Developing a regional approach to wellbeing

Sponsored by Brisbane North PHN and Metro North Hospital and Health Service, Planning for Wellbeing (the Regional Plan) identifies significant opportunities for service and system improvement across three discrete and complementary areas of work – mental health, suicide prevention and alcohol and other drug treatment services.

The Plan articulates a suite of shared objectives that have been developed in partnership and via significant consultation with stakeholders. The shared objectives reflect the commitment to action of healthcare practitioners and organisations across the region, as well as the contribution that will be made by people with a lived experience, and carers who are engaged in work to shape and improve mental health, suicide prevention and alcohol and other drug treatment services.

Tonita Taylor, Program Development Officer, Regional Plan, Brisbane North PHN presenting on the Regional Plan at the 2019 Metro North Health Forum.

Stepped care at the heart of PHN commissioning

Our stepped care approach

In a stepped care approach, a person seeking support is connected to the services that meet their needs and as their needs change, the services change with them. The PHN commissions all our mental health services within a stepped care approach.

We’ve produced a short video to explain stepped care from a consumer’s perspective.

Mental health expo turns eight

We were again involved in the annual Brisbane Mental Health Expo that attracted thousands of locals to Reddacliff Place on 12 October 2018.

The 2018 expo theme ‘Head, Heart, Health’ was designed to help reduce stigma and encourage people to join in the conversation around mental health. Over 60 organisations were represented on the day, with over 20 sponsoring the event in its eighth year.

Consumers and carers drive:
‘Nothing about us without us’

We have a strong commitment to fostering collaborative partnerships with consumers and carers at each stage of commissioning mental health, suicide prevention and alcohol and other drug services.

April 2019 marked the third anniversary of the Peer Participation in Mental Health Services (PPIMS) Network.

During 2018/19, these activities continued to grow and the group contributed to a range of initiatives designed to improve the quality of services for people in our community at a regional, state and federal level.

Highlights and initiatives of the PPIMS network during 2018/19 include:

  • the establishment of two communities of practice—for peer workers and suicide prevention
  • funding scholarships to attend state and national conferences
  • PPIMS members giving presentations at a range of state, national and international conferences
  • the recruitment of PPIMS members for participation within regional planning partnership and governance groups.

In 2018, the PPIMS Network was nationally recognised by the Department of Health who have since funded Brisbane North PHN to chair and manage the National PHN Mental Health Lived Experience Network (MHLEEN).

Services meet local needs

The PHN has commissioned an expanded range of mental health, suicide prevention and alcohol and other drug treatment services in the North Brisbane and Moreton Bay region.

Low intensity psychological services provide entry-level mental health support


65,000 adults living in the region will experience mild levels of psychological distress and could benefit from accessing a low intensity psychological service.


During 2018/19, the PHN funded a number of organisations to deliver low intensity psychological services via phone, online, groups or one-to-one as a less intense alternative to individual sessions with a psychologist for people with or at risk of mild mental illness.

Achieving wellbeing through the Optimal Health Program

Neami National’s Optimal Health Program is an eight-session group and individual program that helps people improve their wellbeing.

The program takes a holistic approach to wellbeing; exploring the roles that the areas of social, emotional, physical, spiritual or values, engagement and intellectual play in our everyday lives.

91 people were supported to improve their mental wellbeing as part of the Optimal Health Program in 2018/19.

Culturally responsive approaches to problems

Problem Management Plus is purpose built for culturally and linguistically diverse communities. It’s a structured program of sessions with a peer support worker and cultural support worker.

84 people from culturally and linguistically diverse backgrounds participated in Problem Management Plus during 2018/19.

Designed to support the transition into aged care

The Change Futures Caring for Residents of Aged Care Program places provisional psychologists in residential aged-care facilities to provide therapeutic programs for groups and individuals.

During 2018/19, Change Futures supported 486 older people as part of the low-intensity program and 170 people as part of the psychological therapies program which commenced in January 2019.

Coaching people on the path to wellness

NewAccess is an early intervention program developed by beyondblue to support people experiencing low-level anxiety and depression. In our region, it’s delivered by Richmond Fellowship Queensland (RFQ).

Launched in July 2017, it’s designed to help people identify their problems, set practical goals and get their lives back on track.

In the 12 months to June 2019, RFQ supported 248 people in the region via the NewAccess program.

Postnatal wellbeing program recognises that life isn’t always peachy

The Sunshine Parenting Program is a six-week postnatal wellbeing program for mothers who are struggling with their mental health, facilitated by Peach Tree Perinatal Wellness Inc and funded by Brisbane North PHN.

62 people were supported by the PHN to access the Sunshine Parenting Program during 2018/19.

