workshops held by the Mental Health Council of Australia and the Australian General Practice Network in 2011 to support early stakeholder input to the development of the operational model.
  
  
• Ongoing bilateral discussions continue to be held between the department and all state and territory mental health directors to identify key issues, explore the learnings and challenges of existing care coordination efforts, and consider how best PIR will complement existing efforts and service systems.
  
  
• An Expert Reference Group (ERG) was established in 2011 to provide expert advice and cross sectoral leadership on the development and implementation of PIR. The ERG membership is available in the media release Mental health matters - an update on reform from the minister.
  
  
• Other meetings have also been held with a range of stakeholders to inform implementation planning. Top of page

A2. What is the difference between care coordination and case management?

PIR will work with all agencies and services in a Medicare Local geographic region that have a role in the delivery of health, welfare and other support services that people with a severe and persistent mental illness and complex needs may come into contact with and could benefit from. Better collaboration and integration between services and sectors will ensure the full range of services and supports the individual requires are delivered in an integrated and well sequenced way. PIR will facilitate this level of care coordination through a system focus, to effect change and achieve improved client outcomes. Care coordination navigates the system on behalf of the client.

Case management tends to focus more on assisting the client to navigate the clinical care system. Few case management models support the capacity to work with the entire system across different sectors to improve client outcomes – this is the focus of the care coordination to be offered by support facilitators through PIR. PIR will recognise and work with existing case management functions to ensure effective approaches are maintained as a key element of the overall support to a PIR client. Top of page

A3. Where do the estimates of 60,000 people with severe and persistent mental illness with complex needs come from?

The size of the PIR target population is based on internal modelling conducted for the department, drawing on multiple sources of information covering prevalence of mental illness and level of severity¹. The estimates were based on three elements:

1. the estimated number of adults with severe mental disorders;
2. the estimated subgroup of this population who have a severe and persistent mental illness; and
3. of this latter group, the estimated proportion who have complex and multiple service needs.

People experiencing severe and persistent mental illness do not all have the same needs for coordinated care in the community. Some live in long term hospital or residential in-patient care and may not require additional coordination or service linkage arrangements. Others may have networks that support them and facilitate access to the services required.

But some individuals with persistent symptoms and significant functional impairment may have lost social or family support networks, and rely extensively on multiple health and community services for assistance to maintain their lives outside of institutional care. Many individuals will have comorbid substance misuse and/or physical health issues. They are likely to experience difficulties maintaining stable accommodation, and experience difficulty in completing basic activities of daily living. This group is the focus of the PIR initiative. Top of page

A4. Why is PIR only helping 24,000 people with severe and persistent mental illness with complex needs when there are 60,000 people in this group that require support?

While PIR will specifically focus on 24,000 people with a severe and persistent mental illness with complex multi-agency support needs, it is expected the system collaboration fostered through PIR will have flow-on impacts to a broader number of individuals and service providers.

PIR is not just about the support facilitators providing care coordination. It is also fundamentally about improving the way all care and support services work together. While PIR will work directly with 24,000 people, the overall intention of the initiative is to create a better care service system for all 60,000 people. This will be achieved through a focus on improving the care and coordination between different parts of the service system, such that effective and smooth referrals and coordinated care can take place for any person experiencing severe and persistent mental illness and complex needs, irrespective of whether they are within the 24,000 direct beneficiaries or the larger group of 60,000.

By way of example, if the local alcohol and drug clinician is meeting with the supported accommodation worker and the mental health nurse to discuss a PIR client's care, they are also, by default building an ongoing line of communication between these three services. And there is a very high likelihood that other people known to the services can also be discussed.

The effectiveness of PIR at the systems-level and at the client-level will be informed by ongoing monitoring and evaluation activities, and these activities will inform the ongoing roll-out of the initiative. Top of page

A5. What does 'incorporated' mean?

To be eligible to apply to become a PIR organisation, Applicants must be an established incorporated non-government health and welfare service provider.²

'Incorporated' refers to a body corporate established under legislation or by royal charter as a separate legal entity having the legal capacity to do anything a legal person may do, including (but not limited to):

• entering into legally binding contracts
• having the capacity to sue and be sued and
• owning property

in its own name.

Examples of some incorporated legal entities are as follows:

• Incorporated Associations. They usually have 'Association' or 'Incorporated' or 'Inc' in their legal name and are incorporated under state or territory legislation.
• Incorporated Cooperatives. They usually have 'Cooperative' in their legal name and are incorporated under state or territory legislation.
• Companies. They may be a not-for-profit or for-profit proprietary company [limited by shares or by guarantee] or a public company. They commonly have 'Pty Ltd' or 'Ltd' in their legal name and are incorporated under Commonwealth legislation (Corporations Act 2001).
• Aboriginal Corporations. They are incorporated under Commonwealth legislation (Aboriginal and Torres Strait Islander Act 2006) and administered by the office of the Registrar of Aboriginal and Torres Strait Islander Corporations.
• Incorporated limited partnerships. They are incorporated under state or territory legislation.
• Organisations established as a body corporate under their specific Commonwealth, state or territory legislation. They include many public benevolent institutions, churches, universities and unions. Top of page

A6. What are the PIR target group estimates?

The target population for PIR is 24,000 people with severe and persistent mental illness with complex needs across Australia. This represents approximately 40% of the total estimated population of 60,000 people nationally with severe and persistent mental illness with complex needs. It is expected that PIR implementation will ramp up each year to reach the target population of 24,000 by 2015-16.

The regional PIR target group estimates on pages 21-22 of the PIR Program Guidelines (last column) are intended to provide an estimation of the number of people within each Medicare Local region that PIR will target when at maximum capacity. To develop these estimates, the Department used 2010 Estimated Resident Population figures provided by the Australian Bureau of Statistics (ABS), based on 2006 Census Collection District data. For additional population figures, you may wish to contact the ABS at www.abs.gov.au.

Applications for PIR funding will need to provide a detailed demographic profile of the region, including identifying the number of people in the region expected to be in the PIR target group, projected client target numbers for each financial year, and articulate a model which will best meet the needs of the specified target group in that region. Applicants can use other data sources in this process, however such data should be drawn from authoritative verifiable sources. It should be noted however, that the Department will determine final funding amounts for each PIR Organisation in the context of total funding available for all regions.

B. Funding and applying for funding

B1. When does the invitation to apply close, and what are the implementation timeframes for PIR?

The closing date for the PIR invitation to apply (ITA) is 2.00pm (AEDT) on Tuesday 18 December 2012.

Indicative timeframes outlined in material released prior to the ITA, such as the PIR program guidelines and information session materials, suggested an earlier closing date. Consideration of issues raised through the PIR information sessions, and the need for stakeholders to have sufficient time to undertake the necessary partnership development and regional planning activities contributed to determining the final closing date.

The PIR program guidelines were released on 7 August 2012. They were deliberately released prior to the call for applications to give services within Medicare Local geographic regions time to undertake the necessary regional partnership building and planning activities.

Based on the outcomes of the ITA process, it is anticipated that PIR organisations will be engaged from early 2013 and will initially focus on building the organisational and workforce capacity, ready to commence delivery of PIR and engagement of PIR clients from mid 2013.

It is intended that one funding round through a national ITA process be undertaken to engage PIR organisations. Through this process, the engagement of PIR organisations may be staged, depending on the categories in which applications will be ranked. Applications ranked 'highly suitable' and 'suitable' will be progressed first. In regions where 'further work required' or 'unsuitable' applications are received, consideration may be given to providing those regions with development support in order to support regional capacity and readiness to participate in PIR.Top of page

B2. Which organisations are eligible to apply to become PIR organisations?

Organisations eligible to apply for funding to become a PIR organisation must be:

• Suitably placed and experienced non-government organisations in the Medicare Local region in which they are applying, who can implement PIR in a way that best complements existing support and service systems and any existing care coordination efforts already being undertaken.
  
