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Royal Commission into Victoria’s Mental Health System

Case study:


Melbourne‑based community health service cohealth uses an integrated model of care for people living with mental illness. Using a person‑centred and strength‑based approach, the organisation provides services that include mental health nursing, individual support, mentoring, residential programs, homeless outreach and complex‑care coordination.

Ms Nicole Bartholomeusz, cohealth’s Chief Executive, said their focus is on providing integrated care for the most marginalised people in the community.

We have a particular focus on the most vulnerable and marginalised people in our community. Our focus is on integration, so that when an individual walks in to access care, they get care for what they present with, and then we work with them to identify other health care and social support, and actively refer them across a broad spectrum of services.

Benefits of the integrated approach include the ability to make referrals and have trusted workers accompany consumers to physical health appointments, for example, with GPs, dentists, allied health, alcohol and other drug services, and group programs. Where appropriate, cohealth also works closely with the Aboriginal, and refugee and asylum seeker health programs.

Ms Bartholomeusz notes that providing a culturally safe environment is central to breaking down barriers between clients and care providers, and is critical to achieving better outcomes.

At cohealth, we attempt, as much as possible, to ensure that our workforce reflects the communities that we serve to bring a level of cultural safety into the workplace. For example, if a client from a diverse background attends one of our clinics, engagement and outcomes are improved if they see one of their own people. Or, if someone who has been unemployed long term, has alcohol and drug issues, walks into a clinic, they should work with a peer worker who has the same kind of social experience or background.

One example of the integrated care service that cohealth offers is the Homeless Outreach Mental Health Service (HOMHS), which is a service that responds to consumers with intersecting homelessness and long‑term serious mental health needs.

Ms Caz Healy, cohealth’s Executive Lead, Services, said HOMHS demonstrates the importance of multidisciplinary teams working in partnership to provide integrated supports to consumers, as well as the benefits of physical co‑location of mental health, physical health and social support functions.

HOMHS works because when needed, a psychiatrist can come out, at sometimes short notice from Melbourne Health, and people can engage with a psychiatrist to assist to stabilise their mental health. It works because we have a multidisciplinary team enabling easier access to the support people need.

Ms Healy pointed to another example of integrated care through the Indigo program, which provides assessment and care plan coordination for consumers with multiple and complex needs.

Care coordination is a key success factor in multidisciplinary teams for people with complex issues. The care plan allows highly skilled individuals to work with a range of providers, to work as one at the directions of a client. The multiple and complex needs model provides assessment over many months, and clients have seen significant success to achieve their goals and live well and safely.

Source: cohealth meeting with Commissioner Armytage, 16 April 2020; Witness Statement of Nicole Bartholomeusz, 9 June 2020; Nicole Bartholomeusz, Correspondence to the RCVMHS, 2020.