Service summary
Better. Together. will provide a range of clinical and non-clinical mental health supports including mental and physical health clinical therapies, care coordination and navigation, and social prescribing. The service will be delivered in person, as part of a region-wide stepped care model, delivered in the general practice setting.
The service is intended to support people with a clinical diagnosis of a severe and/or complex mental health needs who access local general practice for care and support.
Referrals are accepted from all general practices in the region including Aboriginal Medical Services, community managed organisations, local private clinical services and MPHNs Central Access and Navigation (CAN) service. Self and carer referrals are also accepted.
To ensure referrals to the service are appropriate, the service model prescribes the use of the Initial Assessment and Referral Decision Support tool (IAR-DST). IAR-DST Level of Care (LoC) 3 and 4 are considered appropriate for the program.
Service outcomes
Better. Together. intends to:
Improve coordination of care for people living with severe and/or complex mental health needs in the Murrumbidgee region
Increase the proportion of people self-reporting an improvement in their quality of life using a professionally recognised quality of life assessment tool, as a result of services received
Leverage established services that include an MDT and/or service navigation approach, such as MyStep services and MPHNs Central Access and Navigation (CAN) service. Referral information on these services and other services for our region can be found on Murrumbidgee HealthPathway here.
Improve collaboration and integration of services provided by GPs, psychiatrist, Murrumbidgee Local Health District (MLHD), allied health providers and other relevant mental health and social care providers
Reduce unnecessary hospitalisations.
Be informed by the Quintuple Aim
Service model
The service will use a hub and spoke model to facilitate region wide service access.
Figure 1 –Better. Together. hub and spoke service model
Hubs are to belocated in Wagga Wagga, Young, Griffith and Deniliquin and will be established by the Lead Contractor(s). Hubs will act as service bases and will administer and deliver Better. Together. MDT services into at least one General Practice in every Local Government Area (LGA). Hubs will be staffed by non-clinical roles and will engage (employ or subcontract) a range of local Mental Health and Allied health clinicians.
Spokes will be general practices in each LGA. Spokes will host Better. Together. MDT services in their practice.
Figure 2 – Better. Together. operational model
The model requires collaborative organisational relationships.
MPHN will hold funded contracts with Lead Contractor(s) and GP spoke sites.
Lead contractor(s) and GP spoke sites will establish a Memorandum of Understanding (MOU) to formalise and regulate their operational relationship, outline shared goals, clarify responsibilities and provide a framework for a cooperative approach to Better. Together. service delivery.
Local Mental Health and Allied Health clinicians will be engaged by the Lead Contractor(s) to deliver Better. Together services.
A dedicated MPHN Project Officer will oversee the service. MPHN will schedule and chair regular Better. Together. service review sessions to support service delivery, trouble shooting and quality improvement activities.