  
• For legal and accountability reasons, only incorporated, non-government health and welfare service providers³ are eligible to apply for funding. They could be funded by Commonwealth and/or state/territory governments, but would be governed independently, and be non-profit/charitable or for-profit or local community groups.

Given the collaborative nature of PIR, favourable consideration will be given to consortium applications. Consortium applications must identify the lead organisation to be contracted to the department, and outline the role of each partner in the consortium. An authorised representative of the lead organisation must sign the application.

Joined up or multi-regional approaches will also be considered if it can be demonstrated such an approach is a more effective and efficient way to deliver PIR (if, for instance, the PIR target group population numbers in one region are too small to sustain a PIR organisation and the system of service delivery extends to adjoining regions). Top of page

B3. Can state/ territory funded services apply for funding to become PIR organisations?

Only incorporated, non-government health and welfare service providers are eligible to apply for funding. They could be funded by Commonwealth and/or state/territory governments, but would be governed independently, and be non-profit/charitable or for-profit or local community groups.

State-funded services operating within each Medicare Local region will be important PIR partners in enhancing the integration of services and providing a better system response to the most vulnerable of people. Top of page

B4. How many PIR organisations will be funded in a Medicare Local geographic region?

In general, only one PIR organisation will be funded in each of the 61 Medicare Local geographic regions. Only under exceptional circumstances will consideration be given to funding more than one PIR organisation in a Medicare Local geographic region, and strong evidence must be provided in support of this. Such consideration will be given on a case by case basis.

The department appreciates some Medicare Local regions cover a broad geographic area. PIR proposed models should be innovative in their approach to ensure PIR coverage across the region. This could include, for instance, sub-contracting arrangements and the placement of support facilitators in out-posted sites.

Favourable consideration will be given to consortium applications. Consortium applications must identify the lead organisation to be contracted to the department, and outline the role of each partner in the consortium. An authorised representative of the lead organisation must sign the application form, along with a senior representative of partner organisations.

Joined up or multi-regional approaches will also be considered if it can be demonstrated such an approach is a more effective and efficient way to deliver PIR (if, for instance, the PIR target group population numbers in one region are too small to sustain a PIR organisation and the system of service delivery extends to adjoining regions). Top of page

B5. Can PIR funding be used to top-up existing services and programs?

Funding will only be provided for new PIR-specific tasks to be undertaken by an existing and established non-government organisation, even if the organisation engaged as a PIR organisation receives funding from another source to deliver programs and services other than PIR. The funding cannot be used to top-up funding of existing services and programs. Retrospective items/activities will also not be funded through the PIR initiative.

However, the flexible funding pool can be used to purchase short-term supports and services where these are not immediately available to meet the client's needs. Top of page

B6. If there is no suitable housing service immediately available for a PIR client, can PIR funding be used to purchase it?

The PIR flexible funding pool can be used to purchase services and appropriate supports when client needs are identified but are not immediately able to be met through normal channels. However, it cannot be used to pay for long-term housing requirements. The flexible funding pool could be used to arrange emergency short-term housing in the region if there are no suitable housing options immediately available to the PIR client.

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 for the benefits of PIR clients within the region, rather than divert responsibility from existing service providers.

Further guidance is being developed by the department on how the flexible funding should and should not be used, including timeframes, while still allowing flexibility to enable PIR organisations to respond the regional and client needs. Top of page

B7. If a region does not have a specific service available, such as a mental health specialist, can the PIR funding be used to hire one?

PIR organisations will have access to a limited amount of flexible funding which can be used to purchase services and appropriate supports when client 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 for the benefits of PIR clients within the region, rather than divert responsibility from existing service providers.

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 the flexible funding. The 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. PIR organisations should also be aware of the availability of any other funding sources which they could be eligible to use to supplement PIR funding.

Further guidance is being developed by the department on how the flexible funding should and should not be used, while still allowing flexibility to enable PIR organisations to respond the regional and client needs. Top of page

B8. What proportion of the total funding provided to the PIR organisation can be apportioned to the flexible funding pool?

The department recognises that some regions may need to buy-in services, additional service capacity and/or regional resources, to address the short-term or urgent needs of PIR clients that are not able to be immediately met by the existing service delivery system.

In recognition of this, an allocation of up to 50% of the recurrent budget to the flexible funding pool has been provided in the PIR invitation to apply (ITA) as general guidance. Proposed allocation of funds to the flexible funding pool will need to be supported by a strategy that contributes to the achievement of the aims and objectives of PIR. Applicants will need to ensure the suggested allocated amount of the flexible funding pool enables all other costs of implementing PIR within the region to be met. Applications should provide detail that is specific to the proposed PIR model and the regional need and context to justify the funding being sought.Top of page

B9. What are the key elements that need to be included in the application for funding, and how much detail can be developed once successful PIR organisations are engaged?

Information about the assessment of applications is available at part B of the ITA, pages 11-15. Applicants should ensure that all sections of part D (the application form) of the ITA, pages 19-41 are completed. Applicants should ensure that they are familiar with all aspects of the ITA, including the program guidelines.

The model and details outlined in a successful application will form the basis of contract negotiations with the department. Once in contract, PIR organisations will have the opportunity to further develop and refine the project plan and key details of the model, including the map of the existing service system within the region, as learnings are realised. Top of page

B10. What is a lead organisation?

If a joint (consortium) application with one or more other organisations (partners) is submitted, a lead organisation (that will be the PIR organisation) must be nominated. The lead organisation will, if the application is successful, sign the funding agreement with the department, receive the funding, assume legal responsibility for undertaking the activities specified in the funding agreement, and will be accountable to the department.

A lead organisation must be an incorporated body which is able to enter into the funding agreement. The other partner organisations do not have to be incorporated. Evidence must be provided from the partner organisations to demonstrate they support the lead organisation. Top of page

B11. If there is already a successful care coordination model operating within the region, can PIR funding be used to improve existing efforts, or is a new model required to be developed?

PIR aims to be 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.

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.

If an effective care coordination model is already in place within a region, applications should detail how PIR will complement and add-value to existing practices and efforts. It is important to note, PIR funding will only be provided for new PIR-specific tasks to be undertaken by an existing and established non-government organisation, even if the organisation engaged as a PIR organisation receives funding from another source to deliver programs and services other than PIR. The funding cannot be used to top-up funding of existing services and programs. The flexible funding pool can be used to purchase short-term supports and services where these are not immediately available to meet the client needs. Retrospective items/ activities will not be funded through the PIR initiative. Top of page

B12. Are there any GST or income tax-related issues involved in receiving funding?

Yes. The standard funding agreement will outline the taxes (including GST), duties and government charges for which successful funding applicants will be responsible.

The department recommends applicants seek independent advice regarding the income tax implications associated with the receipt of funding through PIR. Top of page

B13. When will my organisation receive the funding?

Successful applicants will receive an initial payment on execution of the funding agreement (that is, once the funding agreement has been signed by your organisation and by the department, representing the Commonwealth). All other payments of the funding will be based on deliverables (e.g. project plan, progress reports) as set out in the funding agreement. Top of page

B14. Can my organisation be allocated less funding than it applies for?

Yes. The program guidelines provide unweighted indicative estimated funding ranges that may be available to each region, based on the estimated number of potential PIR clients within that region (page 14, and 21-22). These funding range estimates have been provided to give regions an idea of the level of funding a region of their size could receive to implement PIR. Applications will need to include a detailed budget, and applicants should use the indicative estimated budget ranges provided in the program guidelines as a guide for this. Final funding amounts will be determined as part of the assessment process, and during negotiation of the funding agreement with the successful PIR organisation. Top of page

B15. Can my organisation apply for PIR funding for alternative projects?

