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, get to know each person so they can develop a collaborative plan and work with them to put this plan into place. Whether this is 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 can manage more themselves, they are discharged to on-going care by their GP.


To be eligible to access, consumers need to:

  • Be aged between 18 and 65 years.
  • Live in the CESPHN region.
  • Experience severe mental illness as evidenced by meeting 3 of the 4 criteria:
    1. Have 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 client’s social, personal and/or occupational functioning.
    3. The mental illness has resulted in hospital treatment in the previous two years.
    4. The client 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.
  • Are not currently receiving clinical care and coordination support through the Local Health District Community Mental Health Services.
  • Do not have a duplication of service through the NDIS or other programs.

NB: Referrer must ensure there is no duplication of services if the client is accessing a National Disability Insurance Scheme (NDIS) package.

All referrals submitted online through the CESPHN central intake are reviewed to ensure eligibility and allocation to One Door Mental Health. Referrers will be contacted to let them know when a PICS mental health nurse will be in contact with them to progress their referral. On average, the referral will take 8 working days.

Mental Health Central Intake Referral Form

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

Program Flyer

Service ProviderOne Door Mental Health
Phone(02) 7227 6700