The Aboriginal Mental Health Transfer of Care (AMHTOC) team provides culturally responsive assessment, care planning and transfer of care for Aboriginal and Torres Strait Islander consumers who are admitted with acute mental health needs in South Western Sydney Local Health District (SWSLHD).
Aboriginal people continue to be over-represented in SWSLHD mental health services, experience higher readmission rates and as a result, experience poorer health outcomes.
In SWSLHD, Aboriginal people represent:
- 2% of the total population
- 7.83% of all mental health inpatients
- 8.5% of all community mental health consumers (11% in the Macarthur region).
- over 10% of all consumers who use the Infant Child and Adolescent Mental Health Service.
Leading with clinical and cultural expertise
The AMHTOC team is the first of its kind in NSW, a dedicated team with clinical and cultural expertise engaging with mental health consumers in inpatient and emergency department (ED) settings. The development of the AMHTOC model of care was based on the AMHTOC team.
The model uses a partnership approach with the established clinical teams, to ensure consumers' cultural and psychosocial needs are considered and addressed as part of therapeutic interventions and the discharge planning process.
The unique elements of the AMHTOC model include:
- ensuring follow-up with consumers and their families 6-8 weeks post-discharge, to confirm they are engaged with appropriate support services
- establishing transfer of care pathways with community based Aboriginal Mental Health Workers and Aboriginal Community Controlled Health Organisations (ACCHOs) to ensure seamless handover
- using well-developed links with Hospital Aboriginal Liaison Officers to coordinate support for Aboriginal mental health consumers in ED settings.
The model is underpinned by strong Aboriginal governance and an established community mental health team to support ongoing care and care navigation. Although the primary focus of the model is to provide short-term care navigation and support for consumers to stay well in the community, it also builds the capacity of existing clinical teams to deliver of culturally informed care and support sustainable change across healthcare settings.
This capacity building is shown through the development of culturally informed assessment and treatment models for mental health and wellbeing, alongside efforts to strengthen the Aboriginal Liaison Officer (ALO) workforce in supporting consumers within the ED.
Addressing existing service gaps
The Aboriginal community was one of the most affected throughout the COVID-19 pandemic. There was a significant increase in mental health issues, with the enforced lockdowns having a significant impact on complex family and community structures. Lockdowns and hospital visitor restrictions also highlighted the gaps in existing services in SWSLHD, and planning commenced for the AMHTOC team during this time.
Prior to the team’s inception, SWSLHD had established a district-wide Aboriginal Mental Health Clinician position to support inpatients, and a multidisciplinary team to ensure culturally responsive discharge and transfer of care.
SWSLHD also undertook a clinical redesign project on transfer of care with the ACI. Unfortunately, due to COVID-19 restrictions and impact on the district, the project did not continue past the solutions phase. Despite this, SWSLHD was able to build on the project, using the work undertaken to inform the development and implementation of the AMHTOC team.
SWSLHD received ongoing funding from NSW Ministry of Health from 2022 until the 2024-25 financial year, as part of the COVID-19 Mental Health Recovery Package. This funded an Aboriginal Mental Health Care Navigator and an Aboriginal Mental Health and Wellbeing Peer Worker position. SWSLHD complemented this funding, adding an additional two full-time equivalent Aboriginal Mental Health Workers, establishing the AMHTOC team.
Reducing unplanned readmission rates
Since the entire AMHTOC team was onboarded in 2023-24, the service has provided patients with a total of 328 referrals, providing cultural support to patients and carers, as well as cultural consultancy to the multidisciplinary treating team. The model has seen a reduction in unplanned readmission rates for Aboriginal mental health consumers from 26% in the 2021-22 financial year to 18% at the time of publication/in 2025.
The AMHTOC team has effectively supported consumer-centred, recovery-orientated interventions for consumers transitioning into the community setting. The team has established and maintained referral pathways to keep people well in the community.
The AMHTOC model has received positive feedback from consumers, carers, community organisations and members of multidisciplinary teams. Results from the 2023-2024 Your Experience of Service consumer survey demonstrate 91% of Aboriginal consumers rated their experience as very good or excellent.
Since the team’s establishment, rates of mental health acute re-admissions within 28 days of separation have reduced by 8% from 25.93% for the 2022-23 financial year to 17.52% in 2025.
Additionally, SWSLHD has seen a 6.9% increase in mental health acute post-discharge community care follow-up (within 7 days) from 69.6% for the 2022-23 financial year, compared to 76.5% in 2025.
This approach has improved clinical engagement with consumers, enabling the development of effective therapeutic relationships and better linkages to care in the community post discharge. The result is an almost 8% reduction in unplanned readmission rates for Aboriginal consumers from 2021-22 financial year, when compared to 2022-23.
The AMHTOC model has not only improved patient and carer experience, but there is a significant cost efficiency achieved by the reduction in unplanned re-admissions, equivalent to approximately $890 for each day the consumer is supported in the community rather than an inpatient setting.
