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General Practitioner and Mental Health Collaborative Care Project

Project Added:
17 April 2015
Last updated:
14 May 2021

General Practice and Mental Health Collaborative Care Project


This project improves the way primary care and mental health services work with consumers to manage their physical health. The new model of care establishes and develops roles and responsibilities, communication pathways, ongoing care and escalation strategies, with an annual review to accommodate the individual needs of each consumer.

Poster from the Centre for Healthcare Redesign Graduation, April 2015 Poster from the Centre for Healthcare Redesign Graduation, April 2015.


To improve physical healthcare for mental health consumers who have significant and enduring mental illness and receive care coordination, by enhancing collaboration between General Practitioners (GPs), community mental health services and consumers.


Patients and consumers

  • Improved screening, treatment and monitoring of physical health, ultimately supporting better health outcomes.
  • Increased uptake of escalation pathways and health services for mental health consumers, e.g. Concord Centre Concord Centre for Cardiometabolic Health in Psychosis (ccCHiP) clinic.


  • Increased mental health staff confidence in talking about and monitoring physical health, including taking regular metabolic observations.
  • Opportunities for the project team to develop additional skills, such as communication and leadership skills.
  • Improved GP and mental health service staff relationships.

Health system

  • More integrated and coordinated care provision, reducing service gaps and duplication.
  • Provides a framework for other health integration initiatives.
  • Better GP understanding of complex mental illness.

Project Status

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

Project started:  23 July 2014.


The life expectancy of people living with significant mental illness is 15-25 years less than the general population. This gap is widening, as gains in health outcomes across the general population are not enjoyed by people with mental illness. Almost 75% of premature death of people with significant mental illness is caused by physical illness. Most of this early death is from cardiovascular disease, often with multiple comorbidities.

Despite being at profound risk of cardiovascular disease, diabetes and related chronic conditions, people living with significant mental illness are less likely to be screened and treated for physical health problems than the general population. Even when attending GPs more often than the general population, mental health consumers are still less likely to receive appropriate physical health care.

A recent audit of SLHD community mental health services found that only 62% of consumers had a regular GP , less than a quarter had evidence of a recent physical health check, and the relationship between the client, SLHD mental health service and GP is almost never formally declared or established with clear mutual expectations.

There is an unmet need for primary care in people living with significant and enduring mental illness. This project provides an opportunity to address this by improving care integration for mental health consumers.

To address this need, a new model of care has been developed, in which roles and responsibilities, communication pathways, ongoing care and escalation strategies are agreed between the consumer, the GP , care coordinator and psychiatrist. An annual cycle of care allows the team to meet each year and complete a health check, update care planning and exchange health information. This annual review also provides the opportunity to refer consumers to specialist care or other services such as oral health. These minimum expectations can be supplemented with additional mutually-agreed strategies, to accommodate the individual care needs of each consumer.


  • Developed and implemented a collaborative model of care. Sourced funding for recruitment of new peer support workers, who will encourage consumers to take ownership of their health, including connecting them with health services and following up on recommendations.
  • Developed resources including a list of GPs with a mental health interest, booking and appointment tips and a Cerner data entry guide.
  • Developing team-based training for mental health staff, including cardio-metabolic training and GP linkage training.
  • Developed consumer-controlled health records, to track ongoing health checks. Currently seeking funding to develop a mobile app, which will help consumers track health checks, physical health indicators and progress towards health goals.
  • Developing Collaborative Care HealthPathway, a localised online decision-making and referral support tool for GPs .
  • Developed and disseminating GP templates, to help GPs provide an annual health summary to mental health services.
  • Implement continuing professional development and networking events for GPs .
  • Plan rollout of secure electronic communication via HealtheNet as per NSW Health and SLHD information technology project timelines, to ensure secure electronic email and document exchange between parties.

Implementation sites

The new model of care is currently being piloted in project teams within SLHD community mental health services, their GPs and mental health consumers in the Camperdown, Redfern, Croydon, Canterbury and Marrickville areas.

The pilot will continue throughout 2015 and once evaluated and revised, will be disseminated as routine practice across SLHD in 2016.


  • Inner West Sydney Medicare Local
  • Agency for Clinical Innovation – Clinical Redesign Program


Evaluation will be completed using the following tools.

