National Disability Insurance Scheme Programme
National Disability Insurance Scheme Transition
Personal Helpers and Mentors
Operational Guidelines
2015–16
July 2015
Preface
The Australian Government Department of Social Services (DSS) has a suite of Programme
Guidelines which provide information about each Programme that provides grants funding,
and the Activities that contribute to that Programme. They provide the key starting point for
parties considering whether to participate in a Programme and form the basis for the
business relationship between DSS and the grant recipient.
These Operational Guidelines are to assist organisations delivering services under the
Persona Helpers and Mentors Activity, within the National Disability Insurance Scheme
Transition component of the National Disability Insurance Scheme Programme. They should
be read in conjunction with the National Disability Insurance Scheme Programme – National
Disability Insurance Scheme Transition Guidelines.
DSS reserves the right to amend these Operational Guidelines, and other documents in the
Programme Guidelines suite, from time to time by whatever means it may determine in its
absolute discretion and will provide reasonable notice of these amendments.
Contents
1 Programme overview - National Disability Insurance Scheme (NDIS) ................................... 6
2 Programme component overview - National Disability Insurance Scheme Transition .......... 6
3 Personal Helpers and Mentors (PHaMs) .................................................................................... 7
3.1 PHaMs overview ........................................................................................................................... 7
3.2 PHaMs aims and objectives ........................................................................................................... 7
3.3 Clients / target groups................................................................................................................... 8
3.3.1
Client eligibility ................................................................................................. 8
3.3.2
Additional client eligibility criteria for specialist PHaMs services: ...................... 8
3.3.3
Ineligible persons ............................................................................................. 9
3.3.4
Target groups .................................................................................................. 9
3.3.5
How to access PHaMs services ..................................................................... 10
3.3.6
Fees .............................................................................................................. 10
3.3.7
What clients can expect ................................................................................. 10
3.3.8
Client rights and responsibilities ..................................................................... 11
3.3.9
Exiting PHaMs ............................................................................................... 11
3.4
Service delivery and eligible and ineligible PHaMs activities ................................. 12
3.4.1
Team approach to service delivery ................................................................ 13
3.4.2
Mandatory caseloads for PHaMs teams......................................................... 15
3.4.3
Duration and intensity of support.................................................................... 15
3.4.4
Individual Recovery Plans .............................................................................. 16
3.4.5
Mental Health Crisis Response ...................................................................... 16
3.4.7
Supporting families and carers....................................................................... 17
3.4.8
Family-sensitive services ............................................................................... 17
3.4.9
What PHaMs cannot provide ......................................................................... 17
3.4.10 Eligible activities .................................................................................................. 17
3.4.11 Ineligible activities ................................................................................................ 18
3.4.12 Service coverage areas ....................................................................................... 18
3.4.13 Funding for PHaMs .............................................................................................. 19
3.5
Links and working with other agencies and services ............................................. 19
3.5.1
Local coordination and collaboration .............................................................. 19
3.5.2
PHaMs Employment services ........................................................................ 20
3.5.3
Partners in Recovery ..................................................................................... 20
3.5.4 Interpreting services ............................................................................................... 20
3.6
Special requirements for PHaMs ........................................................................... 21
3.6.1
PHaMs practice principles.............................................................................. 21
3.6.2
National Standards for Mental Health Services .............................................. 21
3.6.3
Compliance with Relevant Legislation ............................................................ 21
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3.6.4
Privacy and complaints handling .................................................................... 21
3.6.5
Incident reporting ........................................................................................... 22
3.6.6
Volunteer worker support ............................................................................... 22
3.6.7
PHaMs promotional products ......................................................................... 23
3.7
Activity performance and financial reporting .......................................................... 23
3.7.1
Activity performance reporting ....................................................................... 23
3.7.1
Financial reporting ......................................................................................... 24
4 Contact Information ................................................................................................................... 24
Glossary ............................................................................................................................................... 25
Attachment A: PHaMs Practice Principles ...................................................................... 28
Attachment B: Eligibility Screening Tool and Client Data ................................................. 33
What is the EST .............................................................................................................. 33
Nine life areas ................................................................................................................. 33
How to use the EST?....................................................................................................... 34
Informed consent ............................................................................................................. 35
Consent to provide data to DSS ...................................................................................... 35
Attachment C: Client transfers, turning away referrals and exiting clients ........................ 36
Turning away referrals ..................................................................................................... 39
Exiting clients .................................................................................................................. 39
Attachment D: The PHaMs team and roles ...................................................................... 40
Personal qualities ............................................................................................................ 40
Roles ............................................................................................................................... 40
Attachment E: Individual Recovery Plans (IRP) ............................................................... 45
IRP principles .................................................................................................................. 45
Developing an IRP........................................................................................................... 45
Key elements of an IRP ................................................................................................... 45
Attachment F: Individual Recovery Plan SAMPLE ........................................................... 47
Attachment G: Organisational cultural competence ......................................................... 52
Definition of cultural competence ..................................................................................... 52
Culturally competent services .......................................................................................... 52
Organisational cultural competence................................................................................. 52
Attachment H: Incident Report Form ............................................................................... 54
Attachment I: Using the Personal Helpers and Mentors logo ........................................... 56
PHaMs logo and branding instructions ............................................................................ 56
PHaMs - using the logo ................................................................................................... 56
Attachment J: PHaMs services operating in NDIS sites ................................................... 59
Attachment K: PHaMs services operating in an NDIS My Way Site ................................. 61
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1 Programme overview - National Disability Insurance
Scheme (NDIS)
The Department of Social Services (DSS) works to provide improved independence,
participation and lifetime wellbeing for people with disability, people with a mental illness and
their carers.
The NDIS intends to ensure people with disability are supported to participate in and
contribute to social and economic life to the extent of their abilities. People with disability and
their carers will have certainty that they will receive the individualised care and support they
need over their lifetime.
The NDIS aims to improve the wellbeing and social and economic participation of people
with disability, and their families and carers, by building a National Disability Insurance
Scheme that delivers individualised support through an insurance approach. This
Programme also includes existing supports that are transitioning in to the NDIS in a phased
approach as well as services to support the market, sector and workforce to adjust to the
NDIS environment.
2 Programme component overview - National Disability
Insurance Scheme Transition
The NDIS is the new way of providing individualised support for eligible people with
permanent and significant disability, their families and carers. The changes that are required
to existing disability support systems are significant. Arrangements are being made to
ensure the NDIS can be introduced gradually, ensuring a smooth transition for people with
disability and support providers.
The NDIS Transition component supports the market, sector and workforce transitioning to
the NDIS environment by funding eligible organisations that provide:
 early intervention service, information and support to eligible children with a disability,
and their family and carers
 short-term or immediate respite to carers of people with severe or profound disability
and respite services to young carers at risk of not completing secondary education
 outside school hours care for teenagers with disability
 Australian Disability Enterprises assisting supported employees, and
 support services for people whose lives are affected by mental illness (including
Personal Helpers and Mentors services).
The NDIS Transition component aims to manage the transition of existing activities identified
to ensure:
 existing clients are sensitively transitioned into the NDIS in line with the full rollout of
the Scheme
 services and service providers are transitioned gradually to the NDIS in line with the
full rollout of the Scheme
 continuity of service throughout trial sites for clients that cannot access individualised
packages under the NDIS, and
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 an effective framework for transitioning the information, linkages and capacity building
elements of transitioning programmes to provide systemic-level support.
The NDIS will support choice and control by providing needs-based, individualised funding to
be used in a market-based environment. This will be a large shift for providers and clients
currently delivering and receiving services under transitioning programmes. In particular,
over time, there will be a move away from grant and block-funded one-size-fits-all services
towards a purchaser/provider model individually funded by the choice of consumers. While
there will be some provision for information, linkages and capacity building as well as
individually funded services, wherever possible disability services will be provided in line with
this new approach.
All grant recipients funded under the NDIS Transition programme will, therefore, be required
to work closely with DSS and the NDIS to make the shift to this new model.
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Personal Helpers and Mentors (PHaMs)
3.1 PHaMs overview
PHaMs provides increased opportunities for recovery for people aged 16 years and over
whose lives are severely affected by mental illness, by helping them to overcome social
isolation and increase their connections to the community. Clients are supported through
a recovery-focused and strengths-based approach that recognises recovery as a personal
journey driven by the client.
PHaMs workers provide practical assistance to people with mental illness to help them
achieve their personal goals, develop better relationships with family and friends, and
manage their everyday tasks.
N.B. Funding for PHaMs is gradually transitioning to the National Disability Insurance
Scheme. PHaMs providers located in NDIS sites have requirements in addition to those
outside NDIS sites. These are detailed in Attachments J and K.
3.2 PHaMs aims and objectives
PHaMs aims to improve the independence, participation and lifetime wellbeing of people
severely affected by mental illness, including building personal resilience and supporting
them to sustainably manage the impacts of their illness.
The aims of the PHaMs service model are to:
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support recovery for people severely impacted by mental illness
reduce their social isolation, and
improve their employment outcomes.
This is achieved by providing intensive one-to-one support to people severely impacted by
mental illness to increase:
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access to appropriate support services at the right time
personal capacity, confidence and self-reliance
the ability to manage daily activities, and
community participation (both social and economic).
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3.3 Clients / target groups
3.3.1 Client eligibility
To be eligible for PHaMs, persons must:
 be aged 16 years and over (except for remote PHaMs, which may accept clients of
any age)
 have a mental illness (a diagnosis is not required)
 experience severe functional impairment because of their mental illness (denoted by a
score of 3 or more on the functional assessment section in the Eligibility Screening
tool, except for remote services where the functional assessment may not be
appropriate)
 be willing to participate in the service voluntarily and able to make an informed
decision to participate
 be willing to comply with health and safety policies of the service
 agree to address any dual-diagnosed/comorbid drug and alcohol issues during the
course of participation in PHaMs
 reside in the coverage area of the PHaMs service where they are seeking support
(unless homeless or seeking support from a remote PHaMs service)
 not be restricted in their ability to fully and actively participate in the community
because of their residential settings (e.g. prison or a psychiatric facility)
 not be receiving non-clinical community support similar to PHaMs through state or
territory government programmes.
Mainstream PHaMs services may assist up to 10 per cent of clients from outside their
nominated coverage areas without seeking DSS approval. Clients may also transfer from
one service to another if they move to another area or state, or if they are having difficulties
achieving their goals with the current provider, for example where the current provider does
not have staff of the appropriate age or gender.
PHaMs providers may encourage PHaMs clients to seek medical assistance through clinical
mental health services if they are not accessing treatment, but may not exclude clients who
prefer not to.
PHaMs uses a functional assessment rather than clinical diagnosis to determine the impact
of mental illness on the client’s life. There is a functional assessment section in the Eligibility
Screening Tool (EST), specifically developed by DSS, which looks at nine life areas (see
Attachment B: Eligibility Screening Tool and Client Data for further information).
Funded providers are required to complete an EST for all potential clients, to determine their
eligibility for the service and to assess the extent to which their mental illness is impacting on
their capacity to function in the community.
3.3.2 Additional client eligibility criteria for specialist PHaMs services:
For PHaMs Employment Services a person must:
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be in receipt of the Disability Support Pension or other government income-support
payment
be engaged, or willing to engage, with an employment service
include goals relating to employment in his/her Individual Recovery Plan.
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For Remote Services – organisations may also work intensively with community and family
members as an appropriate way of supporting people with a mental illness, and to build local
capacity to respond to people with mental illness.
PHaMs Targeted Services for Vulnerable Groups – some PHaMs providers are funded to
target high-need, vulnerable groups within the community. These vulnerable groups include
Indigenous Australians, homeless people and humanitarian entrants. Arrangements for
delivery of these services, including targeting, are negotiated on a case-by-case basis with
each funded organisation. To be eligible to access support from a targeted service, a
person must be within the prescribed target group for the relevant service type:
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Indigenous – a person, who is of Aboriginal or Torres Strait Islander descent, identifies
himself or herself as an Aboriginal person or Torres Strait Islander, and/or is accepted
as such by the Indigenous community in which he or she lives.
Humanitarian Entrants – people who hold, or have held, a humanitarian visa.
Homeless – there are three kinds of homelessness:
o Primary homelessness, such as sleeping rough or living in an improvised
dwelling
o Secondary homelessness including staying with friends or relatives and with
no other usual address, and people staying in specialist homelessness
services, and
o Tertiary homelessness including people living in boarding houses or caravan
parks with no secure lease and no private facilities, both short and long-term.
3.3.3 Ineligible persons
People who are not eligible for PHaMs services are:
 those who have a mental illness that does not result in functional impairment
 those only with conditions other than mental illness, such as, but not limited to:
Acquired Brain Injury; Intellectual Disability; neurological conditions; Alzheimer’s
Disease or Dementia; and physical disabilities, and
 those whose residential settings limit, restrict or reduce their ability to participate fully
in the community such as in prison, or specialised drug and/or alcohol treatment
service, or a residential mental health or aged care service.
3.3.4 Target groups
PHaMs identifies a number of groups of people as facing additional disadvantage, including,
but not limited to:
 Indigenous Australians, including members of the Stolen Generations
 people with culturally and linguistically diverse backgrounds, including humanitarian
entrants and recently arrived migrants and refugees
 young people aged 16 to 24 years
 people who are homeless or at risk of homelessness
 people who have previously been institutionalised (including Forgotten Australians,
care leavers and child immigrants)
 young people leaving out-of-home care
 people who have been previously incarcerated, and
 people with drug or alcohol co-morbidity.
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Services are required to prioritise and actively target these special needs groups, or others
identified locally, for which there are significant populations in their coverage area, or who
are inadequately supported.
The Department expects services to develop the relevant expertise to be able to focus on
these special needs groups and to manage their caseloads to ensure that uptake is
representative of special needs groups in the local community. Targets for special needs
groups will be negotiated with service providers on a case-by-case basis and specified in
Grant Agreements.
The following considerations will assist with promoting and targeting services to special
needs groups.
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Become known in the community – people need to understand the service provided
and see the value in accessing the service.
Accessible – having an open-door approach, using outreach not just drop-in or
appointment services.
Being accepting – not stigmatising or devaluing further, being acceptable and relevant
to the local community and reflecting its ethnic and cultural values.
Providing good case management – by using bottom-up approaches to planning and
service delivery based on the needs and strengths of individual clients.
Continuity – providing long-term support and enabling a relationship to develop.
3.3.5 How to access PHaMs services
PHaMs service providers are required to maintain open referral and access pathways into
the service. Potential clients are able to access PHaMs through a broad range of entry
pathways including self-referral, referral by friends and family or other community services.
A formal referral from community mental health or clinical services is not required, and there
is no requirement for potential clients to be a registered client of state mental health
services.
PHaMs service providers must ensure that assessment and intake procedures are personfocused, non-threatening and conducted at a pace that potential clients are comfortable with.
This includes using outreach for initial meetings and assessment in familiar places such as a
person’s home or a local library/community centre.
3.3.6 Fees
Services provided by PHaMs must be free of charge to clients.
3.3.7 What clients can expect
Clients can expect support to be provided according to the PHaMs practice principles listed
in paragraph Attachment A.
Recovery Approach: PHaMs services must support clients using recovery-focused and
strengths-based approaches. In PHaMs, recovery is about a personal journey that is driven
by the clients’ points of view, focuses on their strengths, hopes, wishes, goals and
achievements, provides ways for them to cope better within the confines of their illness, and
equips them to overcome difficulties and challenges that they face along the way.
Recovery means that clients learn ways to manage the difficulties in their lives, regain
control, make choices and decisions for themselves, strive to achieve their goals, and
develop skills to help them overcome future challenges.
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DSS expects that each service will be tailored to meet the needs of the individual PHaMs
clients who engage with the service. Services should be designed to take into account not
just mental health issues but also any additional issues faced by people because of past
experiences, trauma or disadvantage. Recovery services must aim to:
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provide reassurance of safety
restore hope, meaning, confidence and motivation
build connections and community strength
promote human dignity
demonstrate understanding and caring
maintain a respectful and accepting attitude
reduce the sense of isolation
provide opportunities to share experiences
reinforce capacity to problem solve and take control
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look for, and identify, strengths that can raise self‐esteem
set realistic goals
provide links with groups or agencies that are understanding and supportive, and
facilitate coping and problem-solving skills.
Consent: PHaMs workers are required to gain written consent from PHaMs clients for the
release of information to specific agencies or organisations they are referring clients to, and
separate consent for the PHaMs service to release de-identified client data to DSS for
Government reporting purposes.
3.3.8 Client rights and responsibilities
PHaMs is delivered in accordance with the National standards for mental health services,
applying to all mental health services, including government, non-government and private
sectors across Australia. Please see Implementation Guidelines for Non-government
Community Services.
Rights: Standard 6 of the national standards lists rights applying to consumers of mental
health services. They include that consumers must be treated with respect, have their
privacy protected, and receive services appropriate to their needs in a safe and healthy
environment.
Responsibilities: Clients have a responsibility to provide accurate information about their
needs and circumstances in order to be provided with quality services. They are required to
comply with the rules and regulations for engaging with services and behave in a manner
that does not compromise the health and safety or privacy of others.
3.3.9 Exiting PHaMs
Clients may exit the PHaMs service at a time they choose, or as agreed with the service
provider. This is most likely to happen when one or more of the following occurs:
 the client states he/she wishes to exit PHaMs
 the goals of the client have been reached
 PHaMs is unable to assist the client with his/her identified goals
 a PHaMs team leader or service manager judges that the client presents a risk to the
safety of other clients or service staff
 the client is incarcerated for a period greater than six months (clients can remain
eligible for services as non-active clients within the PHaMs service, but be classified as
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‘inactive clients’, for a period up to six months. or comes under the care of state or
territory judicial system
the client moves into long‐term (six months or more) psychiatric accommodation, or
the client does not return to the PHaMs service following a period of inactivity
(six months).
PHaMs service providers must ensure clients exiting PHaMs have adequate alternative
supports in place should they require them. This may include access to relevant alternative
support services, family support, and strategies in place to deal with crises should they
occur. The clients should be given assurances they can seek to return to PHaMs at a later
time if appropriate, and pending available places.
Processes for exiting PHaMs clients are detailed at Attachment C: Client Transfers, Turning
Away Referrals and Exiting Clients.
3.4 Service delivery and eligible and ineligible PHaMs activities
PHaMs providers are funded to:
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manage entry to PHaMs through eligibility and functional assessments
support and mentor clients to achieve goals in their Individual Recovery Plans,
including assisting clients to make and attend appointments, manage daily tasks,
facilitate transport, address barriers to social and economic participation, secure stable
housing, and improve personal, parenting or vocational skills, etc.
coordinate support services and help clients navigate the mental health and
community sector supports, and
liaise and work with other stakeholders to make and receive appropriate referrals for
people with mental illness.
Some PHaMs services are funded to provide specialist support to particularly vulnerable
groups, either through funding for a targeted service or funding to deliver additional targeted
services as part of an existing general service. This includes PHaMs Employment Services,
Remote services and services targeted to particular groups such as homeless or Culturally
and Linguistically Diverse (CALD) people.
PHaMs Employment Services: Organisations are specifically funded to provide specialist
support and work with employment services, such as Disability Employment Services, Job
Services Australia, state-funded services and social enterprises, to assist clients to address
non-vocational issues that are barriers to finding and maintaining employment, training or
education. These services assist people with a mental illness who receive the Disability
Support Pension or other Government income support payments and are participating in, or
willing to engage with employment services, and have economic participation as a primary
goal in their Individual Recovery Plans.
PHaMs Employment Services also work to increase the capacity of other PHaMs providers
to better assist clients who wish to achieve an employment or training outcome. This could
include assisting other PHaMs services to navigate the employment services system or
training other PHaMs staff. PHaMs Employment Services play a role in increasing the
capacity of employment services to deliver better outcomes for job-seekers with a severe
mental illness as well.
PHaMs Remote Services: In addition to supporting individual clients, PHaMs are funded to
provide and build local capacity to deliver community mental health support in remote
communities so that members can identify and respond appropriately to emerging mental
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health issues. The Department recognises that these services may need to be tailored to
suit the specific communities in which they are delivered and arrangements are therefore
negotiated on a case-by-case basis with each funded organisation.
Delivery of PHaMs in remote localities recognises and promotes the spiritual, cultural,
mental and physical healing for Indigenous Australians living with mental illness in remote
communities.
In order to support people with severe mental illness in remote communities PHaMs Remote
Services:
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use a community development approach – this means support will be provided to
individuals, as well as their support network which includes family, carers and the
community
use innovative service delivery models that build on existing local infrastructure and
services
train local people to undertake PHaMs team roles over time, and
encourage the development of suitable activities to enable social inclusion and
strengthening of family and community relationships for people participating in the
service.
A portion of funding (10 per cent) is allocated in remote services specifically for community
leadership and training. This funding is to be used to provide appropriate training and
development to clients, family and community members to increase their knowledge of
mental illness and how to manage it, to increase their personal skills and self-confidence,
develop leadership skills and to improve the overall resilience and capacity of the community
to respond to the mental health needs of its members.
PHaMs Remote Services are also funded to undertake community development. While the
focus of PHaMs is on improving outcomes for individuals with mental illness, it is recognised
that this may require intensive work with family members and the community in which a
client lives. This recognises that there are limited resources and support services in small
and isolated communities. In undertaking community development, the service must
demonstrate the beneficial impacts of this work on individuals and families. Community
development should work as an adjunct to intensive assistance to individuals and families.
Services are also expected to deliver assistance in ways that are locationally and culturally
appropriate, safe and relevant.
3.4.1 Team approach to service delivery
Personal helpers and mentors must work together in teams, to ensure the most effective
service delivery and to ensure better outcomes for clients. Team structures are determined
by service providers according to local need, the needs of clients, the availability of staff, and
worker profile. DSS expects a standard PHaMs service to employ a team of about five
full-time equivalent workers. A standard PHaMs team would comprise five personal helpers
and mentors, however some services have been funded for additional positions, specified in
Grant Agreements. Variations may be negotiated with DSS on a case-by-case basis and will
be reflected in Grant Agreements.
PHaMs services must assign a worker to each client to:
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help clients better manage their daily activities and reconnect to their community
connect clients to outreach services if needed
provide referrals and links with appropriate services, such as clinical, drug and alcohol,
employment and accommodation services
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work with clients to develop Individual Recovery Plans which focus on their goals and
recovery journey
engage and support family, carers and other significant people in clients’ lives, and
monitor and report progress against clients’ Individual Recovery Plans.
PHaMs team members must have varied backgrounds, personalities, academic
qualifications, work experiences and knowledge. This will enable the team to offer choice to
clients, bring different knowledge and experience to the team and find innovative solutions to
the many complexities the team will face. Some team members may have professional
backgrounds as social workers and psychologists. This knowledge and experience helps to
build the capability of the team, however, team members are employed as personal helpers
and mentors, not to undertake specified professional roles such as social workers or
psychologists.
All PHaMs services must have a Team Leader and must employ at least one peer support
worker with lived experience of mental illness. The role of the peer support worker within the
PHaMs team can vary and be tailored to the particular service.
The team must be designed to:
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provide a diverse knowledge base among workers that can be shared to benefit the
whole team (by valuing and selecting workers with varied backgrounds and
experiences)
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allow for team support, ongoing training and development, and direct supervision,
debriefing and shared learning experiences and opportunities, and
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offer choice for clients (around the gender and culture of their worker where possible)
as well as who they might prefer to build a long-term relationship with.
There are distinct roles that must be filled within each team. These roles include: a team
leader, a peer support worker, and general caseworkers. These roles are outlined in
Attachment D: PhaMs Team and Roles.
Where a PHaMs service is funded to deliver a specialist service, the PHaMs team must also
include specialist workers, such as employment specialists in Employment Services or
cultural brokers in Remote Services.
PHaMs Employment Services are required to employ workers with a background in delivery
of both community mental health and employment services. While it may not be possible to
recruit workers with both of these skill-sets, it is important that the PHaMs Employment team
as a whole has a mix of these skills and experience.
PHaMs Remote Services are also required to operate through a team structure. The starting
point for PHaMs Remote services is a team of five workers (they do not have to be full-time
workers). DSS recognises that team structures may be impacted by factors such as
difficulty attracting and retaining workers in remote areas, increased operating costs and the
need to tailor service models to the site’s coverage area. The team structure should be
identified as part of the initial strategic planning process. PHaMs remote services are
encouraged to employ local Aboriginal and Torres Strait Islander people to undertake roles
within the PHaMs team.
Information on the roles of PHaMs Employment Workers and Cultural Brokers is at
Attachment D.
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3.4.2 Mandatory caseloads for PHaMs teams
There are different caseload requirements for specialist and non-specialist PHaMs services.
Requirements in relation to minimum service caseloads are detailed in Grant Agreements.
Caseloads for each worker (an FTE ‘worker’ may be one person employed full time or a
number of part-time workers whose hours equate to a full-time worker’s hours, e.g. If two
staff work 50 per cent of the hours of one FTE they would have equal minimum caseloads of
five each. If one worked 60 per cent of the hours of one FTE and the other worked 40 per
cent, the caseloads would be six and four respectively) should be a minimum of 10 and a
maximum of 12 active clients requiring complex support. Higher caseloads are permitted
where several clients with lower levels of support equate to a complex case. This upper limit
recognises the complexity of support needed and longer‐term relationships required to assist
clients in their paths to recovery as well as ensuring the quality of service provided is
maintained at a high standard. PHaMs workers may have clients in their caseloads who
require intermittent or periodic support. This recognises the episodic impacts of mental
illness and that people may only require occasional support to independently maintain their
recovery journey.
Base funding for non-specialist PHaMs services provides for a minimum service caseload of
45 clients at any point in time. This allows for lower active caseloads for team leaders and
some flexibility in structuring the most appropriate role for peer support workers within
teams. Some PHaMs services will be funded at higher levels and will be required to have
larger overall caseloads based on the number of increased FTE provided through the
additional funding.
PHaMs Employment Worker: Each FTE PHaMs Employment worker is required to have a
minimum caseload of 10 intensively supported clients and 10 less intensively supported
clients. The maximum caseload is 24 active intensive clients (12 intensive and 12 less
intensive) for each FTE worker.
A PHaMs Employment Service funded to employ five workers is required to carry a minimum
caseload of 90. This includes a minimum caseload of 45 intensively supported clients and
45 less intensively supported clients. This allows for lower active caseloads for team leaders
and some flexibility in structuring the most appropriate role for peer support workers within
teams.
PHaMs Remote Services have caseloads of up to 45 clients. Recognition is given to
broader community and family capacity building activities undertaken by PHaMs workers in
remote services that aid the recovery journey of individual clients, and exact caseloads will
be negotiated on a case-by-case basis.
Staff should be supported to remain within their caseload capacity to avoid high staff
turnover, which is very disruptive to clients.
3.4.3 Duration and intensity of support
There is no time limit on how long a client can be supported by PHaMs services, as services
are intended to support clients with diverse and complex needs.
The intensity of support provided to PHaMs clients is flexible, negotiated with each client,
and adjusted from time to time as part of Individual Recovery Plans. This recognises the
need of some clients for varying levels of support over an extended period of time due to the
episodic impacts of mental illness.
Generally, intensive support is provided to clients until such time as they have stabilised their
situation and addressed the priorities and goals identified in their Individual Recovery Plans.
15
PHaMs providers are responsible for managing their caseloads to ensure they can meet the
needs of clients requiring intensive support, as well as those requiring less intensive periodic
support.
As places become available because existing clients reduce the level of support needed or
exit the service, new clients should be accepted, with priority going to those with the highest
need.
For PHaMs Employment Services, the duration of intensive support, to overcome nonvocational barriers to employment, provided to clients will be around six months with a
maximum period of 12 months. Once employed or in the workforce, clients will be offered
less intensive support to maintain employment and participation opportunities. Clients may
return to intensive support if required and if there are vacancies with the service.
Details of each client’s agreed, ongoing support arrangements, including any arrangements
for support after hours must be documented in his/her Individual Recovery Plan. PHaMs
services are not expected to provide after-hours services but may agree to support clients on
a case-by-case basis at their discretion, if it is considered important to individuals’ recovery
journeys. Any after-hours arrangements must have the prior approval of the Team Leader.
PHaMs workers must not be coerced into being available after hours if they do not wish to
be.
3.4.4 Individual Recovery Plans
PHaMs provides ongoing, one-to-one support to people with diverse and complex needs,
directed by Individual Recovery Plans developed with each PHaMs client. Support is
focused on providing practical assistance, facilitating increased community participation and
ensuring access to required services in line with goals and priorities identified by the client
and documented in his/her Individual Recovery Plan.
Providers must ensure that, for each person accepted into PHaMs, an Individual Recovery
Plan is developed with the PHaMs client.
The Plan identifies:
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the person’s strengths and recovery goals
activities and supports
a care/crisis plan in the event that the client becomes unwell or crisis occurs, and
expectations for any out-of-hours contact.
Clients will be asked to commit to working towards achievement of goals in their Individual
Recovery Plans. They can expect their worker to help them do things for themselves –
PHaMs workers must not take over and do things for clients.
More information about Individual Recovery Plans is at Attachment E.
3.4.5 Mental Health Crisis Response
Arrangements, should a client become unwell or have a crisis, are to be documented in each
client’s Individual Recovery Plan.
However, PHaMs is not a crisis service and PHaMs workers are not expected to be the
contact for mental health emergencies or to manage clients through such an event. Clients
experiencing mental illness episodes should be encouraged and assisted to seek clinical
mental health support.
16
3.4.7 Supporting families and carers
Because of the significant role of family members and carers in supporting people with
mental illness, PHaMs services should also support families and carers through:
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engaging them as early as possible in Individual Recovery Plans (provided the client
have consented)
making information about mental health services available
providing advice and support in managing mental illness, including recognising
symptoms such as behavioural change
providing support when the person with the mental illness is acutely unwell, and
sharing information, including referral, to support a carer to return to work.
Members of the PHaMs team must have the appropriate skills to work with families and
carers and if required, staff should be trained in working sensitively with families and carers.
3.4.8 Family-sensitive services
It is often difficult to balance the rights of the clients with the expectations of families and
carers. However, families and carers often make the point that the information they need
does not have to breach confidentiality. For example, carers require information about
services that are available for the person they care for and strategies to help them cope with
difficult situations.
Carers also make the point that sometimes they do not need to be told anything, and what
they most want is to be listened to and contribute to the recovery of clients. The input of
families and carers can be invaluable because they know the client better than anyone else
does. Families and carers will often be the first to see changes in the client or behaviours
that are out of the ordinary.
3.4.9 What PHaMs cannot provide
PHaMs must not provide:



