Capital Health Network

From July 2019, people accessing services through the Commonwealth Community Mental Health (CCMH) program required assistance in either applying to the National Disability Insurance Scheme (NDIS) or being transitioned to another suitable program if ineligible for the NDIS.

CHN, ACT’s PHN commissioned Woden Community Service (WCS) to address this through the National Psychosocial Support Transition program and Continuity of Support program.

National Psychosocial Support Transition

WCS had 18 clients that needed to be transitioned. In total, four people were accepted into the NDIS, nine were transitioned to Continuity of Support, four were transitioned to other services and one person disengaged from the process. The remaining three clients were finalised early 2021/22.

Client story – National Psychosocial Support Transition

Betty (pseudonym) was struggling to manage as her daughter was terminally ill with cancer and she was unable to see her due to conflict with her ex-husband. Following her application to the NDIS, additional information was requested. Transition Reporting Information System (TRIS) worked with her psychologist and other supports to gather more detailed information and were able to submit these with the outcome being that she was accepted into NDIS. Sadly her daughter died and Betty was unable to attend her NDIS planning meeting. Her TRIS worker supported her to build her capacity to prepare and attend the appointment. Betty was accepted into the NDIS which was a wonderful achievement that she recognised and she will be able to utilise ongoing supports into the future. This will build her capacity to develop her resilience and to build and maintain positive relationships with family members and friends.

Continuity of Service

Continuity of Service (CoS) provides ongoing support for clients who previously accessed services under the CCMH and are ineligible to receive services under the NDIS. CoS aims to maximise the mental health recovery of participants through the delivery of flexible, person-centred and timely community-based mental health group-based and outreach support. Participants have access to peer group, intentional peer support and targeted 1:1 support at times of greater need. 90% of participants and people in their support network said that the service was useful and met their needs.

Client story – Continuity of Service

James (pseudonym) is an intelligent, engaging man who lives with his wife and two children. James suffered from a complex medical condition: bilateral total hip replacements with heavy metal leakage, impaired mobility and chronic pain. He was assessed as having severe and persistent mental illness with a diagnosis of major depressive disorder and serious suicidal ideation.

Towards the end of the life of the Partners in Recovery Program, James received assistance to apply for the NDIS. After two unsuccessful attempts, he entered the CoS program at WCS. The National Disability Insurance Agency (NDIA) assessed that he was not eligible for a funded NDIS package because it was deemed his functional impairment and mental illness was due to his medical condition. James persisted in applying one final time for the NDIS, with help also obtained from the ACT Disability, Aged and Carer Advocacy Service (ADACAS) and was again unsuccessful. The intense focus on his disability and impairment severely affected James’ mental health during and after each application. The added mental stress exacerbated his chronic pain which resulted in sudden emotional outbursts, anger issues with verbal aggression towards his wife and primary school aged children.

Coming into the CoS program, with its focus on what James can do rather than on what he can’t, gave him the opportunity to seek alternatives to NDIS. CoS assisted the family to successfully gain Community Assistance and Support Program (CASP) funding and made referrals for domestic assistance and gardening services to decrease the household stress. His children were linked to Kookaburra Kids, a fun and educational program funded for children whose parents are affected by mental illness. Through CoS involvement, James’s wife improved her own understanding of her husband’s conditions and gained confidence to seek psychological help herself.

James improved his overall fitness and has started to eat a healthier diet. James put together a business plan and applied for NEIS (the New Enterprise Incentive Scheme) funding and received a grant that will financially support him for thirty-nine weeks. For the first time in over seven years, James is no longer a Disability Support Pension (DSP) recipient. CoS will continue to stay in touch with James and his family through less regular contact, until he feels confident to be independent of this service.