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Go With The Flow

Central Coast Local Health District
Project Added:
8 April 2016
Last updated:
14 May 2021

Go With The Flow


CCLHD developed a new referral pathway and model of care, to improve access to mental health services in the community.

View a poster from the Centre for Healthcare Redesign graduation, April 2016.

Go with the flow poster


To reduce the number of non-acute mental health clients treated by the Acute Care Team ( ACT ), from 27% to 10% by June 2016.


  • Increases access to mental health care in the community.
  • Ensures mental health community services remain affordable and sustainable.
  • Reduces avoidable presentations to the emergency department ( ED ).
  • Provides mental health clients with the right care, in the right place, at the right time.
  • Provides robust criteria for referral pathways.
  • Increases collaboration and shared care with non-government organisations.


In 2013, the mental health ACT was restructured to divert mental health clients away from the ED . Under the new referral pathway, clients used the Mental Health Telephone Access Line to bypass the ED and were followed up by the ACT the following day.

This successfully reduced mental health-related presentations at Wyong and Gosford Hospitals by 6.8%. However, while resources were shifted to accommodate the new pathway, CCLHD still experienced a growth rate of 3.8% in presentations to mental health services within Wyong and Gosford Hospitals. As of October 2014, the number of mental health presentations to the ACT had risen from 2650 to 3218, an increase of 21.4%.

These presentation rates were beyond what was anticipated during the restructure. As a result, the number of clients exceeded the capacity of resources available in the ACT . There was a risk it would need to reduce the number of clients in the service, or increase costs to a point where it would be unaffordable and unsustainable.

CCLHD required a solution that provided mental health clients with care in the community, to reduce avoidable presentations to the ED and ACT . It was anticipated that this would provide clients with the right care, in the right place, at the right time – increasing the quality of care while improving clinician satisfaction.


  • An audit of non-acute team caseloads was undertaken, to assess current clients and capacity. Results were as follows:
    • discharge average length of service (ALOS) was 632 days
    • ALOS for current clients was 769 days
    • 25% of current clients had been with the service for more than 1000 days
    • a follow-up audit is scheduled for June 2016, after the introduction of the Continuing Care Team ( CCT ) model of care.
  • A referral pathway criteria and Crisis Triage Rating Scale ( CTRS ) was developed and implemented in the admissions process, to ensure clients were treated by the most appropriate team.
  • A pilot project with Lifeline Central Coast was implemented, to encourage shared care of selected clients with non-government organisations.
  • Community Treatment Order ( CTO ) management software was developed and introduced across the service, to monitor and report on current and historical CTO data. This provides historical data that was previously unavailable to clinical staff.
  • Education and guidance was provided to staff on the effective use of CTOs .
  • An after-hours non-acute service was developed and implemented with the Assertive Outreach Team ( AOT ). This allows non-acute clients to receive services such as after-hours medication observation, which reduces the need to access ACT resources.
  • New models of care will be developed and implemented across the service, as follows:
  • ACT model to be implemented mid 2016 (partial implementation relating to re-triaging of clients implemented March 2016)
  • CCT model to be implemented mid 2016
  • AOT model to be implemented late 2016.

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • April 2015 – April 2016

Implementation sites

  • Wyong Hospital, CCLHD
  • Gosford Hospital, CCLHD



A full program evaluation will be undertaken in April 2016, incorporating the following measures:

  • number and type of non-acute clients in the ACT
  • effectiveness of CTRS on referral data
  • number of clients referred to Lifeline by the ACT
  • results of Health of the Nation Outcome Scale ( HONOS ) and Kessler Psychological Distress Scale ( K10 ) from clients referred to Lifeline
  • evaluation of the pilot project with Lifeline
  • number of CTOs for the whole Mental Health Service
  • number of models of care completed and implemented to date.

Lessons learnt

  • Staff and union involvement would often take a significant amount of time and some staff did not accept the recommended changes.
  • The definition of clinical leadership varies, depending on the person’s role in the organisation. Educating staff to see themselves as a source of leadership was difficult and did not result in support for the project on a collective front.
  • Communication is poor between most teams, as each has an independent view of work and client requirements. It appeared there was a lack of clarity around the provision of services to all mental health clients.
  • Clients want a service that caters to their own needs and knows what they need when they’re unwell. They want ease of access (rather than shuffled around repeating their story), modern technology and to work with mental health services as partners, not gatekeepers.
  • Increasing demand for mental health services is a bigger issue than first envisioned. It appeared that although some solutions were successful, they did not result in a greater demand for the service.
  • Trying to stay efficient and maintain resources for a service with an increasing demand is a significant issue. A private enterprise model can refocus or change the provision of care to accommodate rising costs, however in the public sector this is not possible.
  • It is important to be realistic about the expectations of staff engagement. Clinicians do not have the luxury of easily shifting workloads to focus on service-level documentation. There need to be dedicated resources with the time and skills to develop strategic plans and models of care for the project. This was evident when engaging teams to write the models of care.

Further reading

  • Central Coast Local Health District. 2015 Acute Care Team (ACT) Referral and Discharge/Transfer: Mental Health Policy PR2011_046.
  • Dawber C. Gatekeeper versus concierge: reworking the complexities of acute mental health care through metaphor. Social Alternatives 2014; 33(3): 53.
  • Deutsch SI, Rosse RB. Defensive psychiatry. Psychiatry Weekly 2009; 4: 28.
  • Hamilton B, Manias E. She’s manipulative and he’s right off: a critical analysis of psychiatric nurses’ oral and written language in the acute inpatient setting. International Journal of Mental Health Nursing 2006; 15: 84-92.
  • Hocking B. Reducing mental illness stigma and discrimination: everybody’s business. The Medical Journal of Australia 2003; 178 (Supplement): 47-48.
  • Lakeman R. An anxious profession in an age of fear. Journal of Psychiatric and Mental Health Nursing 2006; 13: 395-400.
  • Marks P. Editor. Standards of practice for mental health nursing in Australia: setting the standard. Canberra: Australian College of Mental Health Nurses; 2010.
  • Mullen R, Admiraal A, Trevena J. Defensive practice in mental health. Journal of the New Zealand Medical Association 2008; 121(1286): 85-91.
  • NSW Ministry of Health. 2012 Mental Health Triage Policy PD2012_053.
  • Richmond DT. Inquiry into health services for the psychiatrically ill and developmentally disabled. Department of Health NSW: Division of Planning and Research; 1983.
  • Sartorius N. Latrogenic stigma of mental illness begins with behavior and attitudes of medical professionals, especially psychiatrists’. British Medical Journal 2002; 324(7352): 1470-1471.
  • Summerfield D. Does psychiatry stigmatise? Journal of the Royal Society Medicine 2001; 94: 148-149.
    14. Wand T. I'm sorry but your condition is serious, there's only so much you can do. International Journal of Mental Health Nursing 2013; 22: 287.


Oliver Higgins
Performance Improvement Manager, Mental Health
Central Coast Local Health District
Phone: 02 4394 7513

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