provision of clinical services or specialist medical services, although PHaMs workers
may assist clients to access appropriate services
purchase of goods and services for clients (PHaMs Remote services may use PHaMs
funding to purchase items needed to build community capacity or develop supports
that are unavailable in remote communities, such as food for nutritional cooking
classes, supplies for art classes, etc.), although PHaMs workers may help clients
obtain goods and services they need by helping them budget, seek sources of funding
and/or apply for services, including education and training, and
provision of personal care and domestic help for clients, although PHaMs workers may
show clients how to do things, prompt them to do tasks and help them find assistance
to undertake tasks they cannot manage themselves.
3.4.10 Eligible activities
PHaMs funding may be used for:
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staff salaries and on-costs which can be directly attributed to the provision of PHaMs
support as per the Grant Agreement
employee training for paid and unpaid staff, Committee and Board members, that is
relevant, appropriate and in line with the delivery of PHaMs, and
operating and administration expenses directly related to the delivery of PHaMs, such
as:
17
o
o
o
o
o
o
o
o
o
o
telephones
rent and outgoings
computer/IT/website/software
insurance
utilities
postage
stationery and printing
accounting and auditing
travel/accommodation costs (Including accommodation costs incurred where
PHaMs workers are required to travel to distant or remote locations to service
carers, or costs for staff travelling to attend training or personal development
activities), and
assets as defined in Grant Agreement Terms and Conditions, including motor
vehicle purchase or lease.
PHaMs Remote Service funding may be used to broker services to maximise support for
people with a mental illness in remote areas. The planned use of brokered services must be
part of a strategically planned approach, and approved by the Department.
PHaMs Remote Services funded from 2013 are required to use 10 per cent of annual
funding for community leadership and training.
The Terms and Conditions outline how funds must be spent, acquitted and repaid (if
necessary).
3.4.11 Ineligible activities
PHaMs funding may not be used for:

