About Us

PiR banner image template 1174 x 180 - 2013 About us

What is Partners in Recovery?

North Brisbane Partners in Recovery (PiR) is a specialised initiative that seeks to improve outcomes for people who experience severe and persistent mental illness, and also have complex needs.

PiR recognises that many people with severe and persistent mental illness have more complex needs than current systems can meet. Some people require a comprehensive and coordinated response from a range of sectors – including health, housing, income support, disability, education and employment.

PiR aims to better support people with severe and persistent mental illness with complex needs, and their carers and families, by getting services and supports from multiple sectors they may come into contact with (and could benefit from) to work in a more collaborative, coordinated and integrated way.


The ultimate objective of PiR is to improve the system response to and outcomes for, people with severe and persistent mental illness who have complex needs by:

  • Facilitating better coordination between clinical care and other support organisations at a regional level to promote seamless service delivery;
  • Strengthening partnerships and building better links between clinical and support organisations in the region;
  • Improving referral pathways that facilitate access to the range of services and supports needed by the PiR target group; and
  • Promoting a community based recovery model.

Governance and Accountability

To achieve the National objectives for the PiR Initiative, the Brisbane North PHN leads a 12-member Consortium who collectively oversees implementation of the PiR Initiative in the North Brisbane region.

North Brisbane PiR relies on three main mechanisms to drive engagement and collaboration across the North Brisbane region, in order to support effective implementation.

The Consortium Management Committee (CMC) is tasked with management and coordination of North Brisbane PiR, and is made up of a consumer representative, a carer representative, as well as representatives from the following agencies:

  • Brisbane North PHN
  • Metro North Hospital and Health Service
  • Aftercare
  • Communify
  • Footprints
  • Institute for Urban Indigenous Health
  • Mental Illness Fellowship Queensland
  • Neami National
  • Open Minds
  • Queensland Alliance for Mental Health
  • Richmond Fellowship Queensland

A number of criteria were considered in determining membership of the Consortium, including geographic coverage across the region, a diversity of organisations in terms of local, state and national scope, as well as engaging organisations with a significant or exclusive focus on mental health, and with extensive experience in delivering quality services to people with mental illness and their families.


How Does NB PIR Work With People?

Given the ultimate objective of PiR is to improve the system response to, and outcomes for, people with severe and persistent mental illness, the North Brisbane PiR Consortium has articulated a model for Support Facilitation covering engagement, care coordination, service integration and systemic change.


As you will note in the diagram above, the focus of Partners in Recovery (green triangle) is at the right-hand end of the diagram, meaning that we will focus our efforts on system reform activities that achieve service integration and systemic change.  However the day-to-day activity of Support Facilitators is mostly in care co-ordination and service integration (purple segment).  Where ever possible, Support Facilitators will ‘move to the right’, when supporting PiR clients, with a view to supporting and achieving systemic change.

Support Facilitators will work with PiR clients, and any relevant carers, family and/or other service providers, to develop a PiR Action Plan. The PiR Action Plan is informed by a comprehensive needs assessment process, outlining any goals the client wishes to achieve, and identifying a series of actions that will be undertaken to achieve these goals.

These actions may be undertaken by the PiR client themselves, by the Support Facilitator or by other service providers.

The day to day activities of Support Facilitators may include:

  • Receiving, reviewing and assessing referrals to PiR;
  • Conducting an assessment of an individual’s care needs (for eligible individuals);
  • Developing, monitoring and reviewing PiR Action Plans;
  • Building service pathways and networks of services and supports needed;
  • Being a point of contact for PiR clients, their families and carers; and
  • Working closely with existing case managers and other supports to ensure necessary case management functions and existing relationships are established and maintained.

Flexible Funding

North Brisbane PiR has access to a limited amount of Flexible Funding which can be used to purchase services and appropriate supports for PiR clients.

Flexible Funding is only available to address clients’ needs that have been identified as part of the PiR Action Plan, but are not immediately able to be met through other channels. Flexible Funding is intended to be used to build system capacity for the benefit of PiR clients within the region, rather than diverting responsibility from existing service providers.

Principles Underpinning PIR

The implementation of North Brisbane PiR is underpinned by the following principles:

Recovery Oriented

The National Framework for Recovery Oriented Mental Health Services 1 defines personal recovery as being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues (page 4).

When applied to mental health practice, this refers to care and support that:

  • Recognises and embraces the possibilities for recovery and wellbeing created by the inherent strength and capacity of all people experiencing mental health issues;
  • Maximises self determination and self management of mental health and wellbeing; and Assists families to understand the challenges and opportunities arising from their family member’s experiences (page 4).

North Brisbane PiR supports recovery-oriented mental health practice.


The model for delivery of PiR in North Brisbane has been designed to complement existing service delivery systems in the region. The model for Support Facilitation has been designed to allow flexibility in working with consumers, with consideration to their individual strengths and challenges.

Complementary to existing service systems

North Brisbane PiR focuses on multi-service integration and coordination to drive better outcomes, working alongside other organisations who provide services and supports to consumers. North Brisbane PiR facilitates access to the service system, rather than duplicating what is already in place.

Able to better coordinate systems

North Brisbane PiR does not offer a ‘new service’ in the traditional sense; rather it assists in better coordinating existing services and supports. Support Facilitators focus on building pathways between sectors, services and supports to promote seamless service delivery.

1 Australian Health Ministers’ Advisory Council (2013), A National Framework for Recovery-Oriented Mental Health Services: Policy and Theory, Commonwealth of Australia

Who Delivers The PIR Initiative?

The North Brisbane PiR Consortium has engaged a number of Support Facilitators who support the implementation of PiR within the North Brisbane region. These Support Facilitators are located within the following eight community service organisations:

  • Aftercare
  • Communify
  • Footprints
  • Institute for Urban Indigenous Health
  • Mental Illness Fellowship Queensland
  • Neami National
  • Open Minds
  • Richmond Fellowship Queensland

Where Does NB PIR Operate?

North Brisbane Partners in Recovery operates across the Brisbane North PHN region, which also aligns with the boundaries of the Metro North Hospital and Health Service.

Teams of Support Facilitators are located in community service organisations covering the Brisbane City area (Communify and Footprints), Brisbane’s northern suburbs (Mental Illness Fellowship Queensland, Neami National and Richmond Fellowship Queensland) and Redcliffe and Caboolture and surrounding areas (Aftercare, Neami National and Open Minds).

Metro North map_V3

PiR and NDIS eligibility criteria

The PiR Initiative has been designed to support people with severe and persistent mental illness who have complex needs that require support from multiple agencies.

Reflective of the typical development of severe and persistent mental illness, the PiR Initiative is more suited to people aged in their mid-twenties and upwards, but all referrals should be considered on a case by case basis.

The following criteria are used to determine eligibility for North Brisbane PiR:

  1. The person has a diagnosed mental illness that is severe in degree and persistent in duration; and
  2.  The person has complex needs that require services from multiple agencies; and
  3. The person requires substantial support and assistance to engage with the various services they require to meet their needs; and
  4.  There are no existing coordination arrangements in place to assist the person in accessing the necessary services; or where they are in place, those arrangements have failed, or have contributed to the problems experienced by the person, and are likely to be addressed by acceptance into PiR; and
  5.  The person or their legal guardian has indicated their consent to being involved, and indicated a willingness to participate in PiR; and
  6.  The person lives within the North Brisbane catchment area (see map below).

Metro North map_V3