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The Future of Service Cohesion

Croydon Community Health Centre, Concord Centre for Mental Health
Project Added:
25 May 2015
Last updated:
9 June 2015

The Future of Service Cohesion

Crossing the divide between inpatient and community mental health settings.


This project developed an integrated model of care that facilitated early discharge from inpatient units and transferred care back to the community, with home-based treatments provided by an Acute Care Team (ACT). 


To reduce inpatient length of stay (LoS) for mental health consumers and increase access to home-based treatments in the community.


  • Reduces LoS in inpatient units.
  • Increases use of home-based treatments, with least-restrictive care.
  • Improves relationships and experiences between clients, acute care services and community services, through integrated models of care.
  • Improves client transfer of care.
  • Reduces delays in follow-up care.

Project Status

Project status

Sustained - the project has been implemented, is sustained in standard business.

Project dates

  • July 2014 - project start
  • October 2014 - project review and conference presentation
  • February 2015 - presentation at Clinical Excellence Commission (CEC)

Implementation sites

  • Croydon Community Health Centre
  • Concord Centre for Mental Health


The transition between inpatient and community care forms an important point of collaboration and communication between mental health services, on an individual and systemic level. Historically, attempts to improve this transition have resulted in shifting the burden between over-stretched service domains. An integrated model of care was required to streamline the discharge process and provide a smoother transition to community care.

In 2012, the Whole of Community Mental Health Review recommended that ACTs provide mental health home-based treatments in the community. To improve the transition between inpatient and community teams, it was decided that the ACT take over care of the client prior to discharge.


  • Adjusted rostered shifts so a clinician from the ACT could attend clients in a hospital setting.
  • Developed early discharge criteria for inpatient units.
  • Implemented twice-weekly rounds by the ACT to assess clients according to the early discharge criteria.
  • Developed a discharge plan, which is tailored to each client and discussed in a face-to-face consultation between an ACT clinician and the client.
  • Continued 7-day follow-up by ACT for clients after they are discharged.


  • Reduced average LoS in the inpatient unit from an average of 36 days in 2013 to 18 days in January 2015.
  • Improved seven-day follow-up key performance indicators (KPI) by 39%, from 32% in February 2014 to 71% in July 2014. This achieved the NSW KPI of 70%.
  • Home-based treatments increased from an average of three per month to 14 per month.
  • As the client is introduced to the ACT while in hospital, their engagement with post-discharge follow-up and home-based treatments improved due to better communication with the ACT clinician.
  • An online survey of the inpatient and community care teams was used to gain feedback from those involved in the project. Feedback was positive from all parties.
  • Results demonstrated that home-based treatments can be increased for discharged clients using current resourcing, by engaging with inpatient units to improve discharge planning.

Lessons Learnt

  • Buy-in from community and inpatient teams was critical to the success of the project.
  • Community teams were the main driver for this project, however inpatient teams soon saw the benefit, which resulted in rapid buy-in.
  • All teams want better client outcomes, which can be achieved with enhanced follow-up on discharge from hospital.


Iain White
Nurse Unit Manager, Croydon Acute Care Team
Sydney Local Health District
Phone: 02 9378 1100

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