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costs not directly related to PHaMs service delivery
overseas travel
purchase of goods and services for clients, or
profits, dividends, etc. to directors or other stakeholders.
3.4.12 Service coverage areas
Each PHaMs service is allocated a site with a defined service coverage area. The service
coverage area is specified in the Grant Agreement. As a principle, DSS expects services to
provide access to people living within their defined site coverage areas.
Servicing clients outside of the site’s coverage area
It is possible to service someone living outside of the defined site coverage. Up to 10 per
cent of a service provider’s client caseload can come from outside a site’s coverage area.
These clients are referred to as out-of area clients.
Servicing someone from outside the site’s coverage area should be considered on a
case-by-case basis and consideration should be given to the following:




first and foremost, what is in the best interest of the client in the long term?
is there another PHaMs provider that could service the client?
what is the site's capacity to service this individual and what, if any, impact could this
have on servicing clients from within the designated site’s coverage area?
how difficult will it be to service that individual (e.g. if there are long distances for
workers to travel to service that individual, will that individual actually receive the
quality of service expected – would they be better serviced by another provider)?
18
Permission from a DSS Grant Agreement Manager to service one-off clients from outside of
the site’s defined coverage area is not required.
A service provider must seek the approval of a DSS Grant Agreement Manager to service
more than 10 per cent of its caseload outside of its defined coverage area.
Servicing areas that are allocated to another PHaMs site
Service providers can negotiate with one another to support clients that reside in areas that
are not allocated to them. There may be circumstances in which it is easier for another
provider to service a particular suburb rather than the provider that has been allocated the
suburb.
A PHaMs provider should not begin servicing clients (other than one-off cases or those
within the 10 per cent allocation) in areas allocated to other providers without agreement
from the other PHaMs provider. DSS should be notified of any agreement between service
providers on servicing areas outside of allocated site coverage area.
A service provider should request a permanent change to its coverage area when it wants to
cease servicing an area or increase coverage to another area. DSS will consider the
requested change and, if agreed, will vary the Grant Agreement accordingly. This will
ensure accurate information is available on PHaMs service coverage for client referrals.
3.4.13 Funding for PHaMs
PHaMs services are funded under a standard formula based on the geographic location of
service delivery and client caseload size. Funding levels will, however, vary from service to
service, e.g. where services have been expanded because of high demand.
As at 1 July 2015, annual base funding (GST excl.) for a standard PHaMs service is:



$453,960 for a metropolitan service
$502,298 for a non-metropolitan service, and
$545,908 for a remote service.
Funding for PHaMs is provided through block funding to providers. A portion of block
funding for PHaMs in NDIS sites is notionally allocated to the National Disability Insurance
Agency, further detailed at Attachments J and K.
3.5 Links and working with other agencies and services
3.5.1 Local coordination and collaboration
To achieve the best outcomes for clients, PHaMs services should complement and intersect
with other services in the local area, including both clinical and non-clinical community
services. This approach is designed to build on existing arrangements and ensure services
are coordinated to provide holistic and flexible support.
PHaMs service providers are expected to form partnerships and establish formal links with
a range of local networks, services and other stakeholders. This may include:
developing referral processes and managing referrals to other services, including to housing
support, employment and education, drug and alcohol rehabilitation, independent living skills
courses, clinical services and other mental health and allied health services participating in
inter‐agency meetings to ensure better services for clients participating in case coordination
and related meetings, as required.
19
PHaMs services should also refer carers of clients to Mental Health Respite: Carer Support
or the Young Carers Respite and Information Program, and children, young people and their
families to Family Mental Health Support Services, where appropriate.
3.5.2 PHaMs Employment services
These services are required to have formal parallel servicing arrangements in place with
local employment providers, including DES, JSA agencies and other employment services
such as Social Enterprises. These could take the form of memoranda of understanding or
an exchange of letters that sets out how the arrangements will operate, the process for
managing referrals, and the respective roles and responsibilities of each party.
It is not acceptable for an organisation funded to provide a PHaMs Employment service,
which is also an employment service, such as a DES, to only have internal parallel servicing
arrangements in place. Arrangements with a number of different employment providers
ensure diversity in service delivery and choice for clients.
3.5.3 Partners in Recovery
Partners in Recovery (PIR) is an Australian Government initiative managed by the
Department of Health. PHaMs services are required to work collaboratively with PIR
arrangements established at the local level.
PIR aims to support people with severe and persistent mental illness with complex needs,
and their carers and families, by getting multiple sectors, services and supports they may
come into contact with (and could benefit from) to work in a more collaborative, coordinated
and integrated way.
PHaMs and PIR must work in a complementary way to achieve better outcomes for people
with severe and persistent mental illness. Both initiatives are underpinned by principles of
person-centred recovery and are designed to help people access services that are
coordinated, integrated and complementary.
PHaMs must continue to provide one-to-one support to individuals in their recovery journey
by building long-term relationships and helping clients to access the range of supports and
services that they need. PHaMs services will continue to work with individuals and their
families to achieve clients' stated goals, which may include working with regional PIR
organisations to ensure the services required by people with severe and persistent mental
illness and complex needs are coordinated, integrated and complementary.
3.5.4 Interpreting services
Interpreting services may be required in order to assist participants undertake Assessment
or attend services activities.
For this reason, DSS will pay the cost of interpreting services provided by the Translating
and Interpreting Service (TIS National) that are required by each funded MHR:CS service to
assist clients. Grant Agreement Managers can advise on cost recovery for alternative
translating or interpreter services (e.g. Indigenous language interpreter services or
interpreter services for hearing impairment). Service providers should discuss their
requirements with their Grant Agreement Managers prior to engaging the services.
Grant Agreement Managers will arrange for providers to be allocated specific TIS National
client codes for each site, as requested. It is important that the correct code/s be used for
interpreting directly related to the funding, as DSS will be directly billed by TIS National for
these interpreting services. DSS may require organisations to demonstrate that correct
codes have been used and that use of TIS was warranted.
20
TIS National provides both telephone and on-site interpreting (one-week notice using the
Interpreter booking form located on the Interpreter booking form webpage
www.tisnational.gov.au/Agencies/Forms-for-agencies/New-Job-booking-form). Before
booking an interpreter, the provider should consider the time and cost advantage of using a
telephone service rather than an on-site service.
For more information about TIS National interpreting services contact the Client Liaison and
Promotions Team:
Telephone: 1300 655 082
Email: tispromo@border.gov.au.
3.6 Special requirements for PHaMs
Funded organisations are required to deliver services in accordance with relevant legislation
and industry standards. There are a number of special requirements of PHaMs providers as
follows.
3.6.1 PHaMs practice principles
All PHaMs services must subscribe to a set of practice principles that underpin delivery of
support to carers and their families. The principles are detailed at Attachment A.
3.6.2 National Standards for Mental Health Services
PHaMs must be delivered in accordance with the National standards for mental health
services, applying to all mental health services, including government, non-government and
private sectors across Australia. The National Standards were endorsed by the
Commonwealth and state and territory Health Ministers in 1996. They have since been
revised with a particular focus on their implementation in the community mental health
sector. The national standards focus on recovery and are based on values related to human
rights and dignity. They promote the empowerment of consumers of mental health services,
their carers and families. They emphasise practices which support continuous improvement
in service quality.
3.6.3 Compliance with Relevant Legislation
Service providers must ensure that services are delivered in accordance with all relevant
Commonwealth and state and territory legislation, regulations and standards.
Service providers should be aware of any case-based law that may apply or has an effect on
their service delivery. Providers must also ensure that the services meet health and safety
requirements and all licence, certification and/or registration requirements, in the area in
which they are providing services.
3.6.4 Privacy and complaints handling
Privacy: personal information should be only shared with client consent, and it should be
kept safe and secure from access by others. It is very important service providers
understand privacy and confidentiality obligations. DSS also expects providers to meet their
obligations under the Privacy Act 1988 and any relevant state or territory privacy legislation.
Handling complaints: a complaint is defined as: “Any expression of dissatisfaction with a
product or service offered or provided”. Complaints, queries and feedback are considered a
valuable opportunity for PHaMs service providers and DSS to review and improve their
processes and the quality of services provided. Service providers must have an internal
complaints procedure in place and it must be prominently displayed. The procedures should
allow confidentiality of clients/carers in order for clients/carers to express concerns without
21
any fear of their complaint impacting on the support or assistance they receive. PHaMs
complaints handling procedures must:

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
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




have commitment from all levels of the organisation
be fair to all concerned, including the complainant, the organisation and the person
complained about
allow for the involvement of advocates
ensure the complainant does not suffer retribution or intimidation
be accessible – promoted internally and externally, in English and other languages as
appropriate
have flexible methods of making complaints with assistance available to complainants
as necessary. This is particularly important for a service dealing with a vulnerable and
disempowered client group
be responsive – a full impartial and timely process with fair and reasonable remedies
be effective – must address individual complaints, use information to improve overall
service delivery and inform planning decisions
be open and accountable so clients can judge for themselves whether the system is
working effectively
afford privacy, dignity and confidentiality
provide information about alternative avenues for any complaint that cannot be
resolved internally (including referral to DSS)
be provided free of charge, and
where the client/carer does not receive satisfactory resolution of their concerns, the
complaint should be referred to the DSS Contact Person as named in the Grant
Agreement.
3.6.5 Incident reporting
Service providers must notify DSS of any incidents such as accidents, injuries, damage to
property, errors, acts of aggression, etc. that may adversely impact the delivery of services
to carers, or on the Department.
The PHaMs Incident Report Form at Attachment H should be completed by the service
manager and forwarded to his/her DSS Grant Agreement manager within 24 hours of
occurrence/discovery.
Reportable incidents include:
 Death, injury or abuse of a client while in a provider’s care
 Death, injury or abuse of staff or volunteers undertaking delivery of PHaMs tasks
 Inappropriate conduct between a participant, especially a child or young person, and
employee
 Significant damage to or destruction of property impacting service delivery
 Adverse community reaction to the PHaMs activities, or
 Misuse of the PHaMs funding.
Information supplied to DSS should be de-identified. Names and addresses may be
requested if DSS becomes involved in judicial proceedings as a result of the incident.
3.6.6 Volunteer worker support
22
Where service providers engage volunteers, they are required to have operational policies
and procedures in place for engaging, training and supporting volunteers. The policies and
procedures need to be understood, implemented and maintained at all levels of the
organisation. The National Standards for Volunteer Involvement, available on Volunteering
Australia’s website at www.volunteeringaustralia.org, provide a sound basis for the
engagement of volunteers and should form the basis of the operational policies and
procedures developed by PHaMs services.
They cover the following elements:
 the jobs of volunteers are documented and regularly reviewed
 the work of volunteers is controlled and supported by defined processes and
procedures
 information is gathered about work satisfaction
 appropriate support is available, including access to professional debriefing
 effective channels of communication with volunteers are established
 appropriate processes are established to monitor, identify and address all health,
safety and work satisfaction issues.
3.6.7 PHaMs promotional products
Service providers may access PHaMs brochures electronically here. DSS expects service
providers to distribute the promotional materials to local services that could be entry and
referral points for PHaMs.
Brochures should be distributed to potential clients that visit the service or request
information. Service providers should include their site contact information on brochures.
If service providers create any additional promotional materials, they should be approved by
DSS in the first instance.
Service providers may use other forms of promotion, including references in local
newsletters, email newsletters and local media.
Service providers working in designated remote service sites may want to work with local
community members or artists to design more appropriate service imagery to be used to
promote PHaMs in their site. Final imagery should be approved by DSS before being used.
For information on using the logo and branding instructions, see Attachment I.
3.7 Activity performance and financial reporting
3.7.1 Activity performance reporting
The focus of activity performance reporting is to obtain meaningful information about service
delivery outcomes.
The following Performance Indicators apply to PHaMS services:
 Number of clients assisted
 Number of events / service instances delivered
 Percentage of clients with improved knowledge, skills, behaviours and engagement
with services, and
 Percentage of clients from priority target groups/communities
23
Reporting includes:


Client eligibility screening tool (EST) data into an online system (PHaMs Portal)
on-line reporting through the DSS Data Exchange

an annual financial report (as prescribed in Grant Agreements)

other reports requested by the Department.
Reports will be required on the due dates as specified in the Grant Agreement unless
otherwise negotiated with DSS and approved in writing.
The Department has implemented improved programme performance reporting processes in
Grant Agreements. These arrangements are supported by a new and simple to use IT
system, known as the DSS Data Exchange (DEX). DEX:

is a web based portal;

allows submission of data through external approved third party applications, and

supports submission of data through other approved methods.
Performance information required to be collected may include (but is not limited to):

Client consent (where required)

Client identity characteristics

Client demographic characteristics

Service delivery information

Client outcomes.
Services will receive support on IT matters and data collection activities to assist them in
complying with DSS reporting requirements. The DSS Data Exchange Helpdesk can be
emailed at dssdataexchange.helpdesk@dss.gov.au.
3.7.1 Financial reporting
The activity must be managed to ensure the efficient and effective use of public monies.
This must be consistent with best value in social services principles, the DSS Grant
Agreement, and will aim to maintain viable services and act to prevent fraud upon the
Commonwealth.
Financial documents must be provided to DSS as outlined in the Grant Agreement.
4
Contact Information
For enquires regarding current Grant Agreements, service providers should contact their
Grant Agreement Managers. For general programme enquiries contact
Program.help@dss.gov.au or phone 1800 020 283.
Department of Social Services website: www.dss.gov.au
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Glossary
Caseload – the number of clients that each member of the PHaMs Team may be
providing with intensive support at any given time.
Community capacity building – community development activities to improve
community wellbeing through collaborative projects with community groups such as
promoting mental health awareness and first aid and stigma reduction. This can also
include establishing relationships and trust in communities to allow services to be
delivered most effectively.
Co-morbidity – the co-occurrence of one or more diseases or disorders in an individual.
Co-morbidity of mental disorders and substance use disorders is widespread and often
associated with poor treatment outcomes, severe illness and high service use.
Coverage Area – the geographically defined area in which clients of the PHaMs service
must reside in order to qualify for services from that service provider.
Cultural competence – the ability to interact effectively with people of different cultures,
particularly in the context of non-profit organisations and government agencies whose
employees work with persons from different cultural/ethnic backgrounds.
Culturally and Linguistically Diverse (CALD) – people who identify “…as having a specific
cultural or linguistic affiliation by virtue of their place of birth, ancestry, ethnic origin, religion,
preferred language, language(s) spoken at home, or because of their parents’ identification
on a similar basis” (from Victorian Multicultural Strategy Unit (2002) in Australian
Psychological Society Ltd 2008).
Cultural sensitivity – the quality of being aware and accepting of other cultures and
cultural beliefs.
Duty of Care – can be defined as “an obligation, recognised by law, to avoid conduct
fraught with unreasonable risk of danger to others”. Service Providers have a duty of
care to take reasonable care to ensure that their acts or omissions do not cause
reasonably foreseeable injury to their clients (from The Law Handbook, Fitzroy Legal
Service Inc.)
Eligibility Screening Tool – DSS’s purpose-built tool designed to assess an applicant’s
eligibility for PHaMs services.
Employment Worker – a personal helper and mentor employed in a PHaMs
Employment Service.
Family – is a relative, friend or neighbour who has a family‐like relationship with the
person with mental illness.
Forgotten Australians – people raised in institutional or other out-of-home care in Australia
in the 20th century.
Homelessness – homelessness does not simply mean that people are without shelter.
It can also mean that people are without stable or permanent accommodation. A stable
25
home provides safety and security as well as connections to friends, family and a
community.
There are three kinds of homelessness:

primary homelessness, such as sleeping rough or living in an improvised dwelling

secondary homelessness including staying with friends or relatives and with no
other usual address, and people staying in specialist homelessness services, and

tertiary homelessness including people living in boarding houses or caravan parks
with no secure lease and no private facilities, both short and long-term.
Humanitarian entrants – people who are subject to substantial discrimination
amounting to gross violation of their human rights in their home country, are living
outside their home country and have links with Australia. (Dept of Immigration and
Border Protection)
Incarceration – where a person is detained in a prison, remand centre or other
corrective institution for being suspected of, or having committed a criminal offence.
Indigenous – a person, who is of Aboriginal or Torres Strait Islander descent, identifies
himself or herself as an Aboriginal person or Torres Strait Islander and is accepted as
such by the Indigenous community in which he or she lives.
Institutionalisation – the term ‘institutionalisation’ generally refers to the committing of
an individual to a particular institution. However, it is also used to describe both the
treatment of, and damage caused to vulnerable people, when a person becomes
accustomed to life in an institution so that it is difficult to resume normal life after leaving.
Mental health – a state of wellbeing in which an individual realises his or her own
potential, can cope with the normal stresses of life, can work productively and fruitfully,
and is able to make a contribution to his or her own community.
Mental illness – a diagnosable disorder that significantly interferes with an individual's
cognitive, emotional or social abilities. The brochure ‘What is mental illness?’ on the
Department of Health and Ageing website provides more information.
NDIS site – Service outlet located in an area that is a prescribed area for the purposes of a
person meeting the residency requirements under section 23 of the National Disability
Insurance Scheme Act 2013 (an NDIS prescribed area).
Non‐qualifying ‘conditions’ – conditions other than mental illness or mental health
conditions which do not cause severe functional limitations.
Out-of-home care – refers to foster care, kinship care and therapeutic residential care.
It focuses on those children and young people with Children’s Court ordered care
arrangements, where the parental responsibility for the child or young person has been
transferred to the Minister/Chief Executive. It does not refer to young people who just
happen not to be living at home.
Client – a person assessed as eligible for and receiving services from, a PHaMs-funded
service.
26
Peer support worker – a worker with a lived experience of mental illness, who is living
well and is able to support others experiencing mental illness to work towards recovery.
PHaMs Employment service – a specialist PHaMs service specifically to help people
with mental illness on, or claiming, the Disability Support Pension or other income
support, who are also engaged, or willing to engage, with employment services.
Refugees – people subject to persecution in their home country.
Remote sites – PHaMs remote sites are categorised as such based on the Australian
Standard Geographical Classification - Remoteness Area (ASGC-RA) for their coverage
area. As at 30 June 2012, there were 11 PHaMs sites funded as remote sites.
Team leader – a worker who provides guidance, instruction, direction, leadership and
work oversight for the PHaMs team.
Terms and Conditions – means the terms and conditions of the standard Grant
Agreement between the Department and successful Applicants. For further details see
http://www.dss.gov.au/grants-funding/general-information-on-funding/terms-andconditions-standard-funding-agreement.
Volunteer worker – a person who provides services without being paid, though costs
incurred by the worker are reimbursed by the service provider. Volunteer workers may
undertake a variety of roles under appropriate supervision by the organisation.
Young people leaving care – young people who have been in the formal care of the
state and are in the process of transitioning to independence.
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Attachment A: PHaMs Practice Principles
Professor Anthony Williams Ph.D (1993) described eight principles as important in
understanding a recovery-based approach to serious mental health problems. These
principles must be used in designing and delivering PHaMs services. These principles
include recognising that:

each person’s recovery is different

recovery requires other people to believe in and stand by the person

recovery does not mean cure. It does not mean the complete disappearance of
difficulties

recovery can sometimes occur without professional help. People hold the key to their
own recovery

recovery is an ongoing process. During the recovery journey there will be growth and
setbacks, times of change and times where little changes

recovery from the consequences of mental distress (stigma, unemployment, poor
housing, loss of rights etc.) can sometimes be as difficult, or more difficult than
recovery from the mental health issue or illness itself

people who have or are recovering from mental health issues or illness have valuable
knowledge about recovery and can help others who are recovering (peer support)

a recovery vision does not require a particular view of mental health problems.
All PHaMs services must operate with a strengths-based recovery focussed orientation
and subscribe to a set of practice principles that underpin delivery of assistance to
PHaMs clients.
The following principles expand on the principles set out in Part C of the Activity
Guidelines Suite– Personal Helpers and Mentors Service Operational Guidelines. The
principles should guide the development and operation of PHaMs services.
Principle 1: Respect, Trust and Understanding – each client will be made to feel
welcome and valued by their PHaMs worker and treated with respect, dignity and
understanding as a unique person.

Service providers have knowledge and understanding of mental illness and the
impacts it has on people’s behaviours and lives

The lived experience of mental illness and the consumer perspective of the recovery
process are valued and respected by service providers and incorporated into service
delivery. Service providers build meaningful relationships with clients based on
openness and trust

Service providers take all practical and appropriate steps to prevent abuse and neglect
of clients and to uphold client legal and human rights
28
Principle 2: Empowerment – clients are empowered to gain the knowledge, skills and
attitude needed to cope with the changing circumstances in which they live, regain control
of their lives, and undertake valued and meaningful activities in the community.
 Clients have the opportunity to participate as fully as possible in making decisions
about the events and activities of their daily lives in relation to the service they receive
 Service providers develop Individual Recovery Plans with clients guided by the client's
choices, goals and aspirations
 Service providers foster a sense of hope for the future and help clients to improve selfimage and overcome stigma
 Service providers assist clients to access appropriate services and supports so that
clients can develop the skills they need to achieve their personal goals
 Service providers work with clients, their family and carers to understand the needs
and choices of clients in their recovery journey

The service provider promotes the belief and ability of clients to fulfil valued roles in the
community

Service providers build relationships and collaborate with other community and clinical
services to provide clients with the support they need to achieve their goals and lead
meaningful and rewarding lives in the community

Service providers support clients by developing or finding meaningful activities or
opportunities for clients to improve their quality of life, participation and involvement in
the community
Principle 3: Privacy and Confidentiality – each client's right to privacy, dignity and
confidentiality in all aspects of life is recognised and respected.

The service provider complies with the Privacy Act 1988 in order to protect and respect
the rights of individual service recipients

The service provider only collects necessary information and uses it for the purpose for
which it was collected. Information is only released to others with the written consent
of the client

The service provider promotes tolerance and respect for each client’s personal needs
and circumstances

The service provider ensures the protection of information and data from unauthorised
access or revision, to ensure that the information or data is not compromised through
corruption or falsification

The service provider stores information and records in a secure place and disposes of
them in an appropriate manner
Principle 4: Accessibility – services are delivered in a way that ensures all potential
clients in the PHaMs target group are able to access them. This includes delivery
through outreach and in clients’ homes.

The service provider actively seeks out and maintains broad referral and entry
pathways for clients
29

The service provider has effective strategies for promoting the service to people who
are traditionally more difficult to engage, such as those who are homeless or transient,
or who do not wish to access traditional mental health services

The service provider enables people without a formal diagnosis of mental illness to
access the service by applying the Eligibility Screening Tool

The service provider is non-discriminatory in respect of age, gender, race, culture,
religion or disability, consistent with the PHaMs Grant Agreement with the service
provider and the purpose of the service

The service provider’s entry and exit procedures are fair and equitable and
consistently applied

The service provider promotes the PHaMs service, engages with other community and
clinical services to open up referral pathways and service options for clients

The service provider promotes awareness of mental illness, community acceptance
and the reduction of stigma for people with mental illness
Principle 5: Flexibility, Choice and Appropriateness – services are designed to meet
the individual needs and personal recovery goals of clients.

Recovery goals are established objectively to reflect the client's individual needs and
aspirations

Each client’s recovery goals are recorded in an Individual Recovery Plan and used as
the basis for service provision, with the service provider undertaking a process of
planning, implementation, review and adjustment to facilitate the achievement of these
goals

Service providers ensure that clients only undertake activities of their choice and
participate in the service voluntarily

The service provider uses strengths-based recovery approaches in delivering services

The service provider delivers outreach support to PHaMs clients in an environment
that is safe and comfortable for both clients and PHaMs team members

The service provider works collaboratively with other programs, services and agencies
and helps clients to navigate the complex range of services and support available

The service provider manages caseloads effectively to ensure the best support and
outcomes for clients and in accordance with the Grant Agreement

The service provider actively tailors services to meet the needs of special needs
groups

The service provider (as appropriate) engages with and supports the family and carers
of clients to achieve the best possible outcomes for clients
Principle 6: Cultural Competency – services are culturally appropriate.

Cultural competence is embedded in the philosophy, mission statement, policies and
key objectives of the service provider

The service provider has a strong understanding of the cultural profile of their site and
where possible, culturally and linguistically appropriate team members are employed
30

Cultural competence resources are readily available to team members in the
workplace

Team members are encouraged to be flexible in their approach and seek information
on specific cultural behaviours or understandings

Team members receive appropriate training for cultural competence
Principle 7: Appropriate Staff – PHaMs workers have appropriate attitudes,
backgrounds, experiences and qualifications to meet the needs of clients in their site and
receive appropriate training, support and supervision. This includes engagement of paid
peer support workers by PHaMs services.

Service providers provide team members with appropriate training, support and
supervision to perform their role well

The service provider ensures that team members have appropriate attitudes and the
relevant skills and competencies to undertake their role

Each PHaMs site has at least one paid Peer Support Worker (see 8.4 for an
explanation of the Peer Support Worker role)

The service provider ensures the provision of appropriate and relevant training and
skills development for each team member

The service provider ensures that team members have the resources and equipment
to do their jobs effectively, efficiently, lawfully and in a fair and reasonable way
Principle 8: Service Development and Improvement – the service provider’s service
delivery practices are regularly reviewed and revised to meet the needs of clients.

PHaMs clients and their carers/family are aware of the service provider’s procedures
for complaints handling

PHaMs clients and their carers/family are encouraged to raise, and have resolved
without fear of retribution, any issues, dissatisfaction, complaints or disputes they may
have about the service provider or the service they receive

Complaints and feedback are taken seriously by the provider, and are investigated,
addressed and used to improve ongoing services

The service provider has quality management and financial systems in place to ensure
standards of service and optimal outcomes for clients are met

The service provider fosters a flexible and learning culture to ensure improved
outcomes for clients

The service provider understands the community and environment that they service

The service provider identifies and addresses any issues and risks that might impact
on service delivery

The service provider has mechanisms in place to plan future service delivery and set
objectives or goals to improve service delivery

The service provider has strong and effective leadership to provide strategic direction
and uphold and exemplify the PHaMs values and standards

The service provider performs effectively against goals and standards, and annual
service plans
31

The service provider is accountable for their decisions and actions and complies with
legislation, policies, guidelines, instructions and standards

The service provider ensures their activities are being delivered effectively, efficiently,
lawfully and in a fair and reasonable way
32
Attachment B: Eligibility Screening Tool and Client Data
What is the EST
PHaMs does not require a formal diagnosis of mental illness by a clinician before a person
can enter the service. This is to ensure that the service is accessible.
DSS worked closely with the Australian Institute of Health and Welfare to develop an
assessment tool for PHaMs eligibility that became known as the EST. The EST is a
functional assessment tool that determines a person’s level of functioning in managing daily
activities, and living independently in the community. The EST provides a way to ensure
that PHaMs support is accessible and the right people are being targeted – people who are
severely impacted by mental illness.
The EST is designed to collect the minimum amount of information required to work out
eligibility and meet PHaMs reporting requirements. An EST assessment must be completed
for each client and entered on the DSS portal.
Nine life areas
The EST is based on gauging a person’s level of functioning across nine life areas.
The nine life areas are:
Personal capacity Activities
Interpersonal interactions
actions and behaviours of an individual
and relationships
to make and keep friends and relationships,
behaving within accepted limits, coping with feelings
and emotions
Learning, applying knowledge
understanding new ideas, remembering, solving
and general tasks and managing problems, making decisions, paying attention,
demands
undertaking single or multiple tasks, carrying out daily
routine
Communication
being understood, in own native language
or preferred method of communication if applicable,
and understanding others
Community participation activities
Working
actions, behaviours and tasks to obtain and
retain paid employment
Education
the actions, behaviours and tasks an individual
performs at school, college or any educational setting
Community (civic) and
recreation and leisure, religion and economic life
spirituality, human rights, political life and
citizenship, economic life such as handling money
33
Independent living activities
Domestic life
organising meals, cleaning, disposing of
garbage, housekeeping, shopping, cooking home
maintenance
Mobility
moving around the home and/or moving
away from home (including using public transport or
driving a motor vehicle), getting in or out of bed or
a chair
Self-care
washing oneself, dressing, eating, toileting
How to use the EST?
It is important that PHaMs workers understand how to use the EST appropriately. The EST
is designed to be simple and easy to use and not take too much time to complete (although
it may take some time to collect the information).

The EST is accessed and completed on the DSS PHaMs Portal. To gain access to
the Portal complete the USER Registration Form and fax it to the Mental Health Data
Team.

The information required for the EST can be collected manually (on paper) and then
entered in the DSS PHaMs portal at a later time. Blank paper copies of the EST can
be printed from the DSS portal.

The EST is not designed to be an interview tool. Information should be collected from
clients appropriately and sensitively using techniques normally used with clients.

Clients should not be asked to complete the EST themselves or handed a computer
and asked to answer the questions. It is the responsibility of the PHaMs staff member
to gather the required information and complete the EST.

The EST questions should be answered after an appropriate discussion with the
potential client or others (such as carers or GPs – with the person’s permission).

Information from a variety of sources can be considered to answer the questions.

The EST is not designed to be completed all at once in one session on the same day
that the information is collected. It is expected that it might take up to 4 weeks to
collect the necessary information (due to the sensitive and complex nature of some of
the information required).

The questions do not have to be asked exactly as they are written in the EST. It is the
responsibility of the PHaMs worker to approach the issues with sensitivity and
compassion.

The client can be given a copy of their EST assessment. Clients may want to use it to
assist with other assessment processes for other community or clinical services.

