Partnering mental health and primary health services

Ms Jo McElhinney1, Ms Stephanie Aalders1, Ms Elizabeth Wallace2

1Plenty Valley Community Health (PVCH), Epping, Australia, 2Community Team North, Northern Area Mental Health Service (NAMHS), Epping, Melbourne, Australia

Aim: To work collaboratively in reducing the impact of risk factors of physical health conditions  for clients with serious mental illness via a partnership between Northern Area Mental Health Service(NAMHS) and co-located Plenty Valley Community Health, Dietitian and Exercise Physiologist.

Method: Clients of NAMHS are screened through a continuous cycle of metabolic monitoring by NAMHS Physical Health Nurses and referred to Dietitian and Exercise Physiologist.  Before and after receiving services, objective measurements are taken.  These include: weight, BMI, waist-circumference, blood-pressure, lipids, fasting glucