Establish and maintain clear operational governance by strengthening key partnerships and optimising collaboration.
Strong integration between local partners is crucial to delivering effective aftercare.1
Drawing on the expertise and knowledge of local partners benefits the workforce and the consumer. This is especially helpful in rural areas or other environments with limited resources.
Robust operational governance is needed to support this, by:
- supporting communication between services
- facilitating cross-service promotion
- ensuring streamlined service delivery
- protecting services against loss of regional knowledge, due to staff turnover.
Governance is a shared responsibility of all service partners.
Cross-border considerations
Involve cross-border and jurisdiction partners in governance, planning and service delivery to ensure service and state borders do not negatively impact consumers.
Identify local partners
Identify local partners through service and stakeholder mapping. Review these regularly to keep them updated.
Service mapping
Service mapping focuses on the availability of, and linkages with, local services. It aims to:
- identify key services and providers in your region
- increase knowledge of referral, treatment and care options
- highlight gaps in service delivery and/or barriers to accessing services
- identify opportunities to work together with local partners to improve access.
Undertake service mapping in your local area, in collaboration with the PHN, local health district (LHD) and/or specialty health network (SHN). This will ensure accuracy and consistency across the region. Review this regularly to keep the information current.
Focus on identifying the following services within your region.
LHDs and SHNs
- Hospital and community services
- Drug and alcohol services
- Mental health services, including Towards Zero Suicides initiatives
- Aboriginal mental health clinical leader and/or district coordinator
- Aboriginal health unit
Other private and community health providers
- Aboriginal community controlled health organisations (ACCHOs)
- Mental health community managed organisations (CMOs)
- Private mental health providers
- General practitioners (GPs)
- National Disability Insurance Scheme (NDIS) services
- Services or facilities that support older people, e.g. residential aged care facilities, aged care assessment services and aged health services
- Services that support family members, carers, friends and kin, such as:
Social and cultural services
- Social services, e.g. family violence, financial counselling, drug and alcohol, housing, and employment
- Cultural services, e.g. settlement services, Aboriginal community controlled organisations (ACCOs) and other Aboriginal support services
- Other support services for priority populations, e.g. people with a disability, LGBTIQ+ people, children, youth and men
- Recovery colleges
Use service mapping:
- during staff onboarding to support knowledge transfer and service promotion
- for managing incoming referrals when the service is at capacity.
Stakeholder mapping
Stakeholder mapping identifies organisations or individuals for local partnerships and engagement. It may identify contacts not included in service mapping, such as peak bodies.
Complete both service and stakeholder mapping to ensure all key partners are identified and, where appropriate, include them in local governance groups.
Regularly review this to ensure membership is current.
In addition to the key stakeholders identified in service mapping, focus on identifying the following stakeholders within your region:
- Lived experience peak bodies, organisations or representatives
- Family members, carers, friends and kin peak bodies, organisations or representatives
- Other peak bodies, e.g. suicide prevention, mental health professionals, Aboriginal Health and Medical Research Council
- Suicide prevention networks and local response groups
- Social and community groups, e.g. sporting clubs, faith groups
- LHD and SHN Aftercare and Zero Suicides in Care Coordinators
- Key contacts within local PHNs
- Schools
Key partners and roles
The below summary shows how different service partners may work together in a local area. This is not an exhaustive list of stakeholders, nor their responsibilities. Thorough service and stakeholder mapping is essential.
Primary health networks
Funded by the state and Commonwealth to commission aftercare services in a local region.
Roles and responsibilities
- Participate in agreed governance arrangements.*
- Maintain appropriate clinical governance and quality assurance arrangements.*
- Establish and manage the aftercare tender process.
- Oversee aftercare contractual obligations.
- Communicate Commonwealth and state government expectations.
- Support integration and linkages across providers in a local region.
- Establish communities of practice specific to aftercare.
Key contacts
- Suicide prevention commissioning manager
- Mental health and/or suicide prevention managers
- Suicide prevention regional response coordinator or leads
* As per the Mental Health and Suicide Prevention Bilateral Schedule Head Agreement for Aftercare Services in NSW and Relevant Schedules (Roles and responsibilities of the commissioning partners).
Aftercare provider
Funded by the PHNs to deliver aftercare services.
Roles and responsibilities
- Design service and referral pathways.
- Deliver recovery-focused care coordination and support activities to the consumer.
- Connect consumers to peer workers.
- Monitor suicide risk and support consumer engagement with other services, as needed.
- Establish, support and develop aftercare workforce.
- Engage with, and promote, the service across the community.
- Embed and enact operational and clinical governance processes and structures.
- Establish and participate in aftercare community of practice.
- Service promotion among referral pathways and key stakeholders.
Key contacts
- Team leaders
- Service managers
LHDs and SHNs
Deliver clinical and acute mental health, emergency and general healthcare.
Roles and responsibilities
- Support aftercare commissioning process.
