Frequently Asked Questions

Partners In Recovery (PIR) has been designed to help improve the supports provided to people living with severe and persistent mental illness who have multiple support needs, by focusing on improving the response of the system to meet their needs. It works to improve pathways to accessing supports and also to ensure that the services supporting a person, are working together in a coordinated and recovery orientated way, meeting the full range of their support needs.

The ultimate objective of Partners In Recovery is to improve the system response to, and outcomes for, people with severe and persistent mental illness who have complex needs by:

  • Assisting a person to identify their support needs and working with them to link to the relevant services and supports.
  • Facilitating better coordination of these supports, ensuring that they are working together to meet the full range of a person's needs (wrap around, individually tailored care).
  • Strengthening partnerships and building better links between clinical and community supports.
  • Improving referral pathways to facilitate access to the range of services that people experiencing severe and enduring mental illness with complex needs require.
  • Promoting a community based recovery model to underpin all clinical and community support services delivered to people experiencing severe and persistent mental illness with complex needs.

The Department of Health has estimated that there are over 60,000 adults across Australia experiencing severe and persistent mental illness with significant functional impairments requiring services from multiple agencies.

PIR has been funded across Australia by the Federal Government, in recognition of the consistent feedback that support for people with significant mental health issues is not adequately integrated or coordinated and therefore not meeting the full range of their support needs. PIR is targeting 24,000 people across Australia, however by improving system coordination, it is envisaged that this improvement will have a flow on impact for a larger number of individuals.

Partners In Recovery staff members are called Support Facilitators. Support Facilitators provide a care coordination service to individuals. Some of the things they do are:

  • Facilitate recovery oriented, holistic assessment and planning of support needs with a person.
  • Support and promote self-management and self-advocacy.
  • Facilitate referral and access to services and supports across sectors.
  • Work to ensure that support is coordinated, integrated, flexible and responsive to the person's changing needs.
  • Develop partnerships in the community which promote and encourage innovation and collaboration.
  • Facilitate resource coordination, develop networks and create learning and development opportunities across sectors.

Support Facilitators will work one-on-one with people to assist them to identify the areas in their life that they would like support with. Meetings can take place where the person feels most comfortable such as in their home or in the local community. They then work alongside the person as they make plans in relation to these areas and facilitate referrals ensuring that all services are working together to meet the needs of the person. Support Facilitators will also work in partnership with the people who the person identifies as part of their support network such as carers, families, friends or services.

Care coordination aims to improve the operation of the whole service system. In PIR, staff work to improve referral pathways that facilitate access to services across sectors. They identify opportunities to increase the capacity of services to provide supports and also to integrate services in order to achieve better outcomes for consumers.

Case management tends to focus on improving the service delivery for an individual consumer. This is done by identifying supports and linking to services, working in partnership with other agencies to provide effective support to a consumer. PIR recognises and works with existing case management functions to ensure effective approaches are maintained as a key element of the overall support to a person supported by the PIR program.

Central and Eastern Sydney PHN manages the Partners In Recovery Program in South Eastern Sydney region which includes the Kogarah, Rockdale, Hurstville and Sutherland Shire Local Government Areas.

PIR is a collaborative program and therefore Support Facilitation is delivered in partnership by a range of local non-government organisations including;

PIR works with people who are experiencing enduring mental illness with complex support needs and who are currently not engaged in supports and services that meet the full range of their support needs.

The inclusion criteria used to determine who is eligible to access PIR includes people who:

  • Have complex needs that require substantial services and supports from multiple agencies.
  • Have a diagnosed mental illness that is severe in degree and persistent in duration, and are willing to be referred for ongoing clinical treatment.
  • Require substantial support and assistance to engage with the various services to meet their needs.
  • Have no existing coordination arrangements in place to assist them to access the necessary services, or where they are in place, those arrangements have not met the person's needs.
  • Consent to being involved, and indicate a willingness to participate, in PIR.
  • Are aged over 24 years.

You can refer yourself or someone else to PIR either by filling out the referral form on our website For more information, you can phone the SES PIR Intake Officer on (02) 9330 9999.

While Health Care Professionals can refer, you do not have to be from a health or community organisation. People in need, their carer or family members are welcome to complete a referral.

Once your referral has been received we will get back to you within 48 hours. If a referral is received and does not meet the inclusion criteria, PIR will do their best to find a support service that would be suitable. This is called our "No Wrong Door Policy".

Yes, the PIR service is completely free of charge and requires only a referral to the program.

PIR has no time restrictions on the service and will work with the consumer until stable, "wrap around" arrangements are in place, and the consumer is ready to leave the program.

We can provide you with information about the PIR program to give to the person.

With the person's consent, a PIR Support Facilitator can meet with them to discuss the program so they can see if it is something they are interested in. The PIR Support Facilitator could also assist in looking at the range of other options available to them in their local area if PIR is not suitable or not what they would like.

From July 2017, Partners In Recovery will support PIR consumers to transition to the National Disability Insurance Scheme (also called the NDIS). The NDIS is the new way of providing support to Australians with disability including psychosocial disability. NDIS supports may help you achieve goals in many aspects of your life, including independence, involvement in your community, education, employment and health and wellbeing.

We are here to help PIR consumers transition to NDIS supports. SESPIR will assist with testing eligibility and applying for NDIS support, provide support coordination to people with an NDIS support plan and provide PIR support to people who are ineligible or not interested in NDIS supports. Find out more here.

A severe mental illness is one which is severe in its degree. For example; a psychotic illness, or a diagnosis which results in impairment across a range of functioning domains; or results in multiple hospitalisations for treatment of the mental illness. A persistent mental illness is one which is experienced over many years or is likely to be experienced over many years.

A person's support needs may be categorised as complex when there are multiple needs present that require a response from multiple agencies or services. For example, a person may require support with managing their mental illness as well as support with a physical health problem and assistance with addressing an addiction.

PIR acknowledges that families and carers should be recognised, respected and supported as partners in providing care and support to a person in the program. PIR Support Facilitators can work with individuals, their carers and families in developing plans to address the support needs of the person.

Call us on (02) 9330 9999 or email

More Information

For more information, download our PDF brochure.

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Meet Debbie
PIR Consumer Meet Debbie

"I'm focusing and a lot of things have been put in place for me to look forward to and for me to do. I focus on what I can do and what I can accomplish. My depression has improved a lot."

Meet Gavin
PIR consumer Meet Gavin

"Participating in PIR has changed my life because I am having people take notice of me, and what my needs are. Being able to succeed in what I want to do is important. Since PIR has come along, I am actually succeeding in what I want to do."

Meet Trudi
PIR Consumer Meet Trudi

"I have people I can contact and people available to me that I didn’t know existed. I always thought there were only one or two services out there that could help me but Matthew (my Support Facilitator) gave me a whole list."

Working With PIR
Sutherland Shire Community Services Working With PIR

"When working with consumers who are homeless and suffering with mental ill-health it is so important to have a flexible approach in order best meet their needs. We are very appreciative of PIR staff coming to our Tuesday breakfast program each week where they have become very well known to our consumers who are often happy to now self-refer and address problems with PIR before it becomes a huge issue."

In partnership with: Central and Eastern Sydney PHN After Care Benevolent Society Neami National