The EST is currently a point-in-time assessment to determine eligibility. In the future it
may also be used to access clients’ progress.
A comprehensive EST data guide that explains each of the EST questions and the scoring
process is available on the DSS PHaMs portal or from DSS.
34
Informed consent
Informed consent means that the person is provided with enough information on the service
to freely make a decision on whether to participate in the service. Service providers must
ensure that the person understands:

the voluntary nature of PHaMs

the potential benefits and limitations of what PHaMs can provide

their rights and limitations of privacy and confidentiality

what information or data will be collected about them and how it will be used or shared
and in what circumstances

how they will be assessed.
If there are concerns that the explanations are not sufficient for a client or their level of
understanding, service providers will need to think about whether there is a third party, legal
guardian or person with power of attorney, carer or loved one who can take on this
responsibility. Written assurance of the person’s understanding of the points above is
required. A copy of this written consent is to be provided to the client and a copy kept on
their file. Some service providers may need to arrange to have the consent form developed
in appropriate language(s) for use in their site.
Consent to provide data to DSS
The client must complete the DSS provided Consent to Collection, Use and Disclosure of
Personal Information consent form which allows the transfer of data from funded service
providers to DSS. This form must be completed before personal information about the client
is collected or recorded using the EST. Clients are to be reassured that information provided
is de-identified (that is – data may be about them but DSS can’t identify who they are – DSS
does not see the client’s name or address).
The ‘Consent to collection, Use and Disclosure of Personal Information’ form and a plain
English information sheet is on the DSS portal and the Targeted Community Care
Collaborative workspace.
This consent form is a legal requirement and cannot be used for any other purpose and
cannot be altered by service providers. The wording on the form has specific legal meaning
and can’t be changed. A plain language information sheet is provided with the consent form
to assist explaining how and why the information about the client will be shared. A copy of
the signed consent form must be kept on the client’s file.
Service providers are required to develop their own consent forms for use where they want
to make a referral to another service and require the client’s consent to share information.
35
Attachment C: Client transfers, turning away referrals and exiting clients
Client transfers
The procedures for facilitating a transfer of a client between PHaMs service providers will
differ depending on circumstances.
Scenario 1 (example only): A client moves to an area where there is another
PHaMs service provider and the current service provider is made aware prior to
the move.
A PHaMs client is receiving support from a PHaMs service provider in NSW.
The client is moving interstate to Victoria, an area covered by another PHaMs service
provider. The client advises their current PHaMs worker of the move.
The client asks to continue assistance in Victoria with the new PHaMs service provider and
gives permission for their details to be sent to the new service provider.
Procedure for original service provider (NSW)
Original service provider (NSW) contacts the new service provider (Victoria) and ensures the
new service provider has capacity to take on the new client.
If the new service provider is full, the original service provider completes an exit form to exit
the client – stating why they exited PHaMs.
If they do have capacity, then the original service provider (NSW) should do the following to
facilitate the transfer of the client:
Fill in the transfer form with the client to ensure client’s consent to transfer their information.
This includes transferring:

the client’s contact details

a copy of the client’s EST assessment results

a copy of the client’s Individual Recovery Plan

copies of other relevant information.
Contact the new service provider and discuss the timing of the move (if known) as well as
the client’s progress and requirements.
Procedure for receiving service provider (Victoria)
The PHaMs worker must ensure the client completes the new PHaMs consent form to
collect, use and disclose personal information.
File a copy of the transfer form and ensure all contact details are recorded.
Work with client as outlined in the Individual Recovery Plan.
36
If the client has been active in PHaMs and receiving support, a new Eligibility Screening Tool
assessment does not need to be undertaken by the receiving service provider.
Scenario 2 (example only): A client moves to an area where there is another
PHaMs service provider and the current service provider is made aware after the
move has occurred.
A PHaMs client is receiving support from a PHaMs service provider in NSW.
The client moves interstate to Victoria, to an area covered by another PHaMs service
provider. The client does not advise their current PHaMs service provider that they will be
doing this.
The client approaches the service provider in Victoria and asks them to continue to provide
support. The client gives permission for their details to be sent to the new service provider.
Procedure for receiving service provider (Victoria)
Receiving service provider contacts the original service provider (NSW).
Fill’s in the transfer form with the client to ensure client’s consent to transfer their
information.
Discusses the client’s progress and requirements with the original service provider.
Send’s a copy of the transfer form to the original service provider.
Ensures the following information is received to facilitate the transfer of the client:

the client’s contact details

a copy of the client’s EST assessment results

a copy of the client’s Individual Recovery Plan

copies of other relevant information.
The PHaMs worker must ensure the client completes the new PHaMs consent form to
collect, use and disclose personal information.
Files a copy of the transfer form and ensure all contact details are recorded.
Works with client as outlined in the Individual Recovery Plan.
Procedure for original service provider (NSW)
Original service provider is expected to do the following:

file transfer form

send requested information to the new service provider (Victoria).

supports the receiving service provider with information about the client’s progress
and requirements.
37
Scenario 3 (example only): A client moves to a PHaMs Employment service
provider and the current service provider is made aware prior to the move.
A PHaMs client is receiving support from a PHaMs service provider.
The client wishes to be considered for a PHaMs Employment Service.
The client gives permission for their details to be sent to the new service provider.
Procedure for original service provider
Original service provider contacts the PHaMs Employment service provider to ensure that
they have capacity to take on new clients and ensure they are eligible for PHaMs
Employment.
The original service provider should do the following to facilitate the transfer of the client:
Fill in the transfer form with the client to ensure client’s consent to transfer their information.
This includes transferring:

the client’s contact details

a copy of the client’s EST assessment results

a copy of the client’s Individual Recovery Plan, and

copies of other relevant information.
Contact the PHaMs Employment service provider and discuss the timing of the move (if
known) as well as the client’s progress and requirements.
Procedure for receiving service provider
Support the original service provider with information about the eligibility requirements for
PHaMs Employment services.
Confirm whether the service has capacity and if the client is eligible.
The PHaMs Employment worker must ensure the client completes the new PHaMs consent
form to collect, use and disclose personal information. The updated form specifically
addresses consent to disclose their Centrelink Customer Reference Number (CRN), which is
a requirement of PHaMs Employment services.
Send an email to the Mental Health Mailbox (mentalhealth@dss.gov.au) requesting that the
transferring client’s EST be reopened in order to enter the clients PHaMs Employment
information. DSS will confirm by email that the EST has been reopened and is accessible
to make changes/update.
The PHaMs Employment worker should then enter and complete the PHaMs Employment
section (Question 42-46) of the EST, accept the applicant and finalise the EST.
Note: When a client moves from one area to another and a referral is made from the current
PHaMs provider to the new PHaMs provider, the new provider should proceed in a proper,
fair and equitable manner and follow due process.
38
Priority should be given to a current transferring client over a new referral. The exception
would be if the receiving service did not have the appropriate mechanisms in place to
support the requirements of the client being referred. For example, the client may have
special needs and the receiving organisation may not have the experience or skills to take
on the referral.
PHaMs providers must not reject any client based on hearsay or previous history.
Turning away referrals
In the event that demand for services exceeds caseload recommendations, service
providers will need to turn away new referrals. DSS expects service providers to provide the
potential client with information about alternative services which could assist them in the
community.
DSS requires service providers to collect turn away number totals and reasons as part of
routine reporting. DSS does not require service providers to keep a list detailing people who
have been turned away (although service providers may wish to for purposes of filling
vacancies as they occur).
Exiting clients
When a client exits a PHaMs service, the service provider must complete the exit form which
is located on the DSS portal. This form captures information about the reason for exit,
general client demographics, and any referrals or supports established for the client. This
information forms part of the regular reporting obligations to DSS.
PHaMs service providers will ensure that clients exiting PHaMs have adequate alternative
supports in place should they require them
39
Attachment D: The PHaMs team and roles
Personal qualities
Service providers are expected to employ Personal Helpers and Mentors with a range of
backgrounds, qualifications, skills and knowledge, relevant to working with people who
have a mental illness.
All Personal Helpers and Mentors team members should have the following attributes,
personal skills and knowledge:

compassion, patience and ability to empathise

genuine commitment to helping people who have a mental illness in their recovery, a
capacity to relate to them with dignity and respect, and as a unique person

ability to think and act calmly and deal sensitively with distress and unpredictable
behaviour

knowledge of mental illness and skills in working with people experiencing mental
illness

ability to promote the rights, responsibilities, and recovery of clients

effective listening and communication

non-judgmental

knowledge of when to seek help or supervision and how to work in a team
environment

capacity to understand and promote mental health issues and consumer rights and
responsibilities

creative approach to problem solving

promotion of ethical behaviour and anti-discriminatory practice that treats clients,
family and staff with dignity and respect, and balances the right to privacy and
confidentiality with duty of care

cultural competence

ability to work safely

knowledge of local community resources.
Roles
Each PHaMs worker is expected to have a caseload of clients. There are also additional
roles that a PHaMs worker may undertake, including specialist roles such as a Peer
Support Worker, Cultural Broker or PHaMs Employment Worker. A PHaMs worker may
have more than one specialist role within the team and more than one team member can
undertake the same specialist role.
Each role within the PHaMs team has been carefully considered and developed to form
an integral part of the overall PHaMs team and is crucial to the success of the team. No
one role is more or less significant than any other – they each play their own part in
ensuring a balanced team.
40
Team Leader role
Ideally, the Team Leader should be the most qualified or experienced member of the
team as it is their responsibility to provide direction and support to the whole team and to
facilitate team connections with local community and clinical services.
Peer Support Worker role
The Peer Support Worker is a specialist role within the PHaMs team. Peer support
workers are individuals with a lived experience of mental health issues. In PHaMs, the
Peer Support Worker engages with clients at a personal level, assisting or supporting
them through their recovery journey using their own experience of mental illness and
recovery.
Peer Support Workers know what it is to have a mental illness, the difficulties and the
challenges to be faced. They can engage and encourage clients in a way that no-one
else can because they have lived or shared a different but similar experience and learned
how to get through it and regain better control of their life. Peer Support Workers can
share their own recovery journey (the ups and the downs) and show that recovery is
possible. They can encourage clients to share their own stories and experiences, help
them to reflect on their progress and provide them with hope and optimism for the future.
They may also be able to provide practical ways to cope or manage difficulties based on
their personal experiences.
The Peer Support Workers role has been designed to focus on:

Promoting a team culture where the views and preference of clients, family and carers
for recovery are recognised, understood, valued and respected.

Educating the PHaMs team about the personal experience of living with a mental
illness in addition to any clinical or text book knowledge of mental illness.

Representing the perspective of the client to the PHaMs team to ensure workers
understand how mental illness affects the client, their family, their life and how they
want PHaMs to help them on their recovery journey. The Peer Support Worker may
provide support to clients where they are unable to clearly explain their thoughts or
experiences to another team member.

Providing support to clients that comes from the perspective of someone who has
already lived or experienced the recovery journey and can understand, support and
encourage them.

The Peer Support Worker may also take an active role establishing and participating in
client support groups.
A Certificate 4 in Mental Health Peer work has now been established. DSS encourages
on-going training for all Peer Support Workers.
Case Worker role
The Personal Helpers and Mentors Case Worker role is focused on developing a
relationship with a client, understanding the client's personal needs, goals and
aspirations. They then provide opportunities, support and services to develop or
redevelop the client’s skills, build their confidence and help them to reconnect with the
community.
The PHaMs Case Worker also ensures that services accessed by PHaMs clients are
appropriate, coordinated and integrated. They provide direct and personalised assistance
through outreach services and link the client with other appropriate services that support
41
their needs. This is not just a paper referral process rather a personal support that could
and often does involve going with a client to ensure they feel safe and secure and
supporting them until they are comfortable doing it on their own.
PHaMs case workers are directly involved with PHaMs clients – from assessing eligibility
and needs (using the EST and other methods) through to developing and monitoring IRP’s
that reflect the client’s goals and aspirations and linking them with other clinical and
community support services and case managers. The role could involve some advocacy,
mediation, conflict resolution with family and others, and supporting the development of
skills for daily life and independent living. It is a complex and very varied role but is always
focused on developing a trusting, respectful relationship.
Cultural Broker role
The Cultural Broker helps to bridge the gap between the PHaMs service and the local
community. The Cultural Broker builds team awareness and understanding of the cultural
factors of the community and of the ways in which these factors influence the community.
Cultural Brokers are an important specialist role for sites in remote Indigenous remote
communities. Cultural Brokers can be also considered for targeted PHaMs services or in
a site with a high number of CALD community members.
Cultural Brokers should have a history and experience with the local community, which
means that they have:

the trust and respect of the community

knowledge of the values, beliefs, and health practices of the community

knowledge of different groups within the community and how they identify

an understanding of traditional and Indigenous wellness and healing networks within
the community

experience and knowledge of the PHaMs service and health and community support
services in the community.
The Cultural Broker can have many roles:

Liaison and advocacy – help to ensure more effective communication and liaison
between clients (family, carers and community members) and the PHaMs team.
Advocate for clients to ensure that the services they receive are most effective and
meet their needs.

