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Exploring the Stepped Care Model in your community

Being familiar with local mental health care providers or other agencies and referral pathways relevant to the specific mental illness can assist in decision making.

This research should include knowledge of, and familiarity with:

  • local mental health care providers and eligibility criteria
  • other mental health care agencies
  • referral pathways
  • evidence-based treatments
  • workplace employee assistance programs (EAPs)
  • school or university services and local social/council authorities.

The stepped care services can involve four processes, which may vary across communities.

  1. The patient is referred into the system. This may be from the GP, allied health provider, carer or via self-referral depending on the PHN.
  2. The patient is assessed (by the GP or another commissioned service, or by the PHN central intake services, if relevant).
  3. A cycle of therapy is allocated and may be discussed with the GP.
  4. Recovery is evaluated, the patient is reassessed and directed to a different service, or deemed to have their needs met to exit the system.

As defined by the DoH, activities not considered to be in scope for implementation within a Stepped Care Model, managed by PHNs, are those that:
  • are not supported by an empirical evidence base;
  • fall outside the scope of primary mental health care; specifically
    • services principally targeted at providing social support,  with the exception of suicide prevention activities ... ; and
    • bed-based services;
  • duplicate or replace existing services provided by other organisations, including state and territory government services; and
  • are not supported by the funding guidelines for the primary mental health flexible funding pool.6



  1. Department of Health. PHN mental health and suicide prevention implementation guidance: Stepped care. Canberra: DoH, [date unknown]; p. 3. [Accessed 21 February 2019].


Working with the Stepped Care Model