GP and mental health shared care in SLHD – collaborating to improve health

GP and mental health shared care in the Sydney Local Health District (SLHD) is a program to ensure comprehensive and coordinated health care for people experiencing mental illness. This is extremely important as people experiencing mental illness have worse health outcomes including a reduced life expectancy, due to physical health issues, of up to 25 years compared to the general population.

The GP and mental health shared care model has been developed over a number of years in partnership with Central and Eastern Sydney PHN. It has been developed with GP, consumer and NGO input. The mental health service is responsible for initiating the process, in partnership with the consumer.

Mental health shared care is formalised when the consumer, mental health care coordinator and any other relevant parties, such a carers or NGOs, attend a GP appointment to establish a shared care arrangement which is recorded in the mental health shared care checklist. This is structured around an annual cycle of care and allocates tasks to GPs and the mental health clinician. This process facilitates agreement about sharing information to improve health care. Three mental health shared care liaison clinicians have been employed to work within the SLHD mental health service to facilitate the shared care program.

By the end of September 2018 over 26 per cent of the close to 2000 mental health consumers registered with SLHD community mental health teams were engaged in a mental health shared care agreement with their GP. This is well over the expected target of 20 per cent by the end of 2018. A total of 209 GPs across the SLHD geographical boundaries are involved in the shared care program and have mental health shared care plans with their patients.  

One SLHD mental health consumer, Morgan (not his real name) shared his story about establishing shared care between his GP and the SLHD mental health service. Morgan was approached by his mental health care coordinator and a shared care liaison clinician, who explained what shared care was and how it could benefit his healthcare. He agreed to the process and then his mental health care coordinator booked a long appointment with his GP.

Morgan has a diagnosis of schizophrenia. In addition to seeing his GP, Morgan also sees an endocrinologist, a mental health service dietitian and exercise physiologist. He had recently attended a ccCHIP (Collaborative Centre for Cardiometabolic Health in Psychosis) clinic for a comprehensive cardiometabolic assessment.

In April 2018, Morgan, his mother, his mental health care coordinator and the mental health shared care liaison clinician attended an appointment with his GP. Prior to this, a mental health shared care liaison clinician had visited this GP practice in March 2018 and had provided education to the GP about the mental health shared care process.

Morgan has seen his GP for many years, however he and his mother were not aware that the mental health service offered a forum for formally establishing a GP shared care relationship. Prior to this appointment, Morgan’s mental health, GP and specialist care were not connected or communicating.

During the appointment, Morgan’s GP spent an extended period of time reviewing his physical health history, current treatment and also reviewed the recent ccCHIP report recommendations from March 2018. Morgan’s GP was provided with recent clinical notes from his dietician, exercise physiologist and psychiatrist. Morgan’s GP was very appreciative for this information and the consumer’s mother expressed thanks for having the opportunity to better coordinate his care.

Morgan, his GP and his mental health care coordinator discussed and completed the mental health shared care checklist, which formalised and detailed the shared care arrangement.

The Mental Health Shared Care Checklist is available on the Central and Eastern Sydney PHN website for GP practice software and a dedicated Mental Health Shared Care HealthPathway is available for GPs.