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