- Establish and support referral pathways to aftercare services, including how aftercare fits into suicide prevention.
- Confirm and enact consumer escalation or reconnect pathways.
- Contribute to relevant governance or shared care activities.
- Support aftercare workforce with clinical governance or shared care activities, if negotiated.
- Contribute to aftercare community of practice.
- Share relevant data to inform service and care planning.
- Oversee Suicide Care Pathways, i.e. linking aftercare providers in at the ‘Transition of Care’ stage
Key contacts
- Aftercare coordinator
- Staff from Towards Zero Suicide initiatives
- Acute care team leaders
- Psychiatric inpatient nurse unit managers
- Emergency department mental health practitioners
- Aboriginal mental health clinical leader and/or district coordinator
CMOs (including ACCHOs)
Deliver complementary psychosocial and other supports.
Roles and responsibilities
- Contribute to coordinated care and support, based on consumers’ needs.
- If local pathways allow, refer relevant consumers to aftercare.
- Participate in aftercare communities of practice and governance groups, where relevant.
Key contacts
- Team leaders
- Service managers
Formalising partnerships
Formal partnerships allow services to clarify roles and responsibilities, establish referral pathways, promote collaboration and improve knowledge about the service system. It also supports the integration of care across services to ensure the delivery of best-practice care.
At a minimum, formalise partnerships between the PHN, LHD/SHN and local aftercare service providers.3 This will clarify roles, responsibilities and referral pathways.
Formalise partnerships with other services and stakeholders identified in mapping activities, where appropriate.
Establishing networks
Establish local networks and shared ways of working, such as the following.
A local governance group focuses on operational matters and broader issues relating to the effective delivery of an aftercare program. PHNs are responsible for establishing and leading the local governance group.
The group is smaller than a community of practice and includes more managers to guide operational discussions. A targeted membership allows for specific and sensitive discussion in relation to local governance issues.
Aftercare providers are involved to ensure the group meets their needs and aligns with the governance responsibilities as outlined in the Mental Health and Suicide Prevention Bilateral Schedule Head Agreement for Aftercare Services in NSW.
Establishing a local governance group
Define the group’s role and scope in the Terms of Reference, and set regular meetings, such as quarterly. Discussions may focus on:
- performance indicators and data sharing
- operational issues, e.g. referrals
- clinical governance issues and risk escalation protocols
- integration of, and support for, lived and living experience
- strategies for service promotion among referrers, stakeholders and the community.
Include representatives from:
- Aftercare providers
- PHN
- LHD/SHN
- ACCHOs and/or ACCOs
- Primary care, e.g. GPs
- Lived and living experience
- Family members, carers, friends and kin
- Local priority populations
- Key referring organisations
A community of practice (CoP) gathers to share information; promote best practice; improve processes; and identify solutions to local challenges.
There may already be an existing CoP in your area for aftercare providers to connect with. Alternatively, PHNs can establish a local CoP to share best practice and improve support for the aftercare workforce, in close collaboration with providers and local partners.
Include frontline workers involved in the delivery of care and invite key service partners and stakeholders to join the CoP.
Other opportunities
Consider these other opportunities to strengthen local partnerships and promote service integration.
The Murrumbidgee Local Response Group (LRG) involves government and non-government agencies, working collaboratively to respond to deaths by suicide in the local area. Members include the LHD/SHN, NSW Police, NSW Ambulance, the PHN and the service provider (delivering both aftercare and prevention support). The group aims to streamline responses, maximise resources and ensure the right supports are implemented in a timely way.
Aftercare services are included to ensure the provision of holistic and collaborative support to communities and families.
Other LRGs are being established across NSW. Explore opportunities to join, or establish, these groups.
The co-location of aftercare services or staff (e.g. within Safe Havens or other mental health CMOs) is an opportunity for service promotion, collaboration, and workforce development and support.
For example, in Western NSW, the local aftercare provider is co-located with another mental health CMO once a week. This has supported referral pathways and collaboration.
Where there is more than one aftercare provider delivering support within an LHD, establish a standardised referral form and process for use by all providers to reduce the likelihood that referrals are not progressed due to lack of knowledge about when, who and how to engage aftercare services.
Similarly, when safety plans are developed, share these (with consent) with the care team to allow for consistency of care and reduce the burden on the consumer to develop duplicate plans.
References
- Suicide Aftercare Services: An Evidence Check Rapid Review Brokered by The Sax Institute for The Commonwealth Department of Health and Aged Care. Sydney (AU): Sax Institute; 2023 [cited 25 Sept 2024].
- Mental Health and Suicide Prevention Bilateral Schedule Head Agreement for Aftercare Services in NSW (section 9). ACT (AU): Federal Finance Relations, Commonwealth Government; 2022 [cited Sept 2024].
- NSW Agency for Clinical Innovation. NSW Universal Aftercare Project: Consultation Findings [unpublished]. Sydney (AU): NSW Agency for Clinical Innovation; 2024.