Mid-level support for people who need it most

Designed for vulnerable populations

Brisbane MIND and Brisbane MIND Suicide Prevention are designed for the most vulnerable people in the community. The services have strict eligibility criteria and GPs are entitled to only a limited number of referrals each year.

1,387 people received a Brisbane MIND service during 2018/19.

Supporting mental wellbeing for vulnerable children and young people

Services that are responsive to the needs of children and young people

Our health needs assessment recognises that the prevalence of mental health issues has increased over the last five years, particularly among younger residents of the region. That’s why we fund a range of local service providers to support children and young people who otherwise may not have access to services.

Brisbane North PHN funded 2,827 services for children and young people during 2018/19.

Brisbane MIND4KiDS helps respond to distress early, before it escalates

Brisbane MIND4KiDS is designed for vulnerable and disadvantaged families across North Brisbane. The service provides up to six sessions of psychological therapy to children and their families, at no cost.

Brisbane MIND4KiDS is offered across Brisbane North by three private practices: All About Kids, Anita Trendle Psychology and Young Minds. Child Aware, based in Strathpine, is also part of the program, offering a specific response for children who have experienced trauma.

658 children were supported via Brisbane MIND4KiDS during 2018/19, with a further 57 supported by our specialist provider.

Helping young people with their head space

Our region is home to four headspace centres – Caboolture, Nundah, Redcliffe and Taringa. Each centre is run by a local consortium of service providers, funded through Brisbane North PHN.

During 2018/19, these headspace centres provided individual counselling, therapy and group programs for 7,551 young people across the region.

A clinical model, attached to a drop-in youth service

Asha works across Moreton Bay north, in the high-needs areas of Redcliffe, Deception Bay, North Lakes and Caboolture. The Hindu word for hope, Asha offers services through a combination of mobile outreach, home visits, centre-based appointments and drop-in facilities.

The service offers clinical treatment for mental illness, complex problems and suicidal ideation and in 2018/19, supported 91 local young people.

Supporting people with chronic, long-term conditions

A mental health nurse by your side

The Mental Health Nursing in Brisbane North Program (MHNiB) accepts referrals from both GPs and psychiatrists. It was launched by Brisbane North PHN in July 2017, and replaced the Mental Health Nurses Incentive Program (MHNIP), previously funded by the Australian Government.

During 2018/19, our team of mental health nurses, based in hubs at Morayfield Psychology Centre, Toowong Private Hospital and Footprints provided community-based, clinical care coordination and treatment services to 446 people with severe mental illness and complex health issues.

Speaking at the MHNiB launch on September 1 were (L-R): Dr Trish Baker (Brisbane North PHN), Keryn Fenton (Footprints), former Assistant Minister Jane Prentice, Christine Gee (Toowong Private Hospital), Jeanelle Gibson (Brisbane North PHN) and Amy Wong (Morayfield Psychology Centre).

North Brisbane Partners in Recovery

Coordinating across services

In May 2019, staff and service providers gathered to celebrate the end of an era as North Brisbane Partners in Recovery initiative wound up, following six years working to improve outcomes for people experiencing severe and persistent mental illness with complex needs.

Partners in Recovery provided service coordination for individuals with severe and persistent mental illness and complex needs. In our region it was delivered by eight local service providers: Aftercare, Communify, Footprints, Institute of Urban Indigenous Health (IUIH), Mental Illness Fellowship Queensland (MIFQ), Neami National, Open Minds, and Richmond Fellowship Queensland (RFQ).

It was a service-coordination program, intended to provide people experiencing persistent mental illness and complex needs with the support required to navigate the system.

During 2018/19, Partners in Recovery supported 944 people.

  • Pauline Coffey, Paul Martin and Kathy Faulkner - Partners in Recovery Managers over the six year period

  • Partners in Recovery Consortium members at the end of celebration event in May 2019

Transitioning to the NDIS

The National Disability Insurance Scheme (NDIS) is being established across the region, and Partners in Recovery participants were gradually move to the NDIS. In June 2019, Partners in Recovery ceased, and all participants were transitioned to access services through the NDIS or supported through other community-based programs.

With the Partners in Recovery program drawing to an organic end, the support coordinators helped participants to apply for the NDIS.

Finding your way back

Expanded support offers a way back after attempting suicide

The Way Back Support Services helps people who are most at risk of dying by suicide.

The service delivers personalised support to people discharged from Redcliffe Hospital following a suicide attempt.

Redcliffe Hospital is the first Queensland service to trial The Way Back, which was developed by beyondblue. The service opened in October 2017 and, in its first six months, supported more than 53 people following a suicide attempt or suicidal crisis.

In March 2019, the Australian Government announced an additional $1.2 million to expand Brisbane North PHNs local trial of the service, which is delivered by Richmond Fellowship Queensland.