No. The PIR funding is to be used solely for the delivery of the PIR initiative. Applications for funding must include a detailed budget for the proposed PIR model, identifying all associated costs. Budget costs must be justified and be limited to the costs of implementation of PIR within a specific Medicare Local geographic region. Applicants must demonstrate that the budget is sufficient to meet the PIR initiative's objectives and outcomes, and describe the intended benefits of the investment for the region (that is, demonstrates value for money).

Funding will only be provided for new PIR-specific tasks to be undertaken by an existing and established non-government organisation, even if the organisation engaged as a PIR organisation receives funding from another source to deliver programs and services other than PIR. The funding cannot be used to top-up funding of existing services and programs. Retrospective items/activities will also not be funded through the PIR initiative. Top of page

B16. If an organisation did not attend the PIR information sessions can they still apply to become PIR organisations?

Yes. Organisations that meet the eligibility criteria listed in the program guidelines (page 11) and in Question B2 are eligible to apply for funding, regardless of whether they attended the information sessions.

The program guidelines, information paper, fact sheet, information video with key stakeholder interview snippets,a recorded information session, case studies, and literature review are available in the mental health area of the department's website at www.health.gov.au/mentalhealth. Additional information, including the invitation to apply, will be made available at the same website as it is released.

B17. Should all relevant service providers across different sectors in a Medicare Local geographic region be involved in the regional planning process in determining how PIR could best be implemented within a region, and in determining which organisation is best placed to undertake the role of a PIR organisation?

All relevant service providers across different sectors in a Medicare Local geographic region are strongly encouraged to be involved, and actively participate, in the application preparation process. Applications will require detailed evidence of the regional planning and consultation processes undertaken in the preparation of the application, including the level of engagement that has been undertaken with each service provider (and why some service providers were not involved, if this is the case).

As a first step before considering which organisation is best placed to be the PIR fundholder/PIR organisation, regions are encouraged to:

• undertake initial mapping of relevant services across different sectors operating within the region that people with severe and persistent mental illness with complex needs may interact with, or need assistance from
• identify how PIR will build on the existing service system infrastructure within the region
• identify how a PIR model could best engage with the network of regional service providers identified in the mapping
• identify what the specific needs in the region are
• identify who the potential PIR clients in the region are
• identify what the issues are in being able to effectively join up services and sectors, and how PIR could best assist with this
• identify what a suitable PIR model for the region is, and what the service solutions on-the-ground are in the region that PIR could assist with and
• consider how PIR partnerships will be established and what the governance arrangements for the PIR model should be.

Undertaking these tasks first will set the foundations, and assist all relevant services in determining the level of commitment, capacity and capability they could genuinely contribute to ensuring the successful implementation of PIR in the region. This process will also assist in determining which organisation may be best placed to be the PIR organisation for the region and what the governance arrangements might be to oversee and progress implementation of a suitable model.

Organisations initiating these regional discussions should ensure all the relevant parties in the Medicare Local geographic region are advised of the process and invited to actively participate.

Collective agreement and ownership of the proposed PIR model outlined in the application will increase the likely success of effective partnerships continuing in the implementation of PIR. Demonstration of strong regional planning and consultative processes in determining a PIR model for a region will be an important factor in the application assessment committee(s) being convinced of the genuineness of the model and proposed partnerships, that the model has regional support and commitment from relevant sectors and services, and that the application has 'collective ownership' by all major stakeholders. These are all factors that demonstrate the region's (and applicant's) strong understanding of the 'cross-sectoral collaboration' intent of the PIR initiative. Top of page

B18. Are local and state and territory governments expected to be part of the PIR organisation consortia or partnership model?

The success of PIR will rely on the strength of sector and service partnerships created and fostered at a regional level and which build on the existing service system landscape operating within the region. Private, government (Commonwealth and state/ territory), and non-government services and supports expected to be involved may include, but not be limited to:

• Public community and specialist mental health services
• Private psychiatrists and psychologists
• Primary (e.g. GPs), secondary (e.g. OTs, optometrists, diabetes educators, dental) and tertiary (e.g. hospitals, specialists) health care services
• Alcohol and other drug treatment services
• Disability services
• Income support services (e.g. Centrelink as administered by the Department of Human Services)
• Supported accommodation services and other accommodation providers
• State/ territory public housing
• Personal Helpers and Mentors Program providers
• Support for Day to Day Living Program providers and providers of other relevant community based living skills programs
• Parenting support services
• Vocational rehabilitation services
• Education and employment services and
• Child protection, domestic violence and justice services.

PIR organisations will bring sectors, services and supports together to promote collective ownership by all partners and encourage the development of innovative solutions to ensure effective and timely access to appropriate services and supports required to meet the full range of client needs and to sustain optimal health and wellbeing. A number of government (Commonwealth and state/ territory) services and supports are expected to be involved. Indeed, state-funded services operating within each Medicare Local region will be important PIR stakeholders and, in some cases, partners in enhancing the integration of services and providing a better system response to the most vulnerable of people. Top of page

B19. What is the role of a member of a PIR collaboration, consortium or other joint arrangement?

If more than one organisation is involved in the application, one organisation will need to be identified as the lead organisation (that is, the 'PIR organisation' that will be contracted and accountable to the department and would be the holder of funds to implement the PIR initiative in a region) and an authorised representative of the lead organisation must sign the application form. For the purposes of PIR, members of a PIR collaboration, consortium or other joint arrangement are defined as having an integral role in the delivery of the proposed PIR model. For instance, this could include a funded role subcontracted by the PIR organisation. A senior authorised representative of any member of a PIR collaboration, consortium or other joint arrangement must also provide evidence of their support of the application through a formal letter of support.

B20. Can a Medicare Local be a member of a PIR collaboration, consortium or other joint arrangement?

Yes, a Medicare Local can be a member of a PIR collaboration, consortium or other joint arrangement. A Medicare Local may be an informal partner, a formal partner engaged through an MOU or similar agreement, or a lead PIR organisation. Their role, as per the role of other PIR partners in the region, should be jointly determined as part of the regional planning and development of the proposed PIR model, in preparation of the funding application. Applications must include evidence of each member's agreement to participate in the collaboration, consortium or other joint arrangement, as articulated in the proposed model, through a formal letter of support. Top of page

B21. Does the funding to PIR organisations compensate for the additional costs associated with delivering PIR in rural and remote communities, such as travel?

The 2011/12 Federal budget included a finite amount of PIR funding that will be distributed across all Medicare Local regions. The recurrent funding ranges outlined in the program guidelines on page 14 are indicative only and have not been weighted for rurality and socioeconomic disadvantage. When weightings are applied, funding amounts may vary by 20 - 30% per Medicare Local region. It is intended that these weightings will provide additional resources to address the higher costs associated with delivering services for hard to reach groups, including those in rural and remote locations.

Applications must include a detailed recurrent budget for the proposed PIR model, identifying all costs associated with the implementation of PIR within a specific Medicare Local geographic region. All costs, including any costs unique to a particular Medicare Local region, stated in the budget require justification for why those costs are required to support full implementation in the region.

Final budgets to be approved by the department will be primarily guided by population size, and will incorporate weightings for rurality and socioeconomic disadvantage. Top of page

B22. Can a PIR organisation use cross regional models and/or subcontracting models?

The program guidelines provide flexibility to consider cross regional models (i.e. across Medicare Local geographic regions) and subcontracting models to deliver PIR. Joined up or multi-regional approaches will be considered if it can be demonstrated such an approach is a more effective and efficient way to deliver PIR (if, for instance, the PIR target group population numbers in one region are too small to sustain a PIR organisation or the system of service delivery extends to adjoining regions). The PIR organisation may also propose to enter into subcontracting arrangements with other agencies within their, or a bordering, region for the delivery of PIR, particularly in order to be able to innovatively meet the needs of clients in hard to reach locations. This might include the out posting of support facilitators to regional, remote and/or rural areas. Applications that include cross regional models must include a detailed justification as to why such a model is required to support effective implementation of PIR.

