Implementing stepped care in general practice

As general practice is usually the first point of clinical contact for people seeking help with mental health concerns, this means GPs are often in a position where they can identify issues early and intervene preventively.¹ Even when a consumer presents for a non-mental-health request (eg a medical certificate), the GP can undertake an appropriate mental health assessment and clinical decision-making.

As a GP, you might be a referrer, care provider, care coordinator, or all of the above, based on the consumer’s needs and the services that are available.

When implementing stepped care, you should aim to:

• identify mental health and psychosocial needs early
• provide an initial assessment that includes your routine physical health assessment, followed by mental health care such as counselling, psychoeducation and brief interventions, as well as ongoing care
• refer to appropriate stepped care services
• coordinate care provided by other providers
• maintain continuity of care
• the GP–consumer therapeutic relationship is the most important factor in continuity of care and improved outcomes. In some Aboriginal community controlled health organisations (ACCHOs), consumers may see a different doctor each visit, so continuity of care requires adaptation for successful stepped care among rural and remote communities.

A GP’s knowledge of a consumer’s physical health, social circumstances and participation in work or education means they play a central role in understanding and managing the consumer’s mental health needs7. In particular, the ongoing GP–consumer relationship creates opportunities for regular, low-threshold conversations about mental health, which can prevent relapse, reduce escalation, and interrupt the potential cycle of repeated crises.

Stepped care is a preventive and person-centred model, supporting GPs to work collaboratively with consumers to match a consumer’s healthcare to their needs, and to adjust the care over time. For example, Mental Health Treatment Plans and referrals are most effective when completed by the consumer’s usual GP or MyMedicare-registered practice, to maintain safe continuity and clinical oversight.

As continuity of care is fundamental to effective stepped care, you are encouraged to help consumers establish a single, trusted GP or usual practice where their mental health and physical health can be managed together. Although consumers value the efficiency, affordability and accessibility that can be achieved by using multiple services, it is also worth discussing with them that fragmented care can increase the risk of undiagnosed conditions, incomplete remission of symptoms and relapse.

An essential function of general practice is to coordinate and direct care across services, ranging from early intervention and low-intensity supports to higher-intensity, specialist, and coordinated care.

If a consumer is in immediate danger to themselves or others, call 000. If you have any concerns or questions about this issue, contact your medical defence provider, who can provide 24/7 expert medico-legal advice, ensuring you are able to act within legal boundaries.

You must always consider duty of care when managing consumers with severe mental illness. If responsibility for managing a particular individual’s care is transferred between primary care and specialist services (whether state or privately funded), the service and the referring GP still have a duty of care to ensure that the receiving service has accepted care of the consumer and is aware of the consumer’s needs. This is particularly important because of the potential vulnerability of consumers with mental health conditions.

When transferring care (which can often happen because of the episodic nature of some severe mental illnesses), it becomes particularly important for GPs to clearly define clinical responsibility, including:

• who is prescribing medication
• who is delivering treatment
• who is responsible for risk monitoring and review

Australia’s 31 PHNs have a coordination role in Australia’s Stepped Care Model. Although they do not provide comprehensive clinical care themselves, nor replace general practice, they do:

• plan, commission, integrate and monitor services so that people can access the right level of care at the right time
• work in partnership with GPs, community providers, lived-experience organisations, hospitals and state services to strengthen local care pathways and improve consumers’ ability to navigate health services.

As PHN services only account for a small part of the total mental health system, services delivered by other providers may better suit a consumer.

PHNs commission a range of services that may include:

• low-intensity and early-intervention supports
• digital and guided self-management programs
• community-based psychosocial services
• clinical interventions of moderate intensity
• Step Up/Step Down services (where commissioned). Step Up/Step Down refers to the coordinated system of services that offer short-term care when consumers are between inconsumer and community settings. They provide an alternative to (pre-acute) hospital admission and (post-acute) bridging support after the consumer is discharged from hospital. Services are usually delivered at staffed residential facilities or⁸ 

PHNs are responsible for understanding the mental health and psychosocial needs of their local catchment areas, by drawing on information such as:

• population data and epidemiology
• consumers’ use of services and access to data
• local workforce capacity
• input based on community and lived experience.

As a result, each PHN provides or arranges different services. For example:

• some PHNs accept self-referrals from consumers, while others require referrals from a GP or other health professionals
• some PHNs conduct their own intake and assessment processes, while others use a service offered by another provider.

Direct communication between you and your local PHN ensures that you fully understand the services the PHN offers and how the PHN can work with you to make sure that consumers are not ‘lost’ between services.

This is particularly important when a consumer is moving from one step of care to another.

Sign up to your PHN to receive regular communications from it. You can find your local PHN here.

About their services

• What stepped care services are currently available in our area and who are they for?
• Who decides what service is offered and how is that determined?
• Which services are:
  • low-intensity/early intervention?
  • moderate-intensity clinical?
  • psychosocial/functional recovery focused?
• Do you have a list of the services you recommend, for each level of intensity?
• Who provides the service?
• Are there services that accept same-day or rapid referrals?

Services for specific groups

• Are there services for specific populations (eg young people, perinatal, CALD, Aboriginal communities)?
• How do you reach those specific populations?
• Do you have an up-to-date profile on the specific populations in this area, what their needs are, and how do you commission services to meet those needs?
• For consumers with limited literacy, are services available in spoken/verbal formats as well as written materials?
• Are services available in languages other than English?

Accessing their services

• How does a GP or consumer access your services?
• Which consumers are suitable and/or eligible?
• Who isn’t eligible, and why not?

Managing expectations

• What can I expect from you as my PHN?
• What do you need from me as a GP?

Clinical issues

• How does clinical handover occur between the GP and the service?
• How often is the person encouraged to make contact with their GP and how is the GP incorporated into the care plan?
• What feedback will I get after I refer (eg confirmation of acceptance, clinical updates, discharge summaries)?
• What is the process for reporting back to the referring GP?
• Do you have a referral navigation system you can share with me?
• Are there GP-priority pathways?
• How is the consumer reassessed at the end of a cycle of care?

Addressing concerns

• Who do I call if a referral stalls?
• Who does the GP or consumer contact if there are concerns about the service?