Back to accessibility links

Community Integration Team: At Risk Youth Mental Health

Justice Health and Forensic Mental Health Network
Project Added:
2 May 2016
Last updated:
20 April 2021

Community Integration Team: At Risk Youth Mental Health


The Community Integration Team (CIT) is a cohesive statewide health service that coordinates care for young people who have mental health problems and/or problematic drug and alcohol use, while they are in the juvenile justice system and three months after their release.

This project was a finalist in the 2015 NSW Health Awards, Integrated Care category. Watch a video of the project.


To improve health outcomes and reduce recidivism rates for young people in the juvenile justice system.


  • Improves health and social outcomes for vulnerable young people, by providing continuity of care.
  • Reduces social risks and reoffending rates of young people in the juvenile justice system.
  • Helps Close the Gap in health and wellbeing outcomes for Aboriginal young people.
  • Empowers vulnerable young people to take control of their own healthcare.
  • Enhances collaboration with young people, families and carers.
  • Promotes teamwork and partnerships with Juvenile Justice, non-government organisations (NGOs) and community health services.
  • Reduces service duplication and provides a more efficient use of health resources.


The CIT was established in May 2008 as the result of a pilot program conducted in Dubbo called the Juvenile Justice Centre Release Treatment Scheme (JJCRTS). An internal evaluation of the JJCRTS highlighted its success and led to funding provided by the Mental Health and Drug and Alcohol Office (MHDAO) to develop a CIT that expanded on the pilot program.

The target client group for the CIT are young people in the Juvenile Justice system who are faced with complex social and economic circumstances. These young people lack protective factors in their personal life and as a result are more likely to engage in risk-taking behaviours. They often have high levels of mental health and/or drug and alcohol problems, have a family member incarcerated, be in out-of-home care or have an intellectual disability. They may also have compound presentations which are consistent with co-morbidity, causing them to be classified as a high-needs group in the community, who require comprehensive and coordinated assessments and interventions including mental health, drug and alcohol, community health, medical and non-medical services.

The provision of comprehensive and integrated health services to young people in custody in NSW is provided by JH&FMHN and Juvenile Justice NSW. Both organisations are focused on enhancing service provision within NSW Juvenile Justice Centres, to promote positive outcomes for young offenders, reduce the impact of mental health disorders and reduce recidivism rates.

All young people entering NSW Juvenile Justice Centres receive universal health screening as well as selective and specialised assessments and interventions, if they have complex mental health and/or drug and alcohol presentations and are returning to the community. It was determined that existing services needed to be improved, to enhance the continuity of care for young people returning to the community.


  • The CIT program identifies young people who are at risk of entering the Juvenile Justice system and focuses on their health and wellbeing needs before they are released.
  • When the young person re-enters the community, the CIT program offers continuity of care in collaboration with Juvenile Justice Case Workers (JJCWs), NGOs and community health services.
  • The CIT program was the first program of its type in NSW and initially comprised three clinicians, later expanding to 11 clinicians, who worked with JJCWs in community locations around NSW. JJCWs provide case management for young people on community orders and address accommodation, legal and financial issues. CIT clinicians liaise with NGOs and community health services to improve access to health services and treatment compliance. They also provide interventions and education to support healthy life choices, empowering young people to take control of their health.
  • Program participants include young people with mental health, drug and alcohol problems, with a high representation of Aboriginal young people.
  • Regular in-service education is provided to Juvenile Justice staff regarding mental health issues and health treatment planning.
  • Regular reviews are undertaken with CIT staff and stakeholders to identify quality improvements and trends that provide evidence for future strategic health service planning.

Project status

  • Sustained - the initiative has been implemented and is sustained in standard business.

Key dates

  • Project start: May 2008

Implementation sites

The service started in Dubbo, Wagga Wagga and Gosford and expanded to Sydney, Fairfield, Penrith, Newcastle, Wollongong, Kempsey, Grafton and Tamworth.


  • Juvenile Justice
  • Aboriginal Controlled Community Health Organisations


  • There was an improvement in young people’s access to community services and a significant reduction in recidivism rates, with ‘no return to custody’ rates increasing from 60% in 2009-10 to 91% in 2014-15.
  • Feedback provided via the Mental Health – Consumers Overall Perception & Experience of Service (MH-COPES) Survey conducted between January and June 2015, showed the majority of respondents rated CIT as very good or excellent.
  • Since 2008, the CIT program has expanded from four to 11 clinicians across NSW, with a concomitant increase in productivity.
  • Total client numbers increased from 295 in 2009-10 to 560 in 2014-15.
  • 60% of the young people in the program are Aboriginal, which reflects the importance of Aboriginal Controlled Community Health Organisations (ACCHOs) involvement.
  • For the young people who did return to custody, the average length of stay in the community was 41 days in 2014-15.
  • The number of care plans completed increased from 38% in 2013-14 to 43% in 2014-15.
  • There was increased access to healthcare in the community for young people with mental health problems and/or problematic drug and alcohol use, following release from custody.
  • There was improved engagement of young people, their families and carers with community services and better compliance with treatment in both metropolitan and rural/remote settings.
  • The Children’s Global Assessment Scale (CGAS) is a standardised mental health measure that calculates young people’s general functioning across a range of areas. CGAS results show that CIT clients have noticeable problems in more than one area on admission. Testing at the exit point of the CIT program shows an overall improvement in mental health by an increase of 5.3 basis points, with most clients having some problems in one area only and generally functioning fairly well.
  • Although scalability was not specifically addressed in the project, the nature of CIT and its success with young people who have complex health, social and legal problems suggest there is potential for it to be replicated with other vulnerable groups.

Lessons learnt

  • Capturing the correct data and implementation of multi-data collection systems proved time-consuming for clinicians when the project began. Since then, data systems have been reviewed and streamlined.
  • A lack of community services and public transport to services in remote areas of NSW was a challenge. Relocating CIT sites to areas of higher population and need, with more health services available in the community, resulted in improvements to client outcomes.
  • We were challenged with securing ‘early’ appointments with community health services, due to limited resources and a reluctance to engage with the client group. The CIT has since fostered positive relationships with community health services, to successfully advocate on behalf of young people and provide education and health services.

Related resources


Jeanette Toole
Manager, Community Integration Team
Justice Health & Forensic Mental Health Network
Phone: 0408 163 583

Search Projects

Browse Projects

Submit your local innovation
and improvement project