B23. Will my organisation have to spend the funding by a particular date?

Funding will need to be expended in accordance with the funding agreement. Expenditure reports and an annual audited financial statement will be required within the schedule of reporting specified in the funding agreement. Reporting requirements will be monitored to track expenditure and to ensure any potential issues are identified and addressed accordingly.

B24. Can assets be purchased with the funding?

Funding provided to PIR organisations will need to cover all costs and expenses associated with the delivery of PIR within a region (such as staffing and on-costs, administration, regional capacity building, maintaining partnerships and networks, participation in monitoring and evaluation activities, operational costs, and the flexible funding pool). The funding provided cannot be used to fund major capital works, such as a new building, as the PIR organisation is required to be an existing and established organisation with existing base capacity and infrastructure to implement PIR. The acquisition of minor infrastructure, such as office equipment, or minor refurbishment to accommodate PIR, which is required to enable PIR organisations and support facilitators to undertake their roles, will be possible. Top of page

B25. Can PIR assist with the long term accommodation needs for a PIR client?

PIR flexible funding could be used to cover a range of short term expenses to meet the priority needs of a PIR client, while longer term solutions are being negotiated. This could include, for instance, meeting urgent accommodation needs through paying for short term accommodation in a private hotel if public housing or supported accommodation is not immediately available. The flexible funding, however, will not be sufficient to meet housing needs of PIR clients on an ongoing basis. Further guidance on the appropriate use of the flexible funding pool will be made available by the department when it is finalised.

B26. Can flexible funding be used to support parents and carers of PIR clients, including children who are the primary carers for PIR clients?

PIR recognises the important role of all carers and families (including children) in the recovery of a person with a severe and persistent mental illness and the supports that those carers and families may require. The flexible funding pool will aim to directly address the needs of a PIR client and/or better support PIR clients within the region. Further guidance on the appropriate use of the flexible funding pool will be made available by the department when it is finalised.

B27. Can organisations apply for more than one grant under the PIR funding round?

An organisation could apply for funding to be the PIR organisation in more than one Medicare Local geographic region. As required in all applications, evidence should be provided of regional support that the organisation proposed as the 'lead' is the most suitably placed and experienced to deliver the role of the PIR organisation for that region. Top of page

B28. Will extensions to the due date of applications for funding be considered?

The implementation timeframes for the PIR initiative will not allow for extensions to the due date of applications.

The department will only accept a late application if it is as a direct result of mishandling by the department. The invitation to apply will have further information about late applications.

Organisations interested in applying for PIR should use the program guidelines available on the department's website (www.health.gov.au/mentalhealth) to commence the planning and consultation process and ensure that they can finalise the application by the due date.

B29. How will applications be assessed?

Applications will be formally assessed by an assessment committee(s) established by the department. The committee(s) may seek independent advice (from state/ territory government representatives and other relevant stakeholders) to confirm the feasibility of the model proposed in each application.

Applications will be assessed against a series of assessment criteria, which will be clearly outlined in the invitation to apply, and which reiterate those contained in the program guidelines (pages 15-16):

• how well the application's proposed PIR model meets the PIR initiative's aims and objectives
• what the applicant's ability is to implement the proposed PIR model within budget and timeframes, as well as abide by and meet all accountability and audit requirements (as described in the project plan and budget)
• whether the application represents value for money
• how the applicant will work collaboratively with partners
• how the application's proposed PIR model will be communicated to all key stakeholders (as described in the communication strategy)
• what the level and proposed management of risk is associated with the application's proposed PIR model (as described in the risk management plan)
• what the relevance and strength of the knowledge, skills, capabilities and experience of the applicant is in achieving the proposed PIR model
• what the capacity of the applicant is to undertake all establishment phase activities and be ready to start accepting clients within three months of entering into contract with the department and
• what the readiness of the region is to start effectively implementing PIR (as demonstrated by the project plan, risk management plan and the partnership development strategy). Top of page

B30. What format should applications be submitted in?

The applications should be submitted in Microsoft Word 2010 compatible format or PDF format that has been created from other word processing software. This will enable certain elements of your application to be copied and pasted to assist in the assessment process. Scanned applications are not suitable as they are much larger and create inefficiencies for the assessment process. However, scanned images of signed and/or initialled pages within the application, including the declaration in section 5 (page 41) are permitted so long as the total file size does not exceed the 20 megabyte limit. If your application exceeds 20 megabytes, email application attachments separately. Do not zip or password protect your application or attachments.

B31. What is required to address assessment criterion 7 – client management information system on page 31 of the ITA?

As outlined in assessment criterion 7 of the ITA on page 31, applicants must provide comment about a suitable client management information system (CMIS). This should include describing any existing CMIS and associated processes currently being utilised by the organisation that could be used and transferred for use for PIR purposes (and at what cost). If a CMIS and associated processes are not easily transferred for use in PIR, applicants should explain what would be required to acquire or develop such a system/process and/or enable information migration, and indicate approximate costs in the budget.

It is not intended that addressing assessment criterion 7 should be overly onerous or highly technical. The department requires information about what is required to implement PIR, including consideration of a suitable CMIS, as well as associated costs. Applications should specify all costs of the proposed PIR model in the proposed budget, including comment on any costs associated with use of an existing or acquisition of a new CMIS and associated processes.

The program guidelines and ITA are not prescriptive with regard to aspects of the implementation model, and this includes the proposed CMIS to be used by PIR organisations. However, information gathered from responses to assessment criterion 7 will inform any further approach the department takes to support CMIS capacity for all PIR organisations.

Also note, as outlined in the program guidelines (page 7) and the ITA (page 30), PIR organisations will be required to participate in the evaluation and monitoring activities which will involve the collection of information on program implementation and uptake as well as details on PIR organisations, support facilitators, and PIR clients.

PIR organisations will need to consider how best to collate data from organisations participating in PIR across the region. As the holder of funds to implement PIR, the PIR organisation will be responsible and accountable to the department for ensuring that the funding is expended in line with contractual obligations. Top of page

B32. Why is the department asking for information on ‘other sources of funding’ in the ITA?

Information on 'other sources of funding' on page 25 of the ITA is being asked to give the department an idea of true implementation costs (eg. PIR funding received through the ITA, plus any other costs that might support implementation received from other financial sources). Information related only to funding the applicant receives from other sources that would be used to support implementation of PIR in some way is requested. Information on funding the applicant receives for non PIR-related activities is not required.

As per page 2 of the ITA, reference to the 'applicant' throughout the ITA document is to the proposed organisation that, if successful, will execute a funding agreement with the department as the PIR organisation. The table on 'other sources of funding' of the ITA only requests information on funding received by the applicant.

B33. What is an appropriate referee for an application?

The ITA (page 25) asks for the applicant to provide at least two referees who can attest to the applicant's skills, capacity, capabilities and experience in relation to being able to carry out the PIR project. If an application is a collaboration, consortium or other joint arrangement, the two referees should not be a part of the collaboration, consortium or other joint arrangement. A referee could, however, be a stakeholder that is not involved in the collaboration, consortium or other joint arrangement.

B34. Will competitive applications delay or prevent the engagement of a PIR organisation in a region? That is, if there is more than one application received from a region and efforts of collaborative planning in developing one application per region have not worked, will a PIR organisation still be funded in that region?

The success of PIR will rely on the strength and quality of the partnerships and collaborative arrangements that form the foundation of the proposed PIR model in each region. Collective agreement and ownership of the PIR model proposed in applications will increase the likely success of effective partnerships continuing in the implementation of PIR.

Approaches that are based on comprehensive, regional collaboration, consortia or other joint arrangements will be considered positively. Applicants will need to specify which stakeholders in the region were involved in the regional planning and partnership building processes and which were not. In cases where key stakeholders were omitted from planning processes and applications, applicants will need to provide details regarding these omissions.

