GP Mental Health Shared Care Program

What is the GP Mental Health Shared Care Program and who can use it?

The Mental health shared program provides support to the path of recovery and physical health of a consumer whose care is shared by a GP and the Local Health Networks. Shared Care clearly specifies which service will be responsible for identified aspects of their physical health care.

People experiencing enduring mental illness attend the GP more often but are screened less frequently for common conditions than the general population. As a result, this population have a reduced life expectancy of up to 25 years, with most death due to physical causes.

CESPHN has funded three Local Health Networks in the region to deliver Mental Health Shared Care. 


Sydney Local Health District (SLHD)


The new SLHD model includes features to support GPs to undertake physical screening and treatment interventions with this vulnerable population. The Mental Health Shared Care checklist, outlining agreed actions for an annual cycle of care, can be uploaded to GP software from the CESPHN website. It can be printed off, or populated into a Team Care Arrangement.

Two senior clinicians will in-reach to GP practices across SLHD, liaising with practice managers and GPs to assist establishing physical health care for shared patients.

Other initiatives supporting Shared Care between GPs and the public mental health services include:

  • a new Mental Health Shared Care Healthpathway for the physical health of people with a serious mental illness.
  • Online referral to specialist ccCHIP clinics at Camperdown and Concord.
  • Improved referral pathways to community based dental screening and treatment for SLHD care co-ordinated patients.
  • Health Peer Workers who can accompany consumers to GP and other health appointments.


South Eastern Sydney Local Health District (SESLHD)


The shared care mental health nurse (SCMHN) is based within St George Community Mental Health Service (StG CMHS). The nurse provides a recovery orientated shared care service for consumers with complex mental and physical health care needs between the ages of 18 of to 65 years. Direct support is provided to General Practitioner (GPs) or other health services in coordinating care and bridging the gap to mental health care. The nurse provides practical assistance for consumers such as:
  • Health care education
  • Attending medical, psychological or health care appointments
  • Mental state assessments and referrals to concurrent care
  • Linking to social or rehabilitation services


St Vincent's Health Australia


The Nurse has identified a pool of GPs and will coordinate the provision of a number of services for them, which include:

  • Medical detailing to introduce GPs to the service.
  • Coordinating mental health assessments of people from within the service who are being considered for transfer.
  • The production of a personalised collaborative management plan by psychiatrists and the SVH Mental Health Team for consumers.
  • Provide engaged GPs with updates on service developments.
  • Being a point of contact for engaged GPs, ensuring a service linkage function between local GPs and local specialist mental health services including associated nonclinical support services provided by local community managed organisations (NGOs).
  • Providing access to programs and services at SVH that are relevant to the individual’s management plan

The balance between roles of Mental Health Service and GP will be negotiated on a case by case basis.


How to access this service


To be eligible to access, clients need to be care coordinated by either SLHD, SESLHD or St Vincent’s Health Australia Mental Health Services.

How to access the service?

Please click below for the corresponding providers in the area.

Sydney Local Health District (SLHD)

Laura Garcelon
GP & PHN Clinical Partnerships Coordinator | Community Mental Health Service
Croydon Community Health Centre, 24 Liverpool Road, Croydon NSW 2132
Tel (02) 9378 1100 | Fax (02) 9378 1111 |

South Eastern Sydney Local Health District (SESLHD)

Carrod Li

Shared Care CNC | St George Community Mental Health Centre

Level 1, 15 Kensington St, Kogarah

Ph: 95532500 | Fax: 95532525 |

St Vincent’s Health Australia

Jonathan Meisner

Clinical Nurse Consultant | GP Shared Care | Community Mental Health Service | St Vincent's Health Network |

The O’Brien Centre, 390 Victoria Street Darlinghurst NSW 2010

Ph: (02) 8382 1355 | F: (02) 8382 1997 |


NDIS & Disability Program Officer – Sarah O’Connor
Phone: (02) 8752 4907 
Phone: (02) 9799 0933

In 2016, Central and Eastern Sydney PHN (CESPHN) conducted an NDIS Impact, Needs and Planning Project to inform our activity plan and support the implementation of the NDIS across our catchment area. One key action that CESPHN has implemented as a result of the project’s findings is the development and delivery of a continuum of NDIS/Disability education sessions for our members. Information about these sessions can be found on the CESPHN CPD Calendar.

