1. GP Link Program Susan Davis Clinical Nurse Consultant GP Clinical Liaison Officer (GPCLO)

2. What is the GP Link Program? The GP Link Program is an integrated approach to care with GP providing mental and physical healthcare and the Mental Health Service maintaining a supportive role. The program is designed to provide care for consumers with enduring mental health problems that no longer require intensive case management but still need a level of contact with the Mental health Service.

3. Referral Criteria The consumer has enduring mental health problems, for example schizophrenia or bipolar affective disorder The consumer has a nominated GP The consumer has a stable mental state The consumer is able to attend the GP independently There is a continued need for contact with the mental health services for periodic reviews The consumer agrees and gives consent to become involved in the program There has been a psychiatric review in the last three weeks focusing on the consumers eligibility for the GP Link Program

4. What will the GPCLO do? Attends a meeting suitable for you and the consumer to assess eligibility, this could also be when the consumer has their Psychiatric review Consults with the GP involved Organises the case conference with GP and all other parties involved Completes the care plan, relapse prevention and assessment paperwork Arranges future Psychiatric reviews Follows up the consumer in the community

5. Ongoing care The GP will be the primary care provider with the consumer attending the GP practice regularly The GPCLO maintains contact with the GP and the consumer Should problems arise the GPCLO will endeavour to resolve these with the cooperation of the GP and consumer If the consumer deteriorates into a crisis situation, and acute assessment is needed, the consumer will need to be assessed through the acute channels ie ED, ACT The program works in collaboration with the GP for up to a period of two years, within this time individual cases are assessed for eligibility for transfer to the GP’s care.

6. Other projects Networking with the GPNN which includes joint projects and collaborative meetings. Currently reviewing team files to assess suitability of consumers for the GP Link Program and looking at other pathways of care e.g. discharge from services where appropriate Ongoing in-services in regards to bringing awareness to the GP Link Program and GP involvement in mental health care. Completing statistics related to the GP Link Program such as shared care tracking data and evaluation of the service

7. Future projects Assessment clinic Assessment at GP Practices Mental Health supervised clinical attachments Hornsby Hospital

8. Assessment Clinic Based at Hornsby Hospital To establish an assessment clinic specifically for non urgent GP mental health referrals After the initial assessment in the clinic the GPCLO would refer the consumer appropriately for case management, further psychiatric review, the GP Link Program or back to their GP with no mental health follow up needed at this time. The GPCLO would inform the GP in writing of the outcome of the assessment and if appropriate, include a plan of care.

9. Assessment at GP Practices Offer sessions to GPs in their surgeries to discuss clients joint or new Complete assessments with GPs/Practice Nurses in their surgeries for existing and new consumers Improve communication between services Information sharing on consumers Education for GPs on MH assessment and follow up Support GPs with MH consumers

10. Mental Health supervised clinical attachments (GPNN) In this project the GP leaves his/her own practice for a limited time to work, under supervision, in another clinical setting in order to learn or update specific skills or areas of knowledge. GP gains an understanding of methods of assessing, counselling and treating patients with psychological problems GP gains an understanding of the services provided by the mental health services by observing the service at work.