It is important that proposed models and partnership arrangements are genuine and sustainable, and not proposed purely to facilitate early access to funding. Applicants should identify any potential issues with the proposed model and partnership arrangements in the risk management plan (ITA assessment criterion 5), as well as identify strategies to address and mitigate any identified risks.

Applications will be assessed and then ranked according to merit, suitability, readiness, and value for money. Rankings will range from 'highly suitable' (immediate engagement) to 'suitable' (engagement after clarification of issues), to 'further work required' (application needs to be reworked) to 'unsuitable' (not recommended for funding). These rankings are further outlined on page 12 of the ITA (part B - assessment of applications, clause 1.6).

The ITA funding round is not nationally competitive per se, as funding will be available to all regions - in general, one PIR organisation will be funded and established in each Medicare Local geographic region. Funding within the region will only become competitive if more than one application is received, and should multiple applications be received, consideration will be given to whether this reflects a lack of regional agreement about the approach. Funding will be offered in those regions where a coherent, collaborative model is proposed based on the needs of the target group and the existing service delivery system, and where it is demonstrated that the proposed model has the support of all relevant stakeholders across the region. The required PIR partnership building process is not intended to create turf wars or divisions amongst stakeholders, as this works against the intent and objectives of the initiative. The assessment of applications, and the subsequent rankings applied, will need to consider the impact where such dynamics are evident within applications, or through multiple applications being submitted from one region.

Undertaking foundational tasks first (such as working out the needs of the region, the number of people in the region in the target group, a suitable model, what's required to achieve the model) will assist all relevant services in determining the level of commitment, capacity and capability they could genuinely contribute to ensuring the successful implementation of PIR in the region. This process will also assist in determining which organisation may be best placed to be the PIR organisation for the region and what the governance arrangements might be to oversee and progress implementation of a suitable model.Top of page

B35. Will the department run more than one funding round to establish PIR organisations?

It is intended that one funding round through a national invitation to apply (ITA) process be undertaken to engage PIR organisations. Through this process, the engagement of PIR organisations may be staged, depending on the categories in which applications will be ranked. Applications ranked 'highly suitable' and 'suitable' will be progressed first. In regions where 'further work required' or 'unsuitable' applications are received, consideration may be given to providing those regions with development support in order to support regional capacity and readiness to participate in PIR.

Based on the outcomes of the ITA process, it is anticipated that PIR organisations will be engaged from early 2013 and will initially focus on building the organisational and workforce capacity, ready to commence delivery of PIR and engagement of PIR clients from mid 2013.

B36. Will any organisations be given priority or preference to receive funding?

Eligibility criteria for which organisations are eligible to apply for funding are outlined on page 11 of the program guidelines. Also refer to question B19 and question B20.

The department has received feedback that suggests a perception amongst some stakeholders that certain organisations, such as Medicare Local organisations, will be given priority for funding to become a PIR organisation. All eligible and compliant applications will be given equal consideration throughout the assessment process. Top of page

C. Implementation

C1. What are the referral pathways to PIR organisations?

An individual will be referred to the PIR organisation and assessed by the support facilitators.

PIR is not intending to create a new access pathway into services and the PIR program guidelines are deliberately silent on what the referral pathways to PIR organisations might be. Applications for PIR funding will need to specify the most appropriate referral pathways that best fit the PIR model being proposed for that region.

The department anticipates however, that referral pathways will reflect where people in the target group are likely to present (for instance, hospital departments, homeless shelters, employment services, and mental health services).

Applicants for PIR funding will also need to outline what steps will be undertaken to ensure early and thorough communication by PIR organisations across each region to assist in maximising referrals of the intended target group.

A standard PIR referral template will be provided to PIR organisations for use within the region. This, as well as a range of other tools and resources, will be developed in time for organisations to become familiar with during their establishment period. Top of page

C2. How can cross-sectoral engagement and partnerships be developed to support the implementation of PIR within a region?

The success of PIR will rely on the strength of sector and service partnerships created and fostered at the regional level.

Applications to become a PIR organisation will require a detailed description of the proposed PIR model to be implemented in the region. This should include a description of how the PIR organisation will work with and augment existing service delivery systems and care coordination efforts in implementing PIR, including the approach to be taken to establish, maintain and strengthen effective partnerships at the systems level and at the support facilitator level, including governance protocols/ processes to be established and strategies to be used to overcome any partnership barriers. Applications will also need to describe who the PIR project partners within the region will be, what role they will play, and evidence of their buy-in and support. Governance arrangements to be put in place will also need to be described, and detailed letters of support from various partners provided.

In developing applications, services and supports across different sections within each Medicare local geographic region should start getting together now to jointly and collectively determine:

• what the specific needs in the region are
• who the potential PIR clients in the region are
• what the issues are in being able to effectively join up services and sectors, and how PIR could best assist with this
• what a suitable PIR model for the region is, and what are the service solutions on-the-ground in the region that PIR could assist with
• which organisation is best placed and eligible to be the PIR organisation, or the lead organisation in the region
• how PIR partnerships will be established and what the governance arrangements for the PIR model should be and
• who in the region will write the application.

Collective agreement and ownership of the proposed PIR model outlined in the application and partnership development during the application process will increase the likely success of effectively partnerships continuing in the implementation of PIR. If PIR organisations encounter barriers during implementation, the partnership arrangements and communication methods put in place should be re-examined, and discussions should be held with services and supports across different sectors within the region to resolve any issues.

PIR organisations and support facilitators will have access to, and as required, training in the use of, a suite of baseline resources and tools to support and assist them including:

• examples of partnership building and governance tools and protocols, including multi-agency agreements (for instance, Memorandums of Understanding) and regional level service agreements
• examples of information sharing protocols (which have regard to relevant legislative requirements and issues of consumer consent) and
• examples of planning, coordination, and communication tools.

As required, the department will work with the PIR organisation to assist with any issues as they arise. The PIR Capacity Building project (which will enable national networking and information sharing to provide sustained support to, and build the capacity of, PIR organisations and support facilitators) will provide ongoing support to PIR organisations, and 'partnership building and maintenance' is an example of the type of issue the capacity builder could assist with.

Ongoing monitoring and evaluation activities will also track the effectiveness of partnerships in the implementation of PIR. Top of page

C3. Is PIR intended to be parallel to existing state mental health systems or complementary?

PIR is a complementary initiative and 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 existing sectors, services and supports needed by the target group.

The PIR initiative will work within existing service delivery systems – the initiative will add value to current service systems, rather than create a new parallel and competing service system.

State-funded services operating within each Medicare Local region will be important PIR partners in enhancing the integration of services and providing a better system response to the most vulnerable of people. Top of page

C4. In rural and remote areas, what if there are no services to coordinate as part of PIR?

It is recognised that the full range of services that people with severe and persistent mental illness with complex needs require may not always be available in each Medicare Local geographic region. It is important to remember the aim of PIR is to increase the effectiveness of the coordination response to better meet the range of complex support needs of clients through getting greater integration and collaboration between existing services and supports across different sectors.

PIR organisation applications will need to include a map of the existing service system within the region to demonstrate an understanding of regional need and service system environment upon which PIR will build on. This mapping activity should also identify and highlight service gaps. The proposed model of how PIR will be implemented in a region (as outlined in applications) should take account of this mapping process and describe how the existing service system will be utilised to implement PIR and what innovative solutions will be considered in responding to any service gaps.

In instances where the immediate short-term needs of PIR clients cannot be meet through normal channels from existing services, the PIR organisation may use the PIR flexible funding pool as a short-term interim measure to buy-in required services and supports. Further guidance is being developed by the department on how the flexible funding should and should not be used, while still allowing flexibility to enable PIR organisations to respond the regional and client needs.

It is important to note, the flexible funding pool 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. PIR organisations should also be aware of the availability of any other funding sources which they could be eligible to use to supplement PIR funding. Top of page

C5. Will the same 24,000 clients be accessing PIR over the four years?