The expansion will see people who are discharged from Caboolture Hopsital after attempting suicide receive personalised support and follow-up care.

Stigma-free support for alcohol and other drugs

Our region is home to a wide variety of services for people seeking support with alcohol and other drugs – ranging from residential rehab and withdrawal programs through to low-intensity counselling and other talking therapies.

Supporting vulnerable young people

Brisbane Youth Service (BYS) offers a range of services for vulnerable young people from its Fortitude Valley hub. It provides young people with housing services, emergency relief, health care, counselling, advocacy and support. Brisbane North PHN funds BYS’s alcohol and other drug use program.

During 2018/19, PHN-funded services delivered by BYS supported 159 young people.

A stable place to recover

The Queensland Aboriginal and Islander Alcohol and Drug Dependence Service (QAIAS) is a residential rehab that’s home to around 28 people at a time, all on their own treatment journey, and all committed to abstinence for the duration of their stay.

Brisbane North PHN provides funding for a mental health nurse and GP to connect QAIAS clients with primary healthcare and undertake outreach to those who might not otherwise access services.

During 2018/19, these practitioners supported 262 Aboriginal and Torres Strait Islander peoples.

Supporting the supporters

QNADA – the Queensland Network of Alcohol and Other Drug Agencies provides representation and support to the alcohol and other drugs treatment and harm reduction sector.

Brisbane North PHN provides funding to QNADA to support the development of the alcohol and other drug sector both locally and to make connections across the state.

During 2018/19 this included a communities of practice for practitioners and supervisors, revisiting the AoD workforce survey, a forum on the justice, alcohol and other drugs sector, development of an eLearning module on Chemsex and Queensland AOD sector specific supervision guidelines and resources.

Minimising harm, without judgement

We provide funding that allows Lives Lived Well to offer frontline services at Deception Bay, Caboolture, Redcliffe and Strathpine – through individual counselling, group programs, withdrawal support, outreach, non-residential rehabilitation, and wrap-around mental health support.

During 2018/19, Lives Lived Well supported 1,700 people in the region.

Holistic health care for users of illicit drugs

Queensland Injectors Health Network (QuIHN) is a statewide program that offers a full range of health services in our region, including needle and syringe program, peer education and information, medical services with on-site GPs, on-site counselling and health outreach services.

During 2018/19 via their harm minimisation framework, QuIHN provided 1,563 sessions to people in our region.

New mental health services in Brisbane North

Better integration through service hubs

In 2018, the PHN has worked with consumers and carers, service provider organisations and practitioners, and other stakeholders to decide how existing and new primary mental healthcare services commissioned by the PHN will evolve.

As a result of these discussions, from 1 July 2019, Brisbane North PHN will support the establishment of three new integrated mental health service hubs. The hubs will support people with severe mental illness by integrating a range of clinical and non-clinical supports within the one service.

National Suicide Prevention Trial

A local approach to suicide prevention

Brisbane North PHN is one of the 12 trial sites around the country taking part in the trial, with work in the region targeted towards Aboriginal and Torres Strait Islander people, LGBTIQ+ people and men aged 24-54 years of age. There is also national trial activity targeted towards the ‘whole of region’ which aims to build foundations by working through general services—sometimes this is the most effective way of reaching the priority population groups.

Writer and actor Steven Oliver, at the launch of Yarns Heal in Sandgate

The trial within the North Brisbane and Moreton Bay region is guided by the Black Dog Institute’s LifeSpan Model, which combines strategies for suicide prevention into one community-led approach incorporating health, education, frontline services, business and the community.

In 2019, two community campaigns aimed at starting a conversation around suicide prevention were launched as part of the National Suicide Prevention Trial. For more information visit and

  • Comedian, poet and MC Steven Oliver, Indigilez Women’s Leadership Group and Support Group co-founder Rebecca Johnson and gar’ban’djee’lum network Chairperson Dion Tatow.

  • Members from the implementation teams and partnership organisations at the National Suicide Prevention Trial Launch.

Also developed as part of the trial, we launched Reasons to Stay. The campaign targets people who are experiencing or at risk of experiencing a suicidal crisis, and those who are concerned about a friend or family member.

Link-me Trial

A trial linking patients with care navigators

We were one of three PHN sites chosen to conduct a randomised control trial of an approach to assist with the implementation stepped mental health care in general practice.

The Link-me trial ended in February 2019. In our region the online tool was offered to 6,500 people with 61 per cent agreeing to participate.

Of those who were eligible and completed the online Decision Support Tool, 134 were allocated into the mild intervention group, 132 into the severe intervention group and 407 into to the control or ‘usual care’ group.

All evaluation and a final report on the Link-me trial will be completed by the University of Melbourne by 2020.


Supporting frontline healthcare services