Primary Integrated Care Supports (PICS)

About the program


CESPHN has commissioned the PICS program to address Primary Mental Health Care Services for People Experiencing Severe Mental Illness, as part of the Department of Health’s primary mental health care reform activities. One Door Mental Health is the provider for PICS in the CESPHN region.

The aim of the Primary Integrated Care Supports (PICS) program is to provide clinical mental health services and links to psychosocial supports to meet the needs of people who experience severe mental illness who can be appropriately supported in the primary care setting, consistent with the National Framework for Recovery Oriented Mental Health Services.

The service model focuses on integration of mental health services with general practices, use of CESPHN’s centralised referral intake process, retaining and expanding the existing mental health nurse workforce, introducing a peer workforce and applying a stepped care approach to support consumers to self-direct their recovery journey.

Contact information

For all PICS queries please email or contact Asma Yusra from the Mental Health team on 9330 9999.

Who can refer?

Referrals can be made by GPs, psychiatrists, state mental health services, non-government organisations, mental health nurses and peer workers.

All referrals are required to be submitted through the CESPHN central intake process to ensure eligibility and allocation to the most appropriate Provider. The Provider will then allocate the referral to the most suitable mental health nurse and peer worker via CESPHN’s client information management system, WTCC.

Referral forms are available here.

Referrals may be sent via secure FAX on 9330 9988; or via HealthLink using ID: CESPHNMH

Target Population and Eligibility

Program Eligibility - To be eligible to access the proposed services, clients need to:

  • be aged between 18 and 65 years
  • live, work or study in the Central and Eastern Sydney PHN region
  • benefit from accessing primary care mental health services
  • not currently be care coordinated by Mental Health Services through the Local Health District services
  • Referrer ensures that there is no duplication of services if client is accessing an NDIS package.

In addition, consumers must meet THREE out of the FOUR following criteria:

  1. Have a diagnosed mental illness which is severe and either episodic or persistent in nature in accordance with criteria defined in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-5) or the World Health Organisation Diagnostic and Management Guidelines for Mental Health Disorders in Primary Care: ICD-10 Chapter V Primary Care Version.
  2. The mental illness significantly impacts at least two areas of the consumer’s social, personal and/or occupational functioning.
  3. The mental illness has resulted in hospital treatment in the previous two years or there is a risk of hospitalisation within the next 12 months if clinical care by a mental health nurse is not provided.
  4. The client is expected to need ongoing treatment and management of their mental illness.

Once accepted, consumers should continue to receive support for as long as there is an identified need for the program. Consumers will enter the transition phase when their mental illness no longer causes significant functional impact or when they have adequate supports in place and no longer require this program. In the transition phase, the Provider should connect with the consumer every six months to see determine if further support is needed.

What happens after I’ve sent the referral?

Initial communication to referrer and consumer

When a referral is received, and processed by CESPHN central intake, the referrer is advised of the outcome via e-mail within two working days. The provider will then allocate the referral to the appropriate mental health nurse and/or peer worker who will contact the consumer via telephone within two working days to arrange the first face-to-face meeting.

Useful links