CESPHN also distributes a regular Disability Newsletter and facilitates the CESPHN Disability Network, which meets bi-monthly and incorporates a wide variety of stakeholders including individuals with lived experience of disability. For more information on these, and other disability related initiatives, please contact the Disability Program Officer.


What is the NDIS?

The National Disability Insurance Scheme (also called the NDIS) is the new way of providing disability support. The NDIS will provide all Australians under the age of 65 who have a permanent and significant disability with the reasonable and necessary supports they need to enjoy an ordinary life.

Mainstream service systems including the Health and Mental Health systems, have significant obligations in relation to working with the NDIS, these are set out in the Council Of Australian Government (COAG) Agreement and NSW Government’s subsequent Operational Guidance for NSW Mainstream Services on the Interface with the National Disability Insurance Scheme document. CESPHN is facilitating a continuum of education sessions to assist GPs and Allied Health practitioners to understand these obligations and the impact they will have on their practices and interaction with patients, for more information see the CESPHN CPD Calendar.

Additional Information and Resources:

Is my patient eligible?

To become an NDIS participant a person must:

  • Have a permanent disability that significantly affects their ability to take part in everyday activities;

  • Be aged less than 65 when they first enter the NDIS;

  • Be an Australian citizen or hold a permanent visa or a Protected Special Category visa; and

  • Live in a part Australia where the NDIS is available

Additional Information and Resources:

How can patients apply?

If your patient is aged 6 years or younger, the NDIS utilises an Early Childhood Early Intervention (ECEI) approach. This means you can refer the child directly to an NDIS ECEI Provider in their area, they do NOT require an Access Request Form to be completed. A list of NDIS ECEI Providers in NSW can be found here.

Additional Information and Resources:

If your patient is aged between 7 and 65 years and wishes to join the NDIS, they will need to contact the NDIA (the Agency responsible for running the Scheme) and request an Access Request Form. This can be done by:

  • Phoning the NDIA on 1800 800 110

  • Completing an online Contact Form

  • Visiting an NDIA Office (NSW list here)

If your patient is aged over 65, they will not be eligible to apply for the NDIS (see eligibility criteria listed above). If they were already receiving government funded disability supports services prior to the NDIS’ roll-out in their area, they will not be disadvantaged. They will continue to receive supports that achieve similar outcomes to those they currently receive under the Continuity of Supports (CoS) program.

Additional Information and Resources:

What is the GPs role in the NDIS?

Patients seeking join the NDIS will need to complete an Access Request Form (ARF).

GPs play an important role in supporting their patients to complete the ARF, particularly Section F which captures information relating to the impact of the individual’s disability on the functional domains of mobility, communication, social interaction, learning, self-care and/or ability to self-manage. The GP may also help complete other appropriate sections.

In addition to completing the ARF, an applicant may also supply the NDIS with additional documentation to further support their application, such as:

  • Health Template for Supporting NDIS Access – completed by GP

  • NDIS Access Request Supporting Evidence Form – completed by GP or other Health professional

  • Reports from Specialists, Allied Health practitioners or other clinicians.

  • Participant Statement

  • Carer statement

  • Disability Support Pension statement

Some patients may have a specific condition or may be part of a program that automatically qualifies them for entry into the NDIS, or that requires no further evidence of disability.

More information on providing evidence of disability, and a list of these conditions can be found here.

GPs may also be asked to provide updated information about the functional impact of the participant’s disability on their day to day life for consideration during a Plan Review. This information will help the NDIA develop the participant’s updated Plan and address any changes the supports they require.

Additional Information and Resources:

Additional supports and services

National Disability Insurance Agency (NDIA)

Local Area Coordination (LAC), provided by St. Vincent de Paul: 

Ability Links & Early Linkers (0-8), provided by Settlement Services International and St Vincent de Paul: 

  • Phone: SVDP (02) 8622 0456

  • Phone: SSI (02) 9685 0293

CESPHN NDIS & Disability Program Officer

CESPHN facilitates the CESPHN Disability Network, conducts ongoing CPD Education in relation to the NDIS and distributes a regular Disability Newsletter.

NDIS & Disability Program Officer – Sarah O’Connor
Phone: (02) 8752 4907
Phone: (02) 9799 0933