Due to the complexity of needs of the PIR target group, it is not expected that PIR will be a one-off or quick interaction or intervention. 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. However, due to the episodic and long-term complex needs of the target group, it is expected most clients will have a long-term, and in some cases repeated, association with the PIR organisation.

The program guidelines are deliberately silent on what the best model might be to achieve PIR aims and objectives, and how to best reach/manage accessibility for the target population, as this will depend on the actual client numbers and existing service delivery system within each region. Client case loads are also not defined (as this will depend on the proposed model), and it is expected that the number of clients registered with the PIR organisation will likely increase each year (with the maximum number of clients engaged in 2015-16).

Applications for funding will need to outline how the proposed model will manage clients with episodic and varying degrees of support need in the longer term and when exiting the initiative following the provision of more intensive support received as 'active' clients. 'Exit' and 're-entry' criteria and protocols will also need to be outlined. Top of page

C6. Are the clients of state-funded mental health services eligible to access PIR?

Clients utilising state-funded mental health services are eligible to benefit from PIR if they 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 and multiple agencies)
  
  
• 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.

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C7. Are people who are incarcerated or exiting a prison system eligible to participate in PIR?

Individuals with severe and persistent mental illness who are incarcerated in a state/territory prison or other correctional facility are not eligible for PIR as state and territory governments are responsible for all aspects of service delivery to this population. However, individuals on probation or parole may be eligible if:

• they meet the inclusion criteria and
• their parole or probation does not include a condition that requires the state or territory government to be responsible for services comparable to those provided through PIR.

Applicants should also be mindful of the inclusion criteria for PIR:

• 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 and multiple agencies) and
  
  
• 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 and
  
  
• 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) and
  
  
• 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.

Applicants should also be mindful of the limited funding available within the Medicare Local geographic region and how access to services will be prioritised to meet the needs of the target group. Top of page

C8. Are individuals with a DSM-IV Axis II diagnosis eligible to access PIR?

In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) published by the American Psychiatric Association, Axis II disorders include personality disorders and developmental disorders (autism, intellectual disability). While people with a diagnosed personality disorder are eligible, assuming PIR inclusion criteria are met, it is important to note that the PIR initiative is not designed for those with developmental disorders, unless they have a co-existing mental illness and meet other inclusion criteria. A range of other community support and service coordination programs are available for those with a developmental disorder.

Upon referral, support facilitators will need to arrange for the verification of a diagnosis of severe and persistent mental illness, or arrange for a diagnosis to be made (as per the inclusion criteria). As with any referral, referral of an individual with an Axis II disorder will need to be assessed against the inclusion criteria including their level of impairment and complexity of need. The support facilitator should use an appropriate needs assessment framework to assist with this. Top of page

C9. How will the views of carers and families be taken into account in PIR?

PIR recognises the important role of carers and families in the recovery of a person with a severe and persistent mental illness. Support facilitators will have a role in engaging carers and families in the development and implementation of PIR action plans (unless there are legal and/or compelling reasons to prevent this occurring). Where personal relationships have broken down, support facilitators will have a role in facilitating reconnection between clients and their families, carers and other personal supports. Top of page

C10. Will PIR organisations be required to prioritise geographic coverage or target population coverage?

The program guidelines provide broad guidance only on how PIR should be implemented within a region. Applications will need to provide details on the population being targeted in the region and propose a PIR model that represents the most appropriate and effective means to achieve the aims and objectives of PIR to meet the needs of this population group. It is expected that PIR models will vary across regions according to regional need and the existing service delivery system already operating within the region.

The department appreciates some Medicare Local regions cover a broad geographic area, and that the PIR target group may either be dispersed across the region or clustered in certain areas. PIR proposed models should be innovative in their approach to ensure PIR coverage across the region. This could include, for instance, sub-contracting arrangements and the placement of support facilitators in out-posted sites. Top of page

C11. What types of skills should a support facilitator have?

The program guidelines are deliberately silent on what the skills, experiences and qualifications of support facilitators should be in order for them to fulfil their roles and to undertake the day to day tasks of the PIR organisation which may include:

• reviewing referral
• assessing the needs of clients
• developing a PIR action plan that outlines the actions to be undertaken by who and when to meet the client's needs
• engaging with client's existing case managers if they have one
• coordinating services, rather than delivering services
• engaging and chasing up services, and building service pathways and networks
• being a point of contact for clients, their families and carers and
• having a role in monitoring, reporting and evaluation activities.

Flexibility has been provided for PIR organisations to determine what the appropriate skills and experiences of support facilitators should be in order to match the specific roles they will undertake in accordance with the PIR proposed model for the region. As PIR models will vary across regions, it is also likely that the specific skills and experiences of support facilitators may also vary.

Applications will need to describe the staffing profile and requirements needed to support the proposed model – this could also include outlining what skills and experience will be sought in recruiting support facilitators. To deliver the benefits of system collaboration to clients, in general, it is expected support facilitators will have a base level of skills, including having:

• knowledge of the health and welfare sectors relevant to the PIR target group
• experience working with the PIR target group
• high level communication, liaison and negotiation skills
• demonstrated experience in building and maintaining partnerships across a broad range of sectors
• demonstrated experience and understanding of the importance of working with carers and families and
• a strong capacity to work with challenging issues, at both the client and service delivery levels.

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C12. What is the PIR capacity building project and how will it be established?

A PIR Capacity Building project will be established to enable national networking and information sharing amongst PIR organisations, and to provide ongoing support to PIR organisations and support facilitators during their establishment and ongoing operation. A suitable and appropriate organisation will be engaged by the department to undertake the project commencing in 2012. Top of page

C13. What training will be provided to PIR organisations and support facilitators?

A PIR Resource Development project will be undertaken to develop a suite of tools and resources available for use by PIR organisations and support facilitators. Such tools and resources may include:

• PIR operational guidelines
• PIR referral tool (and instructional guide)
• PIR information booklet for consumers, carers and families
• examples of needs assessment frameworks and tools
• an example of a PIR action plan template and
• examples of partnership building and governance tools (such as multiagency and regional/service level agreements).

The PIR Resource Development project will include a training component to ensure PIR organisations, their staff and partners, are familiar with the tools and resources made available to support them in their roles. The organisation engaged to deliver the PIR Capacity Building project may also have a role in training opportunities as part of their national networking activities. Top of page

C14. How will PIR be evaluated and monitored?

The department is currently undertaking a process to engage an external consultant to undertake a monitoring and evaluation project to evaluate the impact of PIR at a system-level and at a client-level, its effectiveness in meeting its objectives, and to monitor its delivery.

The project will explore the extent to which PIR has been an effective approach and improved the system of care available to people with severe and persistent mental illness that have complex multi-agency support needs.

PIR organisations and support facilitators will be required to contribute to this project. The project will aim to ensure that the reporting burden on PIR organisations is minimised. As outlined in assessment criterion 7 of the ITA on page 31, applicants must provide comment about a suitable client management information system (CMIS). This should include describing any existing CMIS and associated processes currently being utilised by the organisation that could be used and transferred for use for PIR purposes (and at what cost). If a CMIS and associated processes are not easily transferred for use in PIR, applicants should explain what would be required to acquire or develop such a system/process and/or enable information migration, and indicate approximate costs in the budget.

Further information will be made available on the department's website at www.health.gov.au/mentalhealth when the consultant is engaged to undertake the evaluation and monitoring project. Top of page

C15. What role are Medicare Locals expected to have in the implementation of PIR within a region?

Medicare Locals may be an informal partner, a formal partner engaged through an MOU or similar agreement, a consortium partner, or a lead PIR organisation. Their role, as per the role of other PIR partners in the region, should be jointly determined as part of the regional planning and development of the proposed PIR model, in preparation of the funding application. Whatever the role, it is expected Medicare Locals will have a valuable contribution to make given their role in population health planning and service development in the primary care context. Top of page

C16. In regions where there are minimal or no formal case managers within the clinical system, can a support facilitator undertake the case management role in the short term and/or long term?

