Commissioned Services

SNPHN Commissioned Services

From July 1, 2016 Sydney North Primary Health Network (SNPHN) began commissioning local health services on behalf of the Australian Government.

CLICK HERE to read about our approach to Commissioning Services.

These newly commissioned services have been designed to improve the efficiency and effectiveness of health services and improve health outcomes for people with priority needs. The services and programs include:

Alcohol and Other Drug Services

In February 2017, SNPHN commissioned the following service providers to deliver Alcohol and Other Drug (AOD) services in the region.

  • Odyssey House McGrath Foundation in partnership with New Horizons

Odyssey House McGrath Foundation and New Horizons will deliver a tailored, integrated psychological counselling and rehabilitation day program for adults with alcohol and other drug misuse issues across the region.

  • Manly Drug Education and Counselling Centre (MDECC)

MDECC will provide a specialised intensive non-residential support program for young people aged 14-25 years residing within the SNPHN region who are experiencing moderate to severe drug and alcohol addiction.

  • ACON

ACON deliver specialist alcohol and other drug treatment services to Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) community members residing in the region.

Mental Health Services

SNPHN has worked to create and contribute to a region-wide stepped care model by commissioning a number of services to meet the mental health needs of the region. The newly created services are well-informed, address identified gaps, and add value to the existing services of the region.

  • Lifeline Harbour to Hawkesbury

Lifeline Harbour to Hawkesbury will provide Low Intensity Mental Health Services across the region with telephone coaching to support usage of mental health self-help tools and digital technologies.

  • Relationships Australia in partnership with the Gaimaragal Group

Relationships Australia and the Gaimaragal Group will provide Aboriginal and Torres Strait Islander Mental Health services, including one-on-one service coordination to support community members to access culturally appropriate and sustainable treatment and support options.

  • Primary and Community Care Services (PCCS)

PCCS will work with existing ATAPS providers to provide one-to-one psychological services to underserviced groups across the Northern Sydney region, utilising the existing local workforce of psychologists and allied health professionals.

  • Lifeline Harbour to Hawkesbury in partnership with Lifeline Northern Beaches

Lifeline Harbour to Hawkesbury and Lifeline Northern Beaches will provide group therapy services across the region.

  • New Vision Psychology

New Vision Psychology will provide psychological services to Mandarin and Cantonese speaking people across the region.

  • Parramatta Mission

Parramatta Mission will provide services for people residing in the region with Severe and Complex Mental Illness. This will include care coordination and psychological therapy tailored to the individuals’ needs.

Youth Mental Health Service

  • headspace

With an estimated 176,522 people aged 12-25 years living in the Northern Sydney area and as many as one in four young people experiencing mental health illness, youth mental health is a key focus for the SNPHN region. To meet this need, SNPHN is now funding and managing the contracts for two local headspace centres operated by New Horizons Enterprises Limited.

headspace is a youth mental health service that has operated for the past ten years across Australia. SNPHN is funding its local drop-in centres located in Chatswood and Brookvale.headspace drop-in centres, provide young people with access to health workers e.g. a GP, psychologist, social worker, alcohol and drug worker, counsellor, vocational worker or youth worker. These services are either free, or have a low cost.headspace also offers an online and telephone service, eheadspace, that supports young people and their families going through a tough time. eheadspace provides confidential support seven days a week between 9:00am and 1:00am.

To learn more about headspace CLICK HERE

Contact Details:

headspace Brookvale
Level 2 Brookvale House, 1A Cross Street, Brookvale, New South Wales 2100
P: (02) 9937 6500
F: (02) 9938 3099
E: info@headspacebrookvale.org.au

headspace Chatswood
30 Devonshire Street, Chatswood, New South Wales 2067
P: (02) 8021 3668
F: (02) 8021 7410
E: info@headspacechatswood.org.au

headspace logo national youth mental health

  • Parramatta Mission

Parramatta Mission will deliver services to young people aged 12-25 years with, or at risk of, severe mental illness. This will include care coordination, psychological interventions, and access to affordable psychiatry.

Aboriginal Health

Northern Sydney Local Health District in partnership with the Gaimaragal Group

These service providers will coordinate chronic disease services to Aboriginal and Torres Strait Islanders in the Northern Sydney region.

