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Annual Report 2022/23

Mental health

Mental health, suicide prevention and psychosocial support services commissioned include the following

commissioned services/programs
clients seen
occasions of service delivered
New Access
Head to Health Canterbury and Hurstville
Aboriginal Health and Well Being for young people – La Perouse and Inner City
Babana Suicide Prevention Service
Psychological Support Services
Primary Integrated Care Supports
Youth Enhanced Services
DBT Group Therapy
Continuity of Supports
Connect and Thrive
Emotional Wellbeing for Older People in RACFs
The Way Back Support Service
Telehealth Psychiatry Service (TPS)

Telehealth Psychiatry Service

The Telehealth Psychiatry Service (TPS) launched in April 2022 and addresses a major regional need in accessing psychiatry support for people experiencing severe and complex mental health issues. Delivered by Dokotela, this service provides free psychiatry support, with psychiatrists also working collaboratively with GPs and support workers to ensure a holistic approach to a person’s treatment and recovery. 

Since the program’s inception, CESPHN and Dokotela have had a strong focus on quality improvement. Feedback is sought from GPs, support workers, consumers, and other stakeholders regularly and has been at the forefront of driving changes and enhancements to the service model, leading to consumer and GP satisfaction reaching 94% and 91% respectively in Q4. 

With the addition of Clinical Care Coordinators (CCCs) to the team, Dokotela has been able to identify and bridge gaps in consumer follow-up care. Often, the support of a CCC reassures the consumer, providing the practical support required to effectively engage in appointments and implement their treatment plan. The CCC also acts as a liaison between the psychiatrist and GP, providing support and information to GPs indirectly to ensure that the approach to the consumer’s care considers their physical, mental, and emotional health and wellbeing. 

Other key improvements include the establishment of Telehealth Hubs to provide more equitable access to the program for those without access to videoconferencing, and the facilitation of case conferencing education sessions with CESPHN’s psychosocial and severe mental health providers to upskill the workforce and provide clinical advice. 

CESPHN and Dokotela will continue to work collaboratively over the coming year to ensure the TPS program continues to meet the needs of people in the region experiencing severe mental illness. 

Psychological Support Services

Following the Evaluation of Psychological Support Services (PSS) in 2022 we have been working with providers to review recommendations and implement a number of strategies to build on the reach, accessibility and effectiveness of the program.

Key achievements include:

  • Reducing the number of review periods so that clients can receive up to 12 sessions of psychological support upon entry to the program. This reduces the administrative and navigation burden on client, referrer and mental health practitioner and has been well received by all stakeholders.
  • Updating promotional resources and engagement strategy to better reach individuals and communities who typically miss out.
  • Expansion of the model to include flexible engagement of mental health professionals into the program including sub-contracting arrangements.
  • Increasing the care coordination sessions available to clinicians to support young people, children and people experiencing suicidal ideation.

Thank you to the wonderful work of the PSS providers: APMHA, Lilly Pilly Counselling, Sydney Mind Health and The Gender Centre.

Supporting intake into the PSS program is the Mental Health Intake and Triage Team who triaged over 4,937 referrals in the year. The team work to ensure that all ineligible referrals receive ongoing care recommendations and support stepping clients up and down in the program when they require more intensive or less intensive support.

Connect and Thrive

The Connect and Thrive program provides psychosocial supports to people experiencing severe mental illness and reduced functional capacity. Delivered by Flourish Australia, the program has supported over 1,170 people since it started in April 2019 and currently receive upwards of 130 referrals per quarter. 

An evaluation and review of CESPHN’s psychosocial support programs was completed in 2022. Over the past year the Connect and Thrive team have made fantastic progress with applying the recommendations identified, with all quality improvement activities delivering positive outcomes both to the people they support and to program staff.  

The Connect and Thrive program continues to grow and expand in its capacity to effectively support the psychosocial needs of people experiencing severe mental illness. CESPHN and Flourish will continue working collaboratively to implement further recommendations from the evaluation to improve the mental health outcomes and the experience of people supported. 

Key achievements arising from the project have been:

  • Initiating a co-design process to redevelop the group support stream, which has had low levels of engagement since program inception. Incorporating feedback from people in the program and from staff, the group support stream is now meeting 150% of its target.
  • Designing a Professional Development Plan to address the identified priority of workforce capability and capacity, upskilling staff to address the complex mental health needs of people accessing psychosocial support.
  • Designing a Flexible Tier-Based Support Pilot to address a key priority of a more responsive approach to service delivery, with the purpose of allowing for the flexible allocation of support hours based on a person’s identified level of need and intensity of support.

The Way Back Support Service

The Way Back Support Service (TWBSS) is a suicide prevention aftercare service that provides non-clinical tailored psychosocial support for up to 3 months to individuals following a suicidal crisis or suicide attempt. The service model was initially developed by Beyond Blue.

Neami National has been the continuing service provider, delivering The Way Back Support Service across the CESPHN region. Referrals to the program are made by:  

  • Prince of Wales Hospital 
  • St Vincents Hospital Network 
  • Royal Prince Alfred  
  • Canterbury Hospital 
  • Concord Hospital 
  • Sutherland Hospital 
  • St George Hospital

Under the NSW and Commonwealth Bilateral agreement for Mental Health and Suicide Prevention, CESPHN has been granted funding to expand TWBSS to a universal aftercare service tailored to the region’s needs. In line with the recommendations from the national evaluation, CESPHN will undertake a co-design process to tailor the service model to better meet the needs of our region’s population. TWBSS will transition to a universal aftercare model.  

Integrated Mental Health Hub

Late in 2022 we co-designed a service model for an Integrated Mental Health Hub able to respond to a range of needs. This process involved service providers, health professionals and people with lived experience of mental health issues, discussing what an ideal service would look like. This resulted in the development of a model of care which aims to provide community-based information, support services and connections for people across a spectrum of mental health needs and situations. While funding remains a challenge, having a model of care ready for implementation will allow us to take advantage of opportunities as they arise.


YourCoachPlus a free, online mental health service was launched in the region this year. The service is operated by PCCS and uses a combination of coaching and social prescribing. YourCoachPlus caters for people aged 16 and over, affected by break-ups, job changes, disappointments, or other unpredicted challenges in life. It uses a guided self-help approach to help break negative thought patterns. There is no wait time and people can choose to attend in-person sessions or connect remotely.


The TPS Service changes the lives of individuals whom are in financial hardship or living in lower socio economical areas based in the Central Eastern part of Sydney. I have seen all walks of life in clinics and I can honestly say without the PHN the patients would not be receiving the help they so desperately need. It could be a simple medication change, however that simple change can be the difference between make or break for patients. Every patient that comes into clinic is very appreciative of the PHN as they do not have the burden of worrying about money stress on top of their mental health concerns.

Feedback from Dokotela’s Clinical Care Coordinator, Leanne who is working in the H2H Canterbury Clinic.

There is continued support and guidance which helps me feel like I’m accomplishing something and having someone to share that with.

Connect and Thrivequalitative client feedback

Really appreciate how culturally appropriate and understanding Dr James Bae was. He made me feel so comfortable as if I was talking to a mate. Appreciate him and this service. I found the interactions with both the admin and the psychiatrist easy and welcoming without judgement. They explained the information I needed about the service and the next steps really well. The psychiatrist was warm and very knowledgeable and made me feel like his number one priority. I felt totally at ease and comfortable. A safe space.

Telehealth Psychiatry Serviceclient feedback

The team have completed a thorough assessment of my son’s needs, and they explained each step. They are very professional. My psychologist always made time for me and was so kind and caring and always helped me without judgement. The service is great and much appreciated.

Client feedback

I don’t think I could ever really express my gratitude towards you and how much you guided me in the right direction during such a difficult time.

The Way Back Support Testimonialsclient feedback

Thanks again for all your help and our catch ups, they’ve been a great support for me and I’m certainly going to miss them ☹

The Way Back Support Testimonialsclient feedback

Their understanding compassion and ability to appease me.

The Way Back Support Testimonialsclient feedback

I always felt safe and comfortable and could communicate my issues with Mikalia easily and she went to great lengths to help me.

The Way Back Support Testimonialsclient feedback

My experience was fabulous. My support worker, Matt really helped me in getting hooked up to the right resources for help. Very honest and always very polite. Great personality and never judgmental.

The Way Back Support Testimonialsclient feedback

Honestly could not have asked for better support. My mother and I refer to Mary as ‘Saint Mary’. My only complaint would be that I don’t get to have her around for longer but we achieved a huge amount in the time allocated and I feel more confident to address issues that may arise in the future, unassisted.

The Way Back Support Testimonialsclient feedback

When the Shared Group Program with NEAMI was announced, I referred a participant for the first Eat, Plant, Learn Class which she really enjoyed. Since then, she has completed a gardening course and started volunteering with the community garden via connections she made in the class. She is also registered for the cooking class and the Active8 team have connected her with an exercise physiologist to develop a personalised exercise routine. The feedback from the participant has been amazing and she describes being really happy.

support workerConnect and Thrive