The department appreciates that there may be some instances in some regions where sufficient or effective case management functions do not exist for a client. Where this is the case, support facilitators could undertake the case management role on an interim basis, with a view to establishing this function and identifying a substantive case manager early in the implementation of the PIR action plan.

The support facilitor would need to prioritise, in collaboration with the PIR organisation, identification and re-engagement or establishment of a new case manager for the client. This might involve identifying where existing case manager functions sit within the region and re-establishing the relationship between the client and the case manager, or engaging with a new case manager.

C17. Who will be responsible for diagnosing an individual as having severe and persistent mental illness with complex needs?

Support facilitators will be engaged by the PIR organisation to undertake day to day tasks in supporting the role of the PIR organisation. 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 assessment and diagnosis of a severe and persistent mental illness if this is not immediately apparent or available through existing records. It is not expected the support facilitator will undertake the necessary assessment to determine diagnosis, rather they will verify or arrange for an assessment and diagnosis from an appropriately trained clinician or health professional qualified to make such a diagnosis. Top of page

C18. What is the inclusion/eligibility criteria for acceptance to PIR?

Referrals will be made to PIR organisations and assessed by support facilitators in line with a clear referral protocol which will clearly define the target group and set out the inclusion criteria to assist in assessing eligibility. Inclusion criteria include:

• the individual 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 and multiple agencies)
• the individual has a diagnosed mental illness that is severe in degree and persistent in duration, and is willing to be referred for ongoing clinical treatment ⁴
• the individual 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 individual, and are likely to be addressed by acceptance into PIR and
• the individual consents to being involved in PIR.

C19. Is PIR an ongoing or lapsing program?

PIR is an ongoing program. Ongoing program administation from 2016/2017 will be informed by the national evaluation. Top of page

C20. What is the eligible age range for clients to participate in PIR?

Page 5 of the PIR program guidelines state that it is expected that individuals within the PIR target group will generally be in their mid-twenties and older, noting that at younger ages there are a range of other government programs aimed at early intervention for young people who may be developing a mental illness. The PIR program guidelines do not specify an upper age limit. However, it is not anticipated there would be a large number of people in the upper age brackets seeking access to PIR supports. The need and eligibility of each client should be determined on a case by case basis by the support facilitator and PIR organisation.

Applications for funding to become a PIR organisation will be required to demonstrate an understanding of the region's demographics and the characteristics and needs of the target group within the region. This may include information on the age range of clients within the region.Top of page

C21. What is the PIR capacity building project?

A suitable contractor will be appointed by the department to undertake a PIR capacity building project which will involve national networking and information sharing, and will provide sustained support to, and build the capacity of, PIR organisations and support facilitators. The project will seek to create an environment that:

• enhances the knowledge base and expertise within PIR organisations
• establishes and maintains strong service delivery partnerships and
• assists Medicare Local geographic regions to implement innovative and effective ways to improve a coordinated, comprehensive system response to better meet the needs of people with severe and persistent mental illness with complex needs.

The project will also:

• build strong networks amongst PIR organisations through establishing formalised opportunities for face to face contact through, at a minimum, an annual national workshop, and state/ territory workshops or network meetings/ activities
• establish a central point of access to the tools and resources developed to support implementation of PIR, and provision of ongoing training and support to use the tools and resources as required
• document and disseminate information/ resources on successful, innovative and best practice approaches to implement PIR
• develop a PIR web portal or similar function that may have social networking tools such as sharepoint, blog, wiki, and other information technologies that enable dialogue, trouble-shooting, information exchange and dissemination, knowledge transfer, and a way to keep PIR organisations abreast of trends and developments and
• have a direct link to the PIR evaluator to ensure information generated through the capacity building project is available to inform PIR evaluation and monitoring activities.

A request for tender (RFT) for the PIR capacity building project was released on 27 September 2012 and closed at 2.00pm local Canberra time on 2 November 2012. The RFT and addendum are available on the AusTender website.

Also refer to question C22 for information on costs associated with PIR organisations' participation in capacity building project-related activities, such as the annual national workshop. Top of page

C22. Will PIR provide financial support for attendance at workshops and meetings?

The PIR program guidelines and invitation to apply for PIR funding to become a PIR organisation specify that applications are required to detail all costs associated with the delivery of the proposed PIR model within the specified region. Guidance is provided on the types of items that would be considered reasonable to include in the establishment funding, recurrent funding and flexible funding pool (which will be a component of the recurrent budget), however additional items may be included if considered necessary for the model being proposed. Applications will need to demonstrate that the budget is sufficient to meet the PIR initiative's objectives and outcomes and describe the intended benefits of the investment for the region (that is, demonstrate value for money).

Funding the attendance of two representatives from each PIR organisation at annual national workshops as part of the PIR capacity building project will likely be covered by the contractor engaged to deliver the capacity building project, so costs for this should not be included in PIR organisation application budgets.

Consistent with the principles of the National Mental Health Strategy, the department encourages PIR organisations to consider supporting the active participation of consumers and carers in the implementation of PIR, including their participation in governance arrangements.

The program guidelines are deliberately silent on the best model to achieve PIR aims and objectives as this will vary from region to region based on the needs of the target population and the existing service delivery system upon which PIR will build.Top of page

C23. What is the PIR resource development project?

A PIR resource development project will be undertaken to establish a suite of baseline resources and tools to support PIR organisations and support facilitators to undertake their roles.

A contractor will be engaged by the department to collate existing and develop new resources and tools to support implementation of PIR. The types of resources and tools that will be made available to PIR organisations may include, for instance:

• PIR operational guidelines, including parameters on how the flexible funding can be used
• a standard PIR referral tool with accompanying instructional guide
• a PIR action plan
• a PIR information booklet for consumers, carers and families
• examples of needs assessment frameworks/tools
• examples of partnership building and governance tools and protocols, including multi-agency agreements (for instance, memorandums of understanding) and regional level service agreements
• examples of information sharing protocols (which have regard to relevant legislative requirements and issues of consumer consent) and
• examples of planning, coordination, and communication tools.

Further information will be made available on the department's website at www.health.gov.au/mentalhealth when the contractor is engaged to undertake the resource development project. Top of page

D. How does PIR relate to other initiatives?

D1. How does PIR relate to the Flexible Care Packages announced in the 2010/11 Federal budget?

The 2011-12 Delivering National Mental Health Reform budget package provided $549.8 million over five years, including $348.3 million in new funding, for PIR. The remaining funds were redirected from other Commonwealth mental health initiatives, including:

• 2010-11 budget measure National Health and Hospitals Network – Mental health - Flexible care packages for patients with severe mental illness (FCPs) ($68.4 million from 2012-13 over 5 years).
  
  
• Mid-year economic and fiscal outlook 2010-11 measure - Mental health – Taking Action to Tackle Suicide - providing more frontline services and support for those at greater risk of suicide ($137.6 million) comprising $100 million from Boosting Non-Clinical Support Services, and $37.6 million from More Community Based Psychiatrists.

Consistent with government policy of being fiscally responsible, the 2011-12 Delivering National Mental Health Reform budget package was required to be offset through savings. The 2011-12 budget provided the opportunity to consolidate policy objectives of existing measures (FCPs, Boosting Non-Clinical Support Services and More Community Based Psychiatrists) into a new initiative (PIR), supplemented with additional new funding, which had a broader aim of ensuring better coordination of the whole needs of a person with severe and persistent mental illness with complex needs. This was a decision of government. Top of page

D2. How could the Personally Controlled Electronic Health Record (PCEHR) be used by PIR clients and organisations?