Hospital Discharge and Care Coordination Services

SNPHN has commissioned two service providers – KinCare and Just Better Care – to provide a hospital to home transition service that is designed to reduce the likelihood of re-admission to hospital after discharge.

Both providers can also work with a range of community and primary health providers to coordinate care for patients that are otherwise at risk of hospitalisation, where short term management could be beneficial.

Public and Private hospitals are eligible to refer the following patients to the discharge follow-up service:

  • People who have suspected or diagnosed dementia
  • A person with a chronic or complex health condition
  • A person who is not receiving adequate support, and would significantly benefit from post-discharge follow-up at home within 24 hours
  • Would significantly benefit from short-term follow-up support
  • Are not currently enrolled in TACP/TRANSPAC
  • Exhibit other characteristics to be agreed

GPs and other primary care based services can refer to care coordination services for patients at high risk of hospitalisation, determined by using one or more of the following tools:

  • Harp ≥24
  • AUSDRISK Tool Score ≥12
  • AACVD risk ≥15
  • 3 or more chronic conditions / comorbidities
  • Frailty screening score ≥3
  • Hospitalised in the previous 12 months

The services will be provided to clients from within the indicated Local Coordinated Networks (LCNs).

Cluster Map LCN


KinCare provides in-home health and wellbeing services to older people and people with a disability. The Heading Home program, is a hospital discharge and preventable service.  The primary goal of the service is to facilitate the smooth transition of a person from hospital to home or alternatively prevent people at risk of avoidable hospital admission. It aims to reduce preventable or re-admissions to hospital, and to ensure all parties in the client’s support network are kept up-to-date through maintaining and improving communication. KinCare’s services are person-centred, flexible and responsive to changing needs.

The LCNs covered are as follows:

  • Ryde (x 1 LCN)
  • Hunters Hill, Lane Cove & Willoughby (x 1 LCN)
  • Mosman & North Sydney (x 1 LCN)
  • Northern Beaches (x 1 LCNs)

To refer: 1300 689 741

CLICK HERE for Heading Home Brochure

KinCare logo small

Just Better Care (JBC)

JBC is a provider of in-home support, enabling people to live independently, maintain their personal and social connections and enjoy a better quality of life. The Stay at Home program is a hospital discharge and preventable service for people who are being discharged from hospital and are at risk of avoidable hospital admission. The service will provide participants with assistance through case management to link into services, supporting them to live as independently as possible in their own homes. A key component of the service is to ensure the patient’s GP is kept well informed of their management plan.

The service will be provided to clients from within the indicated Local Coordinated Networks (LCNs).

The LCNs covered are as follows:

  • Hornsby (x 1 LCN)
  • Ku-ring-gai (x 1 LCN)

CLICK HERE for Stay at Home brochure

CLICK HERE for Stay at Home poster


Reenay Mishra  stayathome@justbettercare.com
Tel: 0437 522 258 (Hornsby Hospital and SAH and all private hospitals)

Just Better Care logo small

Improving Access to End of Life Care Services

Specialist palliative care provider, HammondCare, has been commissioned by the Sydney North Primary Health Network to provide quality End of Life Care education and training for staff working in residential aged care across Northern Sydney.

Hammond Care Liaison Nurses and Palliative Care specialists will provide advice and training to RACF and GPs supporting aged care facilities within the SNPHN region, while strengthening links between networks and integrating pathways. This will upskill and build capacity within RACFs, prevent unnecessary hospital admissions and improve quality of care for aged care residents.

GP support through this initiative will include individual mentoring from Hammond Care’s Staff Specialist and Nurse Practitioner. This will Ensure our GPs have the capacity and confidence to facilitate case conferencing with staff, family and carers. The initiative will also utilise palliative care resources including PHN Health Pathways.

Successful RACF End of Life Care Project – See the list of facilities

Social Work Service to Support GPs

Patients with chronic or complex health care conditions

SNPHN has commissioned two service providers, Primary and Community Care Services (PCCS) and Community Care Northern Beaches (CCNB) to provide a Social Work Service to Support GPs to assist in the prevention of hospital admission or re-admission for patient’s living with chronic or complex health care conditions.

Suitable patients, referred by their GP to the program, will be supported by a social worker who will provide appropriate service access to nutritional, social and welfare support.

Social Work Service to Support GPs – Overview

PCCS logo small

Primary and Community Care Services (PCCS)

The PCCS GP Social Work Support Program adopts a patient-centred medical home approach to supporting the health, social and welfare needs of patients. The model works alongside a GP’s normal model of care and provides social work services to assist patients to improve their health and wellbeing, better navigate the system, access needed support, and avoid unnecessary hospitalisations. Social workers will support GPs and their patients by facilitating and coordinating additional assistance with social, welfare and or community providers. This program will run in Hornsby, Ku-ring-gai, Ryde and Hunters Hill.

CLICK HERE for the PCCS GP Social Work Connect Flyer

CLICK HERE for the PCCS GP Social Work Connect Referral Form

To learn more about the PCCS service CLICK HERE.

CCNB logo small

Community Care Northern Beaches (CCNB)

Access to timely and effective social work services enables people to stay Healthy at Home. CCNB will deliver this model through the provision of a mobile team of experienced and qualified social workers who will work flexibly across the LGAs of Willoughby, Lane Cove, Mosman, North Sydney, Manly, Warringah and Pittwater.

CLICK HERE for the CCNB GP Referral Form
CLICK HERE for the CCNB Flyer for GPs
CLICK HERE for the CCNB Social Work Medical Direction Template (right-click and “Save as…”)
CLICK HERE for the SNPHN instructions on importing templates into Medical Director.
CLICK HERE for the CCNB Social Work Best Practice Template (right-click and “Save as…”)
CLICK HERE for the SNPHN instructions on importing templates into Best Practice.

To learn more about the CCNB Healthy at Home service CLICK HERE

Innovation Grants

In August 2016, SNPHN announced the six primary healthcare projects awarded an innovation grant that will lead to improvements in the areas of chronic disease management, mental health, men’s health, patient hospital discharge and GP education. The projects will commence in 2016/2017.

Men's Health Clinic from MQ Health

Primary Healthcare: Men’s Health Clinic

A dedicated Men’s Health Clinic in Macquarie Park is now providing a male friendly whole-of-health and wellbeing service with access to general practitioners, allied health professionals, specialists, as well as imaging and pathology services all in the one place.

An initiative of MQ Health (Macquarie University Health Sciences Centre), the new Men’s Health clinic which is open each Thursday between 4pm and 8pm has been designed to meet the needs of male patients who generally have poorer health outcomes particularly in the areas of coronary heart disease, diabetes, and mental health. Most of these conditions are preventable, and with timely and effective health interventions longevity can be improved.

For more information about the Men’s Health Clinic or to book CLICK HERE.

For appointments call: (02) 9812 3944.

Mental Health: Consumers & Peers Mental Health Workforce Development

Consumers and Peers working, volunteering or aspiring to work in mental health services and with a lived experience of mental health illness, will have the opportunity to benefit from a workforce development project in 2017.

An initiative of the Northern Sydney Local Health District and partners, the project will provide three forums whereby participants will meet together to share their experiences, provide support and receive training and mentorship to improve their professional development. National standards and national and state government policy for mental health services supports an active and involved consumer/peer workforce in mental health services.

Consumers & Peers Mental Health Workforce Development

WellNet integrated care program

Chronic Disease Management: Integrated Care Program

The ‘Wellnet’ integrated care programs from Sonic Clinical Services Pty Ltd, are built on an evidence based framework of delivering a GP led, patient-centred healthcare home. The programs provide a suite of targeted healthcare interventions for patients with complex conditions in a stepped approach, providing care through the patients regular GP.

The program offers a proactive approach to delivering care and will include risk stratification of patients, care planning, care coordination, electronic health records, after hours support and targeted patient centred care with a view to create a sustainable model that both public and private healthcare partners can support. The aim of the program will be to deliver a chronic care management system for GPs nationally.

Hospital Discharge: A Patient Centred Approach to the Transfer of Care

The Hornsby Hospital and Hornsby GP Unit will join forces to co-design and co-deliver a patient-centred transfer of care model between the hospital and general practice that will enhance the older and complex patient’s journey between leaving hospital and returning to the community.

Improvements in patient safety, patient satisfaction as well as a reduction in patient re-admissions to hospital will be considered successful outcomes of the project. A literature review and patient led qualitative and quantitative study that examines the transition of care of patients discharged from the hospital to the Hornsby GP Unit will inform the development of the model.

Hospital Discharge: A Patient Centred Approach to the Transfer of Care

MC Family Medical Practice chronic disease management

Chronic Care Management: A Practice Approach to Managing Chronic Care

MC Family Medical Practice in Pennant Hills will adapt the ACI (Agency of Clinical Innovation) Chronic Disease Management Model to meet the needs of its at risk patients. The model will identify patients at risk of chronic disease, stratify their risk with the PENCAT (clinical audit tool) and target care appropriately. The practice will also employ other innovative features for these patients including the use of exercise tracking devises, health coaching from local allied health providers and patient education evenings.

To assist with building capacity within the Primary Care team a Chronic Disease Manager and Practice Nurse will act as Care Coordinators and be instrumental in the delivery of this new model of care for patients.

GP Education: Northern Beaches GP Education

A membership based network of GPs the Manly Warringah Divisions of Practice will benefit from new educational opportunities in 2017. The education will help broaden the GPs knowledge of services available in the Northern Sydney region and provide continuing professional development (CPD) opportunities for the group to improve health outcomes for the Northern beaches community.

Mnaly Warringah Divisions of Practice

Grants to assist vulnerable community groups

This year, SNPHN has issued grants to support various NGOs across the region that provide psychological services to vulnerable members of our community. These grants were provided in the following health areas: Aboriginal and Torres Strait Islander youth; carers of people with disabilities; people that are at risk of suicide; and others with mental illness and that are aligned to the Department of Health ATAPS guidance on service provision.

Centre for Disability Studies

The Centre for Disability Studies will use one of the grants to run Intellectual Disability and Mental Health Training in the form of four 1-day education sessions. The four psychotherapy and counselling education sessions will include an introductory workshop, anxiety and depression, family and carer behaviour management support, and trauma response.

The program will be conducted with government and NGO staff working in counselling, social work and psychology.

The Gaimaragal Group

Balance Educate Empower (BEE 1) is all about community consultation and mapping of needs and service providers to better coordinate services for at-risk youth in the region.

There are three components to Bee 1:

  • Run cultural activities to engage with youth and community members to build resilience and cultural/spiritual strength.
  • Conduct healing circles and reflective circles for youth with a buddy system comprised of a community member and social worker.
  • Produce a resource document and blue print for service provision in the region.

The Gaimaragal Group

Similar to BEE 1, BEE 2 aims to better coordinate service provision for at-risk youth.

The programs work on three levels:

  • Meet with local school Principles to articulate needs of local First Australian youth.
  • Run two half-day presentations for community, parents and carers on trauma education to better provide services to youth in crisis.
  • Run two full day professional development workshops for staff. The workshop will outline the layers of trauma across generations and through communities with the critical need for generational healing. It will also cover the implications of historic, social, cultural, complex and developmental trauma, along with the theory and practice of an educated response to trauma.

Lifeline Northern Beaches

The grant given to Lifeline Northern Beaches will allow the organisation to employ an In Shift Supervisor for the 6am to 9am morning shift three days a week for twelve months.

Lifeline Harbour to Hawkesbury (H2H)

The Lifeline H2H Hoarding Disorder Treatment and Support Program offers a 15-week treatment group, a 12-week support group and a peer-led monthly support forum. The first program will commence in August 2016, with the second to follow in March 2017.

Over the past three years, Lifeline H2H has developed and refined their Hoarding Treatment Program and has skilled clinical staff that can deliver this program. The organisation has already run three programs (with 36 participants who have completed it) and is currently running a fourth program with 14 people enrolled. An analysis of results from Lifeline H2H’s first three programs showed a mean improvement in hoarding-related behaviour of 29% by the end of the treatment.

Note: the program is based on the “Buried in Treasures Workshop: A Facilitators manual” (Shuer and Frost, 2011), an evidence based program developed in the USA.

Community Care Northern Beaches (CCNB) lead with NSW FACS – Greenway Wellbeing Centre

This Project will provide a Greenway-based social worker for a period of six months that will reduce the gravitational pull towards hospital services. The purpose is to identify mental health issues early on and disrupt the cycle of ‘being lost in the system’.

It will create an effective community system that coordinates care between specialist providers, developing strong partnerships among GPs and ATAPS providers in the Northern Sydney Region.