Stepped care for specific populations

Table of contents

Stepped care for specific populations

Stepped care can be challenging for a consumer who belongs to one or more specific populations. They might experience, for example, a language or literacy barrier, or feel uncomfortable immediately sharing their mental health concerns.

These, and other issues, can raise questions about access, equity and culturally safe healthcare. Many specific populations, however, including Aboriginal and Torres Strait Islander peoples, bring strong cultural practices, resilience and community-connected approaches that can support meaningful care.

As a GP, you can:

listen non-judgementally and empathetically
be aware of barriers to access
be aware of your own biases.

You can also make sure that you:

use culturally appropriate services where available
avoid rigid application of tools that may cause harm
be aware of western-orientated services (eg could consumers who don’t return perhaps feel that the services are not culturally safe or culturally aware?)

There is not a lot of evidence about the use of stepped care for some population groups, so it’s important to remember that its effectiveness and suitability may be different, depending on a consumer’s cultural background, age, cognitive ability and social or environmental factors.

For example, approaches that are effective for adults may not translate well to children, those suitable for older people may not be effective for adolescents, and people from specific populations (such as the LGBTQIA+ and Aboriginal and Torres Strait Islander communities) may require approaches that differ from those that are effective in the general population. It’s therefore important to not only appreciate these nuances but also to stay informed by reviewing reliable, up-to-date sources (such as clinical guidelines, peer-reviewed research and local mental health organisations) to understand how stepped care might apply to people from specific populations.

How best to provide stepped care for specific populations

Some generic ways you can provide stepped care to people from specific populations include:

adapting stepped care tools for the population (eg working alongside Aboriginal and Torres Strait Islander peoples, communities, Elders and ACCHOs, culturally and linguistically diverse communities, and people with complex trauma, disability or social disadvantage)
becoming familiar with the different issues each population may experience (eg minority stress, language and literacy barriers, stigma, past healthcare harm, intergenerational trauma)
investigating and understanding the population-specific services that are available, and the mainstream services that can be adapted to specific populations
expanding your knowledge of digital interventions that are specifically designed for cultural communities (eg https://www.healthtranslations.vic. gov.au/).

The following table outlines:

the common barriers to care experienced by specific populations
suggestions from Lived Experience groups and organisations on how you can adapt stepped care to overcome these barriers

Common barriers to care	Potential referral options	Adapting stepped care for this population
Aboriginal and Torres Strait Islander peoples
Historical and ongoing impacts of colonisation and racism Experiences of culturally unsafe care Structural and geographic access barriers	ACCHOs Aboriginal Health Workers Cultural liaison	Recognise and build on cultural strengths, connection to Country, community leadership, kinship systems and cultural healing practices Adopt a social and emotional wellbeing approach Implement cultural safety Engage ACCHOs/AHWs if consent is given Work in partnership with community where appropriate Allow for longer consultations Consider intergenerational and systemic trauma
Culturally and linguistically diverse (CALD)
Language barriers Stigma Low mental health literacy	Use professional interpreters Bicultural services Translated materials	Aim for culturally framed explanations of distress Adopt family inclusive approaches where appropriate Use bilingual clinicians/interpreters (do not rely on family) Allow for longer consultations
Children and adolescents
Limited insight Parental or school barriers	Headspace Family-based therapy School collaboration	Use developmentally appropriate family-centred care Engage early via schools, youth services, Headspace Involve parents/caregivers, while respecting the young person’s autonomy Lower the threshold for stepping up if self-harm or suicidal ideation is present Prioritise safety, school engagement and early intervention Allow for longer consultations
LGBTQIA+ community
Fear of discrimination Prior negative experiences Minority stress	LGBTQIA+-affirming GPs and psychologists Peer support services	Use inclusive language and visible safety signals, early peer supports, affirming psychoeducation Refer to LGBTQIA+-affirming clinicians Monitor suicidality during transitions Monitor impact of discrimination and isolation Allow for longer consultations
Veterans
Stigma Reluctance to seek help Complex trauma	Open Arms – Veterans & Families Counselling DVA-funded services	Build trust Normalise help-seeking Integrate pain, sleep and AOD care early Advise of DVA pathways and veteran peer support Screen for post-traumatic stress disorder/moral injury and provide care as required Provide coordinated care (this is often needed) Allow for longer consultations
Refugees
Trauma exposure Trust issues Language and settlement stress	Refugee health services Trauma-informed counselling Settlement services	Address practical needs first (housing, legal, income) Use interpreters and trauma-informed care Avoid premature exposure therapies Refer to specialist trauma services when needed Avoid rushing disclosure of trauma Allow for longer consultations
Older people
Under-recognition Isolation Somatic presentation	Geriatric mental health services Social supports	Consider comorbid physical illness, cognition, grief, isolation Take it slowly, allow for longer consultations and avoid over-medicalisation Involve carers/family where appropriate Step care up or down, based on function and quality of life, not symptom scores alone
People with disability (including NDIS)
Fragmented systems Access and cost barriers Possible systemic barriers and higher trauma exposure	Disability-aware providers NDIS psychosocial supports	Use accessible communication and allow longer consultations Actively avoid diagnostic overshadowing – a cognitive bias where health professionals misattribute a consumer’s physical symptoms to a pre-existing psychiatric, intellectual or developmental condition (such as a disability) instead of investigating for an independent illness Involve carers/support workers with consent Be flexible about stepping care up and down to accommodate access needs
People with alcohol and other drug use
Shame Dual-diagnosis exclusion	Integrated mental health–AOD services	Be trained in trauma-informed care Use a non-judgemental harm-reduction approach Integrate mental health and AOD care at all steps Step up based on risk, dependence and functional impact Recognise the likelihood of non-linear progress Address withdrawal and safety early Allow for longer consultations
People experiencing homelessness
Instability Competing priorities Mistrust of services	Outreach mental health services Homelessness health programs	Prioritise engagement, trust and continuity Treat housing, income and safety as mental health interventions Step up or down based on immediate needs and risk, not attendance Maintain care across transitions and services Allow for longer consultations
Intimate partner violence (IPV) survivors
Fear Safety concerns Shame System navigation	Family violence services Trauma-informed counselling Legal supports	Use a trauma-informed, safety-first approach Allow for longer consultations Avoid couple therapy Respect autonomy and do not pressure disclosure Regularly reassess risk and safety Step care up or down in line with readiness and safety (not symptom severity) and recognise that a step up may be necessary, even if there are mild symptoms (eg if the risk of harm is significant) Integrate advocacy and legal supports alongside clinical care

Downloads

GPMHSC-Guide-Stepped-care-model.pdf