The Australian Government is rolling out a national eHealth record system and people seeking healthcare in Australia can now register for an eHealth record. As people register for an eHealth record and as healthcare professionals join the system, Australia's health system will become better connected which will result in better, faster and more efficient health care.

The PCEHR is an important part of the health system reform landscape and PIR organisations may consider using PCEHR, for instance, as part of their PIR client management system. PIR organisation applications can outline any likely interactions the proposed PIR model might have with the PCEHR.

Further information on the PCEHR is available on the eHealth website. Frequently asked questions are also available. Top of page

D3. What is the difference between PIR and the Personal Helpers and Mentors program?

Personal Helpers and Mentors (PHaMS) and PIR will work in a complementary way to achieve better outcomes for people with a severe and persistent mental illness. Both initiatives are underpinned by principles of person-centred recovery and are designed to help people access services that are coordinated, integrated and complementary.

PHaMS services are a part of the Targeted Community Care (Mental Health) Program, administered by the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA). PHaMS services work with individuals and their families to achieve participants stated goals.

PHaMS helps through:

• supporting people to manage their daily activities
• helping people to access the services they need when they need them including accommodation, social support, health, welfare and employment services
• building participant's personal capacity and self-reliance and
• increasing their level of community participation.

The aim of PIR is to better support people with severe and persistent mental illness with complex needs, and their carers and families, by getting services and supports from multiple sectors they may come into contact with, and could benefit from, to work in a more collaborative, coordinated and integrated way.

PIR will:

• provide better coordination of clinical and other supports and services to deliver 'wrap around' care individually tailored to the person's needs
• strengthen partnerships and build better links between various clinical and community support organisations responsible for delivering services to the PIR target group
• improve referral pathways that facilitate access to the range of services and supports needed by the PIR target group and
• promote 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.

PIR and PHaMS will complement each other to achieve outcomes for people with a severe and persistent mental illness. PIR will support the improvement of client outcomes by improving the way the service system responds to client need in a more integrated and coordinated way. PHaMs will continue to provide one-on-one support to individuals in their recovery journey by building long-term relationships and helping participants to access the range of supports and services that they need. PHaMs services will continue to work with individuals and their families to achieve participants' stated goals, which may include working with a regional PIR organisation to ensure the services people with severe and persistent mental illness and complex needs require, are coordinated, integrated and complementary.

D4. What impact will the National Disability Insurance Scheme (NDIS) have on PIR?

The linkage and intersection between the NDIS and a range of existing mental health programs, including PIR, is currently being explored. This is being progressed through ongoing discussions between relevant Commonwealth departments, including DoHA and FaHCSIA.

Implementation of PIR in regions where the NDIS is being launched will provide a valuable opportunity to explore how the two initiatives will intersect. Stakeholders can monitor developments in relation to the launch of the NDIS via the NDIS website at www.ndis.gov.au.

From July 2013, the first stage of the NDIS will commence in South Australia, Tasmania, the ACT, the Hunter in NSW and the Barwon region of Victoria.

Background

The Productivity Commission estimates that around 410,000 people in Australia have significant and permanent disabilities that require ongoing care and support. Around 295,000 people are supported today through the current arrangements under the National Disability Agreement. In its report to government last year, the Productivity Commission found the current disability system is underfunded, unfair, fragmented and inefficient.

In response, in the recent Federal budget, the Australian Government committed $1 billion to deliver the first stage of the NDIS. This means that more than 20,000 people with disability, as well as their families and carers will benefit from the first stage of the scheme.

The Australian Government is working with states and territories on the key design issues necessary for the first stage, and considering critical questions such as funding, governance, eligibility, assessment and workforce and sector capacity. An essential part of this design is the advice of experts with lived experience – people with disability, their families and carers, disability care workers, service providers and representative organisations and advocates. To ensure these experts are involved, the Australian Government has established the NDIS Advisory Group and expert groups on the national approach to control and choice, eligibility and assessment, quality safeguards and standards, and the disability workforce and sector capacity to help advise the government on key design elements. They have been tasked with actively engaging with the community to ensure a scheme is built that meets the needs of people with disability.

The Australian Government has also provided funding to the National Disability and Carer Alliance to engage with peaks, their members and people with disability, their families and carers from around the country on key design issues. This engagement is taking many forms, including forums and meetings around the country, as well as other activities. The results and feedback from these discussions will then feed into the design of the launch of an NDIS. Information is available on the NDIS website at www.ndis.gov.au. Top of page

D5. How can the Mental Health Nurse Incentive Program (MHNIP) be used by PIR clients and organisations?

PIR will work in a complementary and collaborative way with Mental Health Nurse Incentive Program (MHNIP)-registered organisations to ensure better outcomes for people with severe and persistent mental illness.

The MHNIP funds community based general practices, private psychiatric practices and other appropriate organisations to engage mental health nurses to assist in the provision of coordinated clinical care for people with severe and persistent mental illness. Mental health nurses work in collaboration with psychiatrists and general practitioners to provide services such as monitoring a patient's mental state, medication management and improving links to other health professionals and clinical service providers.

The primary role of PIR organisations is to engage and join up the broad range of sectors, services and supports, required by the PIR target population within a Medicare Local geographic region. This will include clinical services and broader services and supports, such as housing, and education and employment services. PIR organisations will be expected to build and maintain effective relationships and partnerships with MHNIP-registered organisations in order to complement, support and/or influence care coordination activities that may already be underway, and to ensure that access to relevant services is coordinated for PIR clients.

PIR support facilitators will be responsible for receiving and reviewing PIR referrals, assessing the needs of PIR clients, developing and monitoring a PIR action plan in collaboration with the client and relevant PIR partners and/or carers and families, and engaging with existing case managers that may have a role in the care of the client including general practitioners and psychiatrists registered to provide MHNIP services (the primary care providers), as well as mental health nurses working in the MHNIP.

The use of the MHNIP by a PIR client will depend on a number of factors including: if the clinical support and service of the MHNIP has been identified on the client's PIR action plan; if the PIR client meets the MHNIP entrance criteria as outlined in the MHNIP program guidelines; and the geographic location and availability of MHNIP-registered organisations providing services. A copy of the MHNIP program guidelines can be found on the Department of Human Services' website.

In 2012-13, additional funding has been provided to the MHNIP to enable organisations to continue existing arrangements with mental health nurses to provide coordinated clinical care for people with severe and persistent mental illnesses while an evaluation of the program is undertaken. Top of page

E. More information

E1. Who should I contact if I need more information?

If you have any other questions or you need more information, you can contact the Contact Officer identified on the cover page of the invitation to apply or email Partners in Recovery at partnersinrecovery@health.gov.au.

Please ensure that you allow sufficient time for the Contact Officer to answer your query and for your organisation to complete its application before the closing date.

Footnotes

¹ Whiteford, H and Buckingham, B, 2010 'COAG Care Coordinators – Estimating the size of the target population: Adults with severe and persistent mental illness who have complex and multiple service needs', unpublished paper prepared for Commonwealth Department of Health and Ageing, 10 May 2006 and revised 25 October 2010.

², ³ Note: some applicants may not directly deliver health and welfare services, but may be considered to indirectly deliver such services through brokerage arrangements (that is, sub-contracting and funding other organisations to directly deliver the services on their behalf). Such a brokerage role is consistent with the intent of which organisations are eligible to apply for PIR funding, and such organisations would therefore be eligible to apply (pending meeting the other eligibility criteria).

⁴ A standard PIR-specific referral tool with an instructional guide will be developed (by an external consultant engaged by the department) and made available to PIR organisations to use to their best benefit. For instance, PIR organisations may wish to provide the referral tool to service providers and PIR partners within the region. The referral protocol will require referrers to state the individual being referred either has or appears to have a mental illness that is severe in degree and persistent in duration. Prior to acceptance of the referral, the support facilitator will need to verify a diagnosis or arrange for a diagnosis to be made (as per the inclusion criteria).