  • File and Electronic Medical Record (eMR) audits pre- and post- intervention. The initial audit is complete, with the final audit to occur July 2015. Audits will determine baseline and final measures of:
    • consumer linkage to a nominated GP
    • consumers in the project sample receiving an annual physical health GP review, with a summary communicated to the mental health service
    • accuracy of the nominated GP recorded in both the file and eMR .
  • Stakeholder surveys with consumers, carers, GPs , practice nurses, practice administrative and mental health staff pre- and post-intervention, to determine stakeholder satisfaction and gather suggestions to improve the model of care. Pre-intervention surveys are now complete. Surveys with mental health staff, to rate confidence in conducting metabolic observations before and after training.
  • Evaluation of health-focused peer support worker role using the processes and frameworks associated with the NSW Health Integrated Care Planning and Innovation Fund grants.
  • Measurement of relevant HealthPathways usage by GPs .

Lessons Learnt

  • The critical importance of thoroughly and regularly engaging all stakeholders.
  • Navigating the transition of the Medicare Local to a Primary Health Network and accommodating potential resource changes.
  • The project management process generally takes much longer than expected and roadblocks are almost certain to occur.


Further Reading

  • Brunero S, Lamont S, Myrtle L, Fairbrother G. The Blue Card: a hand-held health record card for mental health consumers with comorbid physical health risk. Australasian Psychiatry 2008; 16(4): 238-43.
  • Craven MA, Bland R. Better practices in collaborative mental health care: an analysis of the evidence base. Canadian Journal of Psychiatry 2006; 51(6 Suppl 1): 7S-72S.
  • Davidson M, O’Boyle S. Improving access to primary health care services for people with serious mental illness. Demonstration Project: Final Project Report. Eastern Metropolitan Region and Southern Metropolitan Region Mental Health Service, Victoria; 2010.
  • Department of Health Victoria. Improving the physical health of people with severe mental illness: no mental health without physical health. Ministerial Advisory Committee on Mental Health Report. Melbourne: Victorian Government; 2011.
  • Druss BG, Rohrbaugh RM, Levinson CM, et al. Integrated medical care for patients with serious psychiatric illness: a randomised trial. Archives of General Psychiatry 2001; 58: 861-8.
  • Ehrlich C, Kendall E, Frey N, Kisely S, Crowe E, Crompton D. Improving the physical health of people with severe mental illness: Boundaries of care provision. International Journal of Mental Health Nursing 2014; 23(3): 243-251.
  • Everett A, Mahler J, Biblin J, Gangull R, Mauer B. Improving the health of mental health consumers. International Journal of Mental Health 2008; 37: 2.
  • Horner D, Asher K. General practitioners and mental health staff sharing patient care: working model. Australasian Psychiatry 2005; 13(2): 176-80.
  • Hyland B, Judd F, Davidson S, Jolley D, Hocking B. Case managers' attitudes to the physical health of their patients. Australian and New Zealand Journal of Psychiatry 2003; 37(6): 710-4.
  • Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. Collaborative care for patients with depression and chronic illnesses. New England Journal of Medicine 2010; 363(27): 2611-20.
  • Lester, H. Shared care for people with mental illness: a GP's perspective. Advances in Psychiatric Treatment 2005; 11: 133-139.
  • Mai Q, Holman D, Sanfilippo FM, Emery JD, Stewart LM. Do users of mental health services lack access to general practitioner services? Medical Journal of Australia 2010; 192: 501-506.
  • Mitchell G, Del Mar C, Francis D. Does primary medical practitioner involvement with a specialist team improve patient outcomes? A systematic review. British Journal of General Practice 2002; 52(484): 934-9.
  • Modi R, Ledingham D. Cardiovascular health monitoring in patients with psychotic illnesses: A project to investigate and improve performance in primary and secondary care. BMJ Quality Improvement Reports 2013; 2(1).
  • NSW Department of Health. My Health Record Mental Health Pilot Project Evaluation Report Summary and Distribution Protocol. Better Health Centre: North Ryde; 2009.
  • NSW Department of Health. Physical Health Care of Mental Health Consumers: Guidelines. North Sydney: NSW Department of Health; 2009.
  • NSW Mental Health Commission Living Well: Putting people at the centre of mental health reform in NSW. Sydney: NSW Mental Health Commission; 2014.
  • Syfret D. Correspondence with general practitioners. Australasian Psychiatry 2014; 22(2): 202-203.
  • Smith S, Soubhi H, Fortin M, Hudon C, O’Dowd T. Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. British Medical Journal 2012; 345: e5205.
  • Sydney Local Health District. Physical Health Care of Mental Health Consumers Policy Directive; 2014.


Laura Garcelon
GP & Medicare Local Clinical Partnerships Coordinator
Sydney Local Health District
Phone: 02 9378 1226

Liesl Duffy
Program Officer, Executive Unit
Sydney Local Health District
Phone: 0455 069 049

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