The aftercare workforce involves peer workers, care coordinators, team leaders and mental health clinicians, each having primary and shared responsibilities.
All members of the aftercare team work together to coordinate care and support for the consumer, while recognising each other's unique skills and experience.
The aftercare team will include peer workers, care coordinators, team leaders and clinicians, depending on the model of care.
Shared responsibilities of the aftercare team
- Ensure care is person-centred and person-led.
- Advocate for the consumer and support them in their recovery.
- Support care navigation and connections.
- Work collaboratively across the team to ensure consistent care, using regular team meetings and other communication methods.
- Listen, validate and encourage consumers.
Roles and responsibilities
Below is a summary of the key roles within the aftercare workforce, their responsibilities, and required knowledge and skills.
The roles of peer workers and care coordinators will vary depending on the team structure. Peer workers can generally undertake all care coordinator responsibilities.
The below is intended as a guide only to show how duties may be assigned to maximise the capacity of peer workers for consumer engagement.
People with lived or living experience of suicide may have experienced suicidal thoughts; survived a suicide attempt; cared for someone through a suicidal crisis; or been bereaved by suicide.
Peer worker
Peer workers draw on their lived and living experience to connect with, and support, people in their recovery. They are the conduit between the consumer, aftercare service, psychosocial services and support networks.
In the context of aftercare services, a peer worker is someone with lived or living experience of suicide. Experiential evidence shows the importance of including peer workers in the aftercare workforce.1 Prioritise employment of peer workers, and design entry to care so consumers have their first contact with a peer worker.1
If this is not possible due to local workforce availability, the aftercare provider can draw on local partners with a peer workforce to seek advice on appropriate ways to engage and support people.
Responsibilities:
- Provide emotional and social support to consumers through shared experience, building a mutual relationship that fosters hope and optimism.2
- Aim to support recovery of a person’s whole life, inclusive of personal passions, social interactions, study and work.2
- Bridge the gap between services and the consumer, through their understanding of isolation, shame and stigma following a suicide attempt or crisis.
- Facilitate improved engagement between consumers and non-acute care and outpatient providers.3
Examples:
- Advocate for the person and support their recovery journey, from a lived and living experience perspective.
- Develop and reviews both support and safety plans.
- Facilitate peer-led group sessions for consumers (if appropriate and trained in group facilitation).
- Promote involvement from family members, carers, friends and kin.
- Link consumers to support services.
- Provide in-person support in an environment where people feel safe.
Knowledge and skills:
- Trained in safe storytelling, to facilitate meaningful use of their lived and living experience in supporting people in their own recovery.
- The core skills of peer work are learned through lived and living experience. Peer workers will have strong interpersonal skills, communication and listening skills; are able to provide hope and validation; draw upon problem-solving skills; and have a compassionate and warm approach with others.
- Formal credentials for a peer worker, such as a Certificate IV in Mental Health Peer Work and Intentional Peer Support (IPS), are desirable. However, mandating formal requirements can be a barrier for peer workers trying to enter the workforce who may not be able to access further education. Foster an environment for the peer workforce to grow.
- Services must provide appropriate supports to the peer workforce, and an environment for professional development.
Peer work in practice
The aftercare service in Murrumbidgee Local Health District delivers a Peer Support Program. This is a trauma-informed, non-clinical program delivered by trained peer workers with a lived and living experience of suicidality, a suicide attempt and/or suicide bereavement.
The program focuses on empowering consumers by providing compassion, guidance, encouragement, motivation and follow up. Its peer workers support consumers to develop the skills, confidence and knowledge to improve their wellbeing and community connections, while encouraging them to engage actively with their care team, to maximise the benefits from these services.
Care coordinator
Coordinates and oversees the care and recovery of people in collaboration with peer workers.
Responsibilities:
- Provide comprehensive non-clinical psychosocial support to consumers.
- Work collaboratively with peer workers to provide tailored, holistic and comprehensive support to consumers throughout service delivery.
- Build trust and rapport with consumers.
- Maintain collaborative communication with other care providers (with consent).
Examples:
- Action inbound referrals.
- Complete intake and service delivery tools.
- Refer to relevant community-based supports.
- Develop and review both support and safety plans.
- Provide in-person support in an environment where people feel safe.
- Promote involvement of family members, carers, friends and kin, in collaboration with peer worker.
Knowledge and skills:
- A detailed knowledge of the local community demographics and service networks.
- Expertise in working with vulnerable and at-risk populations.
- Strong interpersonal, communication and listening skills; drawing upon problem-solving skills; and a compassionate and warm approach to others.
Team leader or manager
Supports peer workers and care coordinators in the delivery of services and overall workforce wellbeing, through a trauma-informed lens. Team leaders ensure compliance with clinical governance and risk escalation procedures.
Responsibilities:
- Oversee and coordinate aftercare services.
- Ensure the service provides innovative, evidence-informed care that is tailored to the community they support.
- Guide and support staff, while managing consumer reviews, service demand, and risk and escalation processes.
- Support reflective practice and consumer care review, if they have the appropriate qualifications.
Examples:
- Assign and screen inbound referrals for eligibility and suitability.
- Manage and support peer workers and care coordinators.
- Ensure service is delivered in line with clinical governance and contractual requirements.
- Provide oversight of risk and incident management, and clinical escalation processes.
- Develop and maintain strong referral pathways (clinical and non-clinical).
- Engage with local governance groups and promote the aftercare service.
- Provide professional and personal development opportunities for peer workers and care coordinators.
Knowledge and skills:
- Experience in leadership and coordinating a multidisciplinary team.
- An understanding of local services and community demographics.
- Ability to use a trauma-informed approach and build working relationships with stakeholders – clinical and non-clinical – to support integrated care and referral pathways for consumers.
- Foster career pathways for peer workers and care coordinators, who may not have clinical experience or qualifications, to become team leaders. This is an opportunity to promote career progression; highlight the importance of peer work and care coordinator experience in a team leader role; and centralise lived and living experience in leadership positions.
Mental health clinician
Works collaboratively with aftercare providers to offer clinical support and perspective to the consumer; or they may only work with the aftercare workforce to provide guidance and consumer review.
While aftercare is designed as a non-clinical service, some models of care in NSW incorporate a clinical component to their service. This is not a requirement of aftercare services but, for some regions, it may best meet their community’s needs.
Responsibilities:
- Work collaboratively with peer workers and care coordinators in the provision of aftercare services.
- Participate in consumer reviews, safety planning, support planning, aftercare plans or transition plans, alongside the peer worker and/or care coordinator and consumer.
- Participate in consumer care reviews with the aftercare workforce.
- Support other clinical governance processes.
In practice:
The Next Steps Aftercare Program in Southern NSW and Illawarra Shoalhaven Local Health Districts uses a model of care involving mental health clinicians.
For example, social workers or psychologists work alongside consumers and their peer worker to:
- develop an aftercare plan
- conduct 4-weekly check-ins
- develop a transition plan to support consumer reviews.
Resources for employing people with lived and living experience
National Lived Experience (Peer) Workforce Development Guidelines
Guidance for decision-makers, including employers and funding bodies, on supporting the implementation of a lived experience workforce in the mental health sector.
Source: Australian Government National Mental Health Commission
Primary Health Networks (PHNs) mental health care guidance – peer workforce role in mental health and suicide prevention
Guidance on the mental health and suicide prevention peer workforce, and how PHNs can support the employment of peer workers as part of multidisciplinary teams, for better mental health care.
Source: Australian Government Department of Health and Aged Care
Readiness to be involved in suicide prevention
Information for those with lived and living experience of suicide. It provides an overview of key considerations and reflections for determining if you are ready to become involved in suicide prevention.
Source: Roses in the Ocean
The Lived Experience Framework for NSW
Includes a language guide, vision, guiding principles, actions and an implementation approach to embed lived experience across mental health and social services systems.
Source: Mental Health Commission of New South Wales
References
- Lived Experience of Suicide Service Guidelines: Aftercare. Sydney (AU): Roses in the Ocean; 2024 [cited 25 Sept 2024].
- Resources: Peer Work. Melbourne: Orygen; 2024 [cited 29 Nov 2024].
- Lopresti AL, Drummond PD, Sibbritt D, et al. Effects of Psychological Interventions on Suicidal Ideation in Adults: A Systematic Review And Meta-Analysis. BMC Psychiatry. 2020;20:305. DOI: 10.1186/s12888-020-02688-9.