Cultural competency – can help the PHaMs team to incorporate culturally and
linguistically competent principles, values, and practices. They can ensure the PHaMs
team environment is safe, non-threatening and non-judgemental for clients and
community members. They can advise about non-traditional ways to deliver services
that could be more effective in the local community context. They can help to develop
educational and promotional materials that will help clients and the community to learn
more about the PHaMs service and mental health more generally.

Mediation – Cultural Brokers can help to ease the historical and inherent distrust that
may exist between the community and the PHaMs team (as outsiders to the
community). To do this, the Cultural Broker must be able to establish and maintain
trust and have the capacity to devote sufficient time to build meaningful relationships
between the PHaMs team and clients. The use of the Cultural Broker in this role
should improve access to PHaMs services in the community.
42

Models and mentors – They model and mentor behavioural change, which can break
down bias, prejudice, and other institutional barriers that exist. They work toward
changing attitudes and relationships, so that the PHaMs team can build capacity from
within to adapt to the changing needs of the community.
Cultural Brokers have a range of skills that enable them to:

communicate in a cross-cultural context

communicate in two or more languages (at least one should be English and the other
language from the community)

interpret and/or translate information from one language to another

advocate with and on behalf of clients and community members

negotiate health care and other service delivery systems

mediate and manage conflict.
The benefits of using a Cultural Broker include:

more positive experiences for clients and an increased likelihood of access to services

service delivery that is more effective and better received because it respects and
incorporates community cultural perspectives

community members are more likely to seek support (and sooner) if they know that the
PHaMs team understands and respects their cultural values and health beliefs and
practices

clients will be better able to communicate their needs more effectively and better
understand their support and recovery options.
PHaMs Employment worker
The role of the PHaMs Employment worker will include providing intensive support to 10
to 12 clients, for a maximum of 6-12 months. This will include:

working directly with the clients and providing practical support to address issues in
their lives that have been identified as barriers to employment, for example securing
stable housing and improving relationships with family.

supporting the client’s family and support networks as needed to ensure they
understand and support the client’s transition to work.

communicating with clinical and primary care providers to ensure they are aware and
supportive of client’s employment goals and tailor treatments accordingly.

assisting clients to navigate employment services and Centrelink systems, including
referring clients to appropriate employment services and accompanying clients and
advocating for them at appointments and assessments.

providing less intensive ongoing support to 10 to 12 clients, for 1-2 years, including
‘checking in’ with clients on a regular basis about their progress.

being available to both the client and employer to assist if circumstances change
and/or a client’s job is in jeopardy (for example, the person has an episode of their
mental illness).
The PHaMs Employment worker will be required to work closely with employment
consultants, including:

Coordinating supports for clients, to ensure roles are complementary, not duplicatory.
43

preparing client profiles which can be given to an employment consultant to assist their
understanding of a client’s background, current circumstances, skills and employment
goals.

providing on-the-job support as necessary, to assist the client to maintain a job –
particularly beyond the 13 and 26 week points, when the capacity of employment
consultants to provide ongoing support reduces.

facilitating employment peer support networks and activities.
The PHaMs Employment worker will have an important role in building the capacity of
general PHaMs services to better assist clients to achieve employment goals, through such
things as assisting services to navigate the employment services system and training of
PHaMs workers. This capacity building role will also include:

providing an education service for both employment services and employers to build
their capacity and willingness to work with clients and employees with mental health
issues.

publicising and marketing the availability of PHaMs employment support to
employment services and other referring agencies.

promoting the benefits of employment for people with mental illness.
44
Attachment E: Individual Recovery Plans (IRP)
The Individual Recovery Plan (IRP) is central to PHaMs effectiveness and success, as it is
the basis around which all activities take place. It is how a client’s aspirations, goals,
planned activities and services, achievements and progress are recorded.
Every client in PHaMs must have an IRP tailored to meet his/herneeds.
Service providers operating in designated remote service sites or who are providing
services to CALD clients may need to arrange to have the IRP developed in the client’s
first language or develop other suitable arrangements to ensure clients are aware of and
kept informed about changes to the content of their IRPs.
IRP principles
The IRP is central to the PHaMs principle of client empowerment. The following principles
must be followed when working with clients to develop recovery plans.

The client is central to all planning processes.

Discussions between the client and their PHaMs worker should be based on the
client’s life goals, not just their mental illness.

The IRP should focus on the client’s goals aspirations and preferences and affirm the
strengths, talents and capacities of the person.

Other people involved in the IRP development need to be personally invited by the
client.

The IRP is a living document and can and should be regularly reviewed to reflect the
person’s recovery journey. It should be updated six monthly as a minimum. At this
time, PHaMs workers are encouraged to seek feedback from the client on their
experiences of the service and any recommendations they may offer.

The IRP is owned by the person and not the PHaMs service. It is considered as
‘Mary’s IRP’ rather than ‘the IRP for Mary’. The client should always be able to have a
copy of their plan and know exactly what is in it. Nothing should be in the IRP that the
client did not agree to.

The IRP should use the client's language or way of expressing their needs and goals
and not service or clinical language.

The process of planning and developing an IRP is a shared responsibility between a
PHaMs worker and the client. It is not something prepared without the client.

The plan should be entirely directed by the client. The client should have all the
options presented and explained to them and be allowed to make choices that are
always to be respected.
Developing an IRP
A sample IRP is provided at Attachment F and it is also on the PHaMs portal.
Service providers adapt the sample template or develop a new plan template. However,
there are some key elements that should be contained in any IRP that is used for PHaMs.
Key elements of an IRP
The key elements that must be contained in a PHaMs IRP are:

identifying a client’s strengths, goals and aspirations
45

identifying areas where support is needed by the client (this can be done through using
the EST based on conversations with the client)

detailing any planned activities that the client wishes to undertake (including when and
how these are to occur and who is responsible for arranging them)

recording any referrals made to other services

a crisis/care plan which documents what is to happen in the event that the client
becomes unwell or a crisis occurs.
46
Attachment F: Individual Recovery Plan SAMPLE
Case Example:
Fred is a 24-year-old man who has experienced several occasions where he hears voices
commenting on and directing his behaviour. Fred’s first experience of this was during his
teenage years when he was living with his family in a rural area, and it was apparent it
interfered with his schoolwork. Fred and his family gained assistance through their GP
and local mental health service. With therapy and the support of family and community,
the voices disappeared and Fred was able to complete his schooling and gained entry to a
tertiary institution in the city.
In the city, Fred slipped into a demanding study, social and part-time work schedule. At the
end of his first-year exams, he heard voices again but found that alcohol and sleeping later
helped to manage them. During his break, he focused on employment to save for the year
ahead, and the voices went away.
Over the next two years Fred found that the voices would return with more frequency and
he needed to drink and sleep more to prevent them interfering. Unfortunately, during this
time he stopped studying, lost his employment as a result of his drinking and eventually
lost his accommodation.
Fred goes to a homeless centre for food, company and to gain any other help he needs.
He has been living on the streets and in homeless shelters. Last week, he went to the
centre and said he does not want to keep living this way and wants to regain his life but
does not know where to start. The worker in the homeless centre discussed the Personal
Helpers and Mentors Activity with Fred, who agreed to give the Activity a try.
Fred met a Personal Helper and Mentor, agreed to an assessment and was found to be
eligible. The Eligibility Screening Tool highlighted a number of areas Fred might focus on
for his recovery journey. Fred has discussed these with his Personal Helper and Mentor
and prioritised his goals and considered his next steps. Fred, in discussion with the
Personal Helper and Mentor has identified the following plan which he would like to follow
for the next three months.
47
Personal Helpers and Mentors Program
Individual Recovery Plan – SAMPLE
Client Name
Fred
Areas of need identified in assessment
Nowhere to live
Sometimes can’t control voices and this distresses me and stops me from doing things
No money, usually benefit goes on alcohol
Difficulty changing lifestyle because can’t access help
Loss of contact with supportive people who can help recovery
My strengths
Good sense of humour
A relaxed attitude towards self and others, used to be a good mate to others
Previously had a strong relationship with family
A good mind and academic ability - commenced environmental studies
Able to survive when homeless
Know when becoming unwell
A good and willing worker when well and holds employment skills – able to work on farms,
in hospitality, and in research and related to environment
Previously played sport: soccer, tennis, cricket
My goals and aspirations
Find somewhere to live
Stay well for longer
Gain work
Planned activities – Refer to planning worksheet at the end of this document
What I can do to stay well
Get some help when I notice I am becoming unwell.
Limit alcohol.
Slowly become more involved with activities and people that I enjoy which will support
recovery.
People who can support me
48
Who
Phone number
What I need them to do
Toby – Personal Helper
and Mentor
55501555
Reassure me that I can manage this;
remind me of the steps to take. Help
me get the assistance I need; including
food and payments.
Jenny – Homeless Centre
Worker
55015555
Listen to me and help with getting
assistance if Toby is not available
Nathan – Friend
55555501
Tell me if I am losing it; help me phone
Toby and Joe; make sure my bills are
paid and I stay in touch with people.
Joe – GP
55550155
Listen to what I am experiencing and
help me with medication and getting the
levels right.
I do not want the following people involved in any way in my care (list names and
(optionally) why you do not want them involved)
Joanne – ex-girlfriend. Do not want her involved because she convinces me to drink more.
Signs that I may be beginning to feel worse: anxiety, excessive worry, overeating,
sleep disturbances
When I don’t get enough sleep, when others are pressuring me for money or to drink, and
when I notice I am beginning to worry, my mind goes over and over things, I can’t make a
decision, and I begin to hear voices.
What I can do if I am starting to feel worse: mark those that you must do--the others
are choices
*Tell Toby and Nathan what is happening.
*Follow the directions of Toby and Nathan.
What I want from my supporters when I am well
Listen to me and respect that I know what I am doing and what I need to do.
Help with moving towards my goals.
What I don’t want from my supporters when I am unwell
To make decisions about me and what I should do.
To talk to others about me without my agreement.
How I want disagreements between my supporters settled
I will decide what will happen for me.
49
If I am unwell I trust Jenny to settle the disagreement because she has known me a long
time.
Things I can do for myself
I can speak to others on my own behalf, although at times I may need someone to provide
supportive references.
I can judge when I am becoming unwell.
Record of referrals
Name of Agency
referred to
Date
referred
Date
accepted
Ongoing
assistance/support
required
SAAP/Community
Housing
Priority access for housing
GP
Treatment review, Application
for DSP
Centrelink
Application for DSP
Budget advisor
Discuss options for managing
money and gaining bond
money
Community cricket
Return to sporting activities
Contact
This plan was completed on
/
___________________________
________________________________
Client name
Signature
Original to Clien
Copy on file
/
50
Planning Worksheet (SAMPLE)
Task or Responsibility
Step
When you would
like to take this
step
Get to know Toby
Meet Toby twice a week for two
weeks at the Homeless Community
Centre for coffee and a talk. Decide
in 2 weeks if the Personal Helpers
and Mentors Activity is right for me.
Immediately
Apply for assistance to
gain accommodation
Appointment with Housing to apply
for private housing assistance.
Toby will come with me.
Next week
Money for rental bond
Appointment with budget counsellor
to help with letter of support.
Appointment afterwards with
Centrelink for rental assistance.
Toby will come with me.
Next week
Get better control of voices
Appointment with GP Joe and Tony
to discuss voices and how best to
manage these.
This week
Get better control of
alcohol
Appointment with Alcohol counsellor
to talk about strategies.
Two weeks
Reconnect with others that
will help maintain health
Return to cricket through the local
community cricket game.
Starts next month
51
Attachment G: Organisational cultural competence
Definition of cultural competence
Cultural competence is the ability to interact effectively with people across different
cultures. It has four main components:

being aware of one’s own cultural worldview (one’s own assumptions and biases that
could affect decision making and actions)

having a positive, respectful and accepting attitude towards cultural differences

having knowledge of different cultural practices and world views

having good cross-cultural communication skills.
A person who is culturally competent can communicate sensitively and effectively with
people who have different languages, cultures, religions, genders, ethnicities, disabilities,
socio-economic backgrounds, ages and sexualities. Culturally competent staff strive to
provide services that are consistent with a person’s needs and values.
Culturally competent services
In delivering culturally competent services, service providers should:

Seek to identify and understand the needs of specific special needs groups
(Indigenous, Culturally and Linguistically Diverse (CALD), Humanitarian Entrants
etc) within the site.

Investigate, understand and take into account a client’s beliefs, practices or other
culture-related factors in designing services.

At all times be respectful of a client’s cultural beliefs and values.

