Commonwealth Psychosocial Support (incorporating Integrated Chronic Care) – Northern and Western Region


1 July 2022 – 31 October 2023

Funding Amount:







Moonee Valley

Melbourne Macedon Ranges Yarra Moonee Valley Darebin Maribyrnong Hobsons Bay Wyndham Brimbank Moorabool Melton Hume Merri-bek


From 1 July 2022, North Western Melbourne Primary Health Network (NWMPHN) embedded its Integrated Chronic Care (ICC) pilot program into its Commonwealth Psychosocial Support (CPS) program. This activity covers 5 local government areas, in which it supports consumers who have severe and persistent mental illness, and are at risk of developing one or more physical health conditions.

The ICC program began as a pilot in July 2019, responding to the lower life expectancy of people accessing the public mental health system in the NWMPHN catchment. The organisation commissioned Neami National and cohealth to deliver it, using registered nurses and mental health peer workers. The Social and Global Studies Centre at RMIT University evaluated the pilot. Its final report was released in February 2022.

The ICC pilot has ended, and its lessons have been incorporated into the CPS program, which is also delivered by Neami National and cohealth. The CPS program supports people with severe mental illness to participate in their community, manage daily tasks, undertake work or study, find housing, get involved in activities, and make connections with family and friends. Incorporating lessons from the ICC trial ensures there is a focus on and relevant support for physical health needs.


This activity addresses the intersection of physical and mental health needs of a complex consumer cohort. Its expected outcomes include:

  • providing a streamlined and seamless support service to consumers with severe and persistent mental illness who are at risk of developing one or more physical health conditions
  • improving the physical health of people living with mental illness by offering care coordination
  • reducing the need for more intensive and acute physical and mental health services, resulting in more appropriate use of the health system
  • establishing referral pathways to ensure consumers are directed to the service and support options that best meet their needs. These may include other services commissioned by NWMPHN, mainstream external services and tertiary mental health services
  • implementing a consistent intake and assessment process to ensure consumers’ needs are met within reasonable timeframes without duplication.

Services involved