Care plan support and coordination service for Wanneroo community

A service supporting individuals with multi-morbidity and other mental health and/or alcohol and other drug related problems to be run through participating GPs in Wanneroo, Butler and Merriwa.

Data analysis from Primary Health Insights team has shown Wanneroo town centre, Butler and Merriwa have communities with relatively high levels of mental health and alcohol and other drug (AOD) issues. These community members also experience:

  • Socio-economic barriers that make the provision and uptake of effective treatment more difficult
  • Higher Aboriginal populations and displacement from inner suburban locations where culturally appropriate services are more available

During 2021, we engaged wellrounded to conduct a stakeholder needs assessment through consultation involving local general practice, peak bodies and community members. The Stakeholder Engagement Summary Report was released December 2021 supporting WA Primary Health Alliance (WAPHA) to commission an authentic and meaningful project with 14 key recommendations.  

Supporting Documents

Project Status:

Service launched 16 January 2023

New service helping people to better manage long term conditions

For further information on how to reach this service, read the media release

This free service will support eligible people to:

• help make and keep appointments (including arranging transport)
• understand any health advice that they have received
• access mental health and/or alcohol and other substance use support services
• find other health care options if they are getting stuck or are waiting too long for services
• access community-based social supports like financial, relationship and grief counselling services.


Stakeholder Needs Assessment (wellrounded)

December 2021

Stakeholder Engagement Report released

15 March 2022

Tender for service provider opens

12 April 2022

Tender for service provider closed

July 2022

Service provider announcement – Silverchain appointed to establish the service

January 2023

Service launched

Project Updates

Click to expand

Silverchain announced as Your Space Support Service service provider

13 July 2022

Following an open-tender process, WAPHA has appointed Silverchain as the awarded Commissioned Services provider to commence planning for the delivery of the in-practice service to operate from early 2023.

Silverchain, with the support of WAPHA, will soon commence a 6-month service establishment phase. Outcomes of service establishment will include GP engagement, service mapping, determining clinical governance arrangements and management system setup. The successful delivery of the Service will be attributed to the valuable insights and expertise of GPs working at nominated practices during this establishment period and at end-user delivery.

For interim service information or questions, please contact our Contracts Team.

Service commissioning update

12 April 2022

All public tenders for the service are currently in review. The service will be delivered by nurse generalists, working in partnership with GPs, to offer an enhanced level of support for individuals with multi-morbidity and subsequent other mental health and/or alcohol and other drug related problems.

The awarded service provider announcement is expected by July 2022. In consultation with local stakeholders, the naming of the service will be undertaken by the commissioned organisation. The unique name decision will consider links to the local region and the recommendation to consult with the City of Wanneroo Elders Group.

Service Model and Objectives

Users will access the free of charge* Service through their participating local GP. At the practice, a nurse generalist will work closely with the service user to establish the care plan needs, treatment and support service recommendation. The care plan is reviewed by the service user and nurse generalist together with the user’s local GP, with care plan actions made according to the user’s progress.

The Service aims to provide:

  • A small, self-managed team of nurse generalists working within a defined catchment.
  • In-reach services to meet the needs of the target group through partnerships with specialist alcohol and other drug / mental health services including psychiatry. *Medicare Benefits Schedule (MBS) items are available that reflect shared care.
  • Treatment support services that address the barriers for those lacking the personal resources necessary to engage with care effectively. These could include a social worker, family therapist, transport, etc.
  • Strong partnerships with community mental health and general health services, provided through North Metro Health Service and other local providers, to support integrated care.

The Australian Government provides funding to WAPHA for new services in line with the priorities for our regions. Practices who decide to offer the new Service will work closely with the commissioned organisation during the establishment phase on clinical governance arrangements and clinical management system setup.

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