Ensure that the work environment and practices are culturally inviting and helpful.

Ensure that services are flexible and adapted to take account of the needs of
specific special needs groups and individual clients.

Provide access to culturally specific training and supports to improve team
understanding of the local community groups and effective communication
methods.

Regularly monitor and evaluate cultural competence of the service and staff
(including obtaining input from clients and the community).

Use information and data about specific special needs groups to inform planning,
policy development, service delivery, operations, and implementation of services.
Organisational cultural competence
It is important that cultural competence is valued and is a key consideration at the
organisational level. Consideration of the following will assist to improve organisational
cultural competence.

Is the organisation’s governing body educated about cultural competence?

Are community members represented on the governing body and advisory
committees?
52

Does the organisation have both formal and informal alliances and links with local
community representative groups?

Are regular reports provided to key stakeholders on the cultural competence activities
undertaken?

Is cultural competence embedded in the philosophy, mission statement, policies and
key objectives?

Does the organisation have formal cultural competence-related policies (that were
formulated with input from the community) regarding staff recruitment and retention,
training and staff development, language, access and communication, cultural
competence-related grievances and complaints?

An effective complaints mechanism is important to all clients that are vulnerable and
should also be easily accessible and useable by CALD or Indigenous Australians with
specific cultural needs.

Does the organisation have processes in place to obtain client, community and staff
input in the development of cultural competence-related plans?

Does the organisation regularly self-assess cultural competence?

How can the organisation collect client-level cultural competence-related information,
conduct regular community needs assessments and evaluate cultural competencerelated activities? How will this data inform service quality improvement activities?

How are Individual Recovery Plans conducted for clients where English may not be a
first language?

What types of culturally appropriate materials are required to communicate effectively?
Is signage and key written materials available in the language(s) of the local
community and appropriate to the literacy level of your community? This can be
expensive so are there alternative strategies that can be use?

Does the organisation recruit staff with suitable skills and experience who are
connected with the local community and can provide appropriate support? Are there
any cultural issues in doing this?
53
Attachment H: Incident Report Form
PERSONAL HELPERS AND M ENTORS
INCIDENT REPORT
ORGANISATION: _________________________________________________________________
SERVICE ACTIVITY (PHAMS ):______________________________________
SITE:_________________________________________________________________________
DETAILS OF INCIDENT
DATE OF INCIDENT:________________________TIME OF INCIDENT:____________________________
NO. OF INDIVIDUALS INVOLVED: ______________GENDER OF INDIVIDUALS INVOLVED:___________
AGE OF INDIVIDUALS INVOLVED: ______________STATUS OF INDIVIDUALS INVOLVED (STAFF,
CLIENTS ETC):____________________________
WHERE DID THE INCIDENT TAKE PLACE?__________________________________________________
WHAT OCCURRED? (DESCRIPTION OF INCIDENT)___________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
RESPONSE TO THE INCIDENT:___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ACTION THAT HAS BEEN TAKEN OR CAN BE TAKEN TO PREVENT THE INCIDENT FROM HAPPENING
AGAIN:_______________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________ ________
_____________________________________________________________________________________
_______________
HAS THERE BEEN OR IS THERE LIKELY TO BE MEDIA COVERAGE OF THE INCIDENT;_____________
_____________________________________________________________________________________
NAME OF SITE MANAGER:__________________________________DATE:________________________
54
SIGNATURE OF SITE MANAGER: _________________________________________________________
GUIDELINES FOR REPORTING INCIDENTS
Providers should report incidents to their DSS Grant Agreement Manager within 24 hours of
occurrence/discovery. Reportable incidents include:
 death, injury or abuse of a client while in a provider’s care
 death, injury or abuse of staff or volunteers undertaking delivery of PHaMs tasks
 inappropriate conduct between a participant, especially a child or young person, and
employee
 significant damage to or destruction of property impacting service delivery
 adverse community reaction to the PHaMs activities
 misuse of the PHaMs funding.
55
Attachment I: Using the Personal Helpers and Mentors logo
PHaMs logo and branding instructions
The logo has been issued for the purposes of the promotion of the Personal Helpers and
Mentors service only.
The PHaMs logo should be used according to the following guidelines:

the logo should appear in its entirety.

the logo should appear in colour (see CMYK and Pantone values below) or greyscale
ONLY. No other variation is permitted.

the CMYK values for the colour logo are 73.100.0.0. The Pantone value is 527C.

the logo should be no smaller than 40mm wide to ensure the text remains legible, and
no other font should be substituted.

if the logo is resized, the proportions must be maintained.

the logo must contrast strongly with the background: it should not be placed on colours
similar to the blue and purple used in the design.

for ease of use, the preference is for the logo to be used against a white background.

the greyscale and white version of the logo should be used when the document will be
printed in black and white.

the logo and its component parts should NOT be distorted or modified in any way.

the ‘Personal Helpers & Mentors’ text font is Helvetica Neue.
PHaMs - using the logo

The logo should always include the "An Australian Government Initiative" text.

The logo must be either greyscale logo (with shades of grey and black) OR colour.

Do NOT distort the logo.

The logo should NOT appear on merchandise or stationery.

The logo should NOT be used with service provider or auspice body branding.

The logo has been issued for the purposes of the promotion of the Personal Helpers
and Mentors service only and has been given to PHaMs service providers on this
basis. If you have any queries, please contact your PHaMs Grant Agreement
Manager.
56
The logo should
always include the
‘An Australian
Government
Initiative’ text
The logo must be
either:
greyscale logo
(with shades of grey
and black)
  
  
OR
Colour
Do NOT distort the
logo
 
57

The logo should
always include the
‘An Australian
Government
Initiative’ text
The logo should
NOT appear on
merchandise or
stationery
PLEASE NOTE
  
 

The logo can only be used with the permission of the Australian
Government Department of Social Services. If you have any
queries, please contact your PHaMs Grant Agreement Manager.
QUERIES
58
Attachment J: PHaMs services operating in NDIS sites
The National Disability Insurance Scheme
Funding for Personal Helpers and Mentors (PHaMs) is transitioning to the National Disability
Insurance Scheme (NDIS). To facilitate the transition of PHaMs funding to the NDIS these
Guidelines take into consideration the different transition arrangements across the country.
Each site is transitioning to the NDIS with different timeframes and for different cohorts. It is
the responsibility of each PHaMs service to understand when the NDIS is being phased in
for their clients. Information about transition to the National Disability Insurance Scheme is
available at www.ndis.gov.au
Registration
Services operating in an area where the NDIS is available are required to register with the
National Disability Insurance Agency. The registration form and other important information
is available at www.ndis.gov.au.
Services must register to enable the use of in-kind funds for NDIS-eligible clients.
Funding
PHaMs services in NDIS sites operate on an ‘in-kind’ arrangement. This means PHaMs
services will continue to receive block funding with a portion notionally committed to the
NDIA by the Commonwealth, to fund supports provided to NDIS clients. In-kind service
provision is when an organisation provides a support to an NDIS client and lodges a claim
(also known as ‘drawing down’) against its notional in-kind allocation. The in-kind allocation
has been calculated based on the number of clients in the service area who are expected to
be eligible for the NDIS. In-kind allocations, do not impact on existing levels of funding for
providers.
Claiming in-kind on the NDIS portal does not generate a payment from the NDIS however it
draws down against the allocated in-kind amount.
Claims are made against the NDIA catalogue of supports. Providers can only claim for
supports they have registered to provide.
In-kind services can be provided either to existing programme clients who have become
NDIS clients, or new clients with an individually funded support package through the NDIS
who become PHaMs clients.
DSS will advise the amount of in-kind allocations for providers. These figures are also
available on the NDIS Provider Portal.
Providers must make their best efforts to draw down their in-kind allocations.
The Department will monitor draw-down and will work with providers to address any issues
or concerns.
Once providers have exhausted their in-kind allocation they can claim fee for service through
the NDIA.
Please note that providers must not claim fee for service through the NDIA and use PHaMS
block funding for the same support provided to the same client. Any supports provided
through an NDIS individually funded plan must be either funded by drawing down against the
in-kind allocation or claimed as fee for service from the NDIA.
59
National Disability Insurance Agency (NDIA)
PHaMs service providers are expected to work closely with the NDIA in their localities in
order to:
•
support existing clients to test their eligibility for NDIS support
•
refer applicants for PHaMs services to the NDIA if they are potentially eligible for NDIS
support, i.e. the applicant meets geographic and/ or age cohort requirements
•
establish and/or promote referral pathways to the NDIA (where relevant) so that
people who are potentially eligible for NDIS support are referred to the NDIA in
advance of PHaMs services
•
participate in local planning and coordination activities as relevant.
Clients
As the NDIS becomes available in PHaMs service catchment areas, service providers are
required to support clients (meeting geographic and age cohort requirements) to test their
eligibility for the NDIS. This may involve assisting clients to gather relevant documentation,
complete application forms and attend meetings with the NDIA.
If a client is deemed eligible for the NDIS, the PHaMs service can continue to provide
support to that client. The PHaMs service must draw down against its in-kind funding for any
services delivered that are identified in a client’s Individually Funded Package (IFP).
Please note that providers must not claim fee for service through the NDIA and use PHaMs
block funding for the same support provided to the same client. Any supports provided
through an IFP must be either funded by drawing down against the in-kind allocation or
claimed as fee for service from the Agency.
Caseloads
The time required to assist clients to access the NDIS, or the extra supports clients are
receiving in their IFPs, may impact caseloads. Services must discuss any difficulties in
meeting their caseloads with their Grant Agreement Managers. The Department will work
with providers to address issues that are impacting on caseloads as they are identified.
Reporting
In addition to reporting through the DSS Data Exchange, providers in NDIS sites must
complete a table that identifies clients accessing the NDIS and the outcomes of the access
process. This must be completed quarterly to enable the Department to monitor the
transition of PHaMs to the NDIS and to understand the experiences of people with
psychosocial disability and providers to inform the full roll out of the NDIS.
60
Attachment K: PHaMs services operating in an NDIS My Way Site
The Western Australia (WA) NDIS My Way Model
From 1 July 2014, Western Australia started participating in a two-year trial of the National
Disability Insurance Scheme (NDIS).
The NDIS trial in WA includes the implementation of two different models in different
locations over a two-year period: the Commonwealth’s National Disability Insurance Agency
(NDIA) NDIS model and the State Government's WA NDIS My Way model
The WA trial provides an opportunity to compare and contrast the two different models. Both
models will be independently evaluated over the two-year trial period and the outcome will
inform how disability services are provided into the future in WA and nationally.
The WA NDIS My Way model is being implemented by the WA Disability Service
Commission (DSC).
Registration
Organisations wanting to provide supports and services as part of the WA NDIS My Way trial
need to apply to be on the Disability Services Commission’s Panel Contract for Individually
Funded Services.
Funding
PHaMs services in NDIS My Way sites operate on an ‘in-kind’ arrangement. This means
PHaMs services will continue to receive block funding with a portion notionally committed to
the WA Disability Services Commission by the Commonwealth, to fund supports provided to
NDIS My Way clients. The in-kind allocation has been calculated based on the number of
clients in the service area who are expected to be eligible for the NDIS.
WA Disability Services Commission (DSC)
PHaMs service providers are expected to work closely with the DSC in their localities in
order to:
•
support existing clients to test their eligibility for support
•
refer applicants for PHaMs services to the DSC if they are potentially eligible for
support, i.e. the applicant meets geographic and/ or age cohort requirements
•
establish and/or promote referral pathways to the DSC (where relevant) so that people
who are potentially eligible for support are referred to the DSC in advance of PHaMs
services
•
participate in local planning and coordination activities as relevant.
Clients
As the NDIS My Way becomes available in PHaMs service catchment areas, service
providers are required to support clients (meeting geographic and age cohort requirements)
to test their eligibility for the NDIS. This may involve assisting clients to gather relevant
documentation, complete application forms and attend meetings with the DSC.
Please note that providers must not claim fee for service through the DSC and use PHaMs
block funding for the same support provided to the same client.
Caseloads
The time required to assist clients to access the NDIS, or the extra supports clients are
receiving in their IFPs, may impact caseloads. Services must discuss any difficulties
61
meeting caseload requirements with their Grant Agreement Managers. The Department will
work with providers to address issues that are impacting on caseloads as they are identified.
Reporting
In addition to reporting through the DSS Data Exchange, providers in NDIS My Way trial
sites must complete a table that identifies clients accessing the NDIS and the outcomes of
the access process. This must be completed quarterly to enable the Department to monitor
the transition of PHaMs to the NDIS and to understand the experiences of people with
psychosocial disability and providers.
62