Implementation guidelines for non-government community services

Standard 9. Integration

Page last updated: 2010

The MHS collaborates with and develops partnerships within its own organisation and externally with other service providers to facilitate coordinated and integrated services for consumers and carers.

The intent of this standard is to ensure that mental health services are integrated and provide continuity of care for consumers and carers at several levels, from the individual consumer level, to the person coordinating the care, the team and organisational levels, through to that involving other service providers.

This standard focuses on when a public or private service is the primary provider of treatment.

In this case, staff from non-government services will generally be team participants rather than care coordinators. If on any occasion they do take on the role of care coordinator - such as when an interagency interdisciplinary team is involved in treatment and recovery support - criteria 9.1, 9.2, 9.3.and 9.4 apply.

Other reasons they may take on the role of care coordinator are, for example in the interests of the long term stability of the consumer, or in response to service options in particular geographic areas. In these cases criteria 9.1, 9.2, 9.3 and 9.4 also apply.

In this context, Standard 9 Integration gives guidance on what non-government providers should expect when consumers are referred from a public or private service that is the primary provider.

Continuity and coordination of care (criterion 9.1) (partially applicable to the sector)
Support for interdisciplinary care teams (criterion 9.2) (partially applicable to the sector)
Collaborative planning (criterion 9.3) (partially applicable to the sector)
Links with primary health care providers (criterion 9.4) (partially applicable to the sector)
Interagency and inter-sectoral links (criterion 9.5)

Continuity and coordination of care (criterion 9.1) (partially applicable to the sector)

The coordinator of care's role is to make sure everyone involved in a treatment - in and outside the organisation - works together. This involves matching consumers with the most appropriate providers across the continuum of care, ensuring seamless and timely transition to other levels of service, and minimising duplication in assessment, planning and delivery.

The coordinator is selected as soon as possible after a consumer enters the service, and the consumer and, where appropriate, carers are informed that this person is responsible for:
  • coordinating assessment
  • coordinating treatment and support
  • facilitating a smooth transition of care to other services as required
  • planning collaboratively with the consumer and carers
  • communicating with the consumer and, where appropriate, carers regarding all aspects of care
  • coordinating the interdisciplinary care team. Top of page

Support for interdisciplinary care teams (criterion 9.2) (partially applicable to the sector)

The mental health service should schedule regular interdisciplinary care team meetings to ensure there is a shared focus.

There should be regular auditing of treatment, care and recovery plans during each episode of care to document what has been done.

Team members contribute their particular expertise. The team should share information and work together. Team leadership should be task-dependent with tasks defined by the individual consumer's situation. The coordinator should be a member of the team and coordinate functions so the team achieves the best possible outcome for the consumer.

Collaborative planning (criterion 9.3) (partially applicable to the sector)

Service providers should provide information and inform staff, consumers and carers about the range of health care and related services that are available.

Service providers can provide treatment and support at several sites such as inpatient, community based rehabilitation, recovery centre and home.

For organisations with many sites, the process of engagement with the service and transfer between services should be standardised. Consumers need to be informed where services will be provided.

To promote integration and continuity of care between programs and sites there should be regular team leader meetings and service-wide meetings that include inpatient and community staff as appropriate to the consumer's circumstances.

Contacts with internal and external services and providers should be documented - this includes referrals, policies and procedures.

Service providers should ensure that staff are familiar with the policy and procedures relating to contact with internal and external services and providers.

Service providers should have an up-to-date resource folder in hard and soft copy to inform staff, consumers and carers about the range of other health and related services.

There should be regular meetings with other service providers to maintain links and partnerships - or establish them - that facilitate continuity of care for the consumer. Top of page

Links with primary health care providers (criterion 9.4) (partially applicable to the sector)

Shared care arrangements between general practitioners (GPs), private psychiatrists, non-government organisations and other applicable agencies should be used to facilitate consumer recovery.

Examples of shared care arrangement models include but are not limited to:
  • GPs and other mental health care providers, such as the Better Access Program, which aims to increase community access to mental health professionals
  • Community Mental Health Case Manager, the Mental Health Intake and Assessment Team and the Acute Mental Health Unit.
When clinical supervision is being transferred to the primary care provider, such as the GP, the service provider should provide feedback to help the GP manage the consumer. This feedback should contain:
  • notification of discharge from hospital and what has happened to the consumer
  • any change in legal status of the consumer, for example community treatment orders (CTO) or community care orders (CCO), changes in treatment, medication, physical health, pathology results
  • treatment recommendations for the GP
  • contact person and process for re-entry to the service provider if the consumer relapses. Top of page

Interagency and inter-sectoral links (criterion 9.5)

Service providers should work in collaboration with other related service providers, including welfare services, primary care practitioners, disability support services, emergency departments and aged care providers in ways that support consumers to achieve their recovery goals.

For some service providers, according to the service types provided and the extent to which relationships are systemic rather than around individual consumers, links and partnerships with other services such as Alcohol and Other Drug Services (AODS), youth support services and community housing services might be supported by formalised service agreements or MOUs.

Evidence that this criterion is met could include:
  • referral processes into the service and from the service
  • documenting team meetings
  • individual support plans that include engagement with other services to support the consumer to achieve their recovery goals
  • MOUs with other service providers
  • links and partnerships with other service providers.
Policies and procedures to demonstrate compliance with Standard 9 Integration will include, but not necessarily be limited to, those that address:
  • referral processes into the service and transfer to other service providers
  • staff involvement in multidisciplinary interagency teams
  • collaborative partnerships and conditions for MOUs
  • the service provider's resource directory.
It is important to remember that policies and procedures alone are not sufficient to demonstrate that a service provider is meeting a standard's requirements. It is also necessary to demonstrate how the policies and procedures have been implemented and guide organisational practices and behaviours.