Primary Integrated Care Supports (PICS) Program

Primary Integrated Care Supports (PICS) provides clinical care and coordination through recovery-oriented mental health services to people who are living with severe and persistent mental illness in the Central and Eastern Sydney Primary Health Network region.

People are paired with experienced and credentialed mental health nurses, who work closely with peer workers. The nurse will consult with the referrer and get to know each person so they can develop a collaborative plan, and work with them to put this plan into place. This includes coordinating care with GPs and psychiatrists, liaising with family and carers, reviewing mental health and wellbeing, supporting self-management of mental and physical health, monitoring compliance with medication, developing links with health and community services, and above all, developing a therapeutic relationship to support people to stay well whilst living in the community.

The PICS mental health nurses may work with peer workers – people with a lived experience of mental illness who have been trained to use this experience to support people in their recovery. Peer workers have a non-clinical role, focusing on supporting people’s needs and recovery. Most often, peer workers are supporting people to access the services they need, whether that is sorting out Centrelink payments, getting to a GP appointment or just going for a walk.

As people are supported by PICS and build their individual capacity and resilience, they are discharged to ongoing care with their GP.

Eligibility

To be eligible to access, individuals need to:

• Be aged between 18 and 65 years.
• Live in the CESPHN region.
• Experience severe mental illness as evidenced by:
  1. Having a diagnosed mental illness which is severe and either episodic or persistent in nature (according to the criteria defined in the World Health Organisation Diagnostic and Management Guidelines for Mental Health Disorders in Primary Care: ICD 10 Chapter V Primary Care Version, or the Diagnostic and Statistical Manual of Mental Health Disorders – Fifth Edition DSM-5).
  2. The mental illness significantly impacts at least two areas of the individual’s social, personal and/or occupational functioning.
  3. The individual is expected to need ongoing treatment and management of their mental illness (for a maximum of two years).
• Benefit from accessing primary care mental health services.
• Not be currently receiving clinical care and coordination support through the Local Health District Community Mental Health Services.
• Provide consent to receive treatment from an MHN and/or support from a PW
• Not be receiving a duplication of service through the National Disability Insurance Scheme (NDIS) or other programs.

NB: Referrer must ensure there is no duplication of services if the individual is accessing a NDIS package.

Referrals

Referrals are received electronically via the CESPHN Central Intake Referral Form and processed by the One Door Mental Health Intake Team to assess and ensure eligibility. Referrers will be contacted to advise when a PICS mental health nurse will progress the referral and contact the person referred.

Referrals can be made by GPs, psychiatrists, mental health services, community organisations, mental health nurses and peer workers.

As of November 2025, PICS has expanded its referral options to include self-referrals. To arrange this, please contact the PICS team directly via the contact details below.

Mental Health Central Intake Referral Form

The Gift Box: Group Support Pathway

In May 2025, One Door Mental Heath added a group support stream within the PICS program. The Gift Box is a 16-week group program that supports participants to develop the skills to express themselves through emotional regulation, identifying unhelpful patterns, and recognising and articulating thoughts and feelings.

Similar to the skills taught through Dialectical Behaviour Therapy (DBT), The Gift Box focuses on building resilience and connection to move from a vicious cycle of distress and crisis to a victorious one.

To join The Gift Box support pathway, it is not necessary to be an existing PICS participant. Please make a referral at this link, identifying it as a ‘Group Only’ referral.

PICS Program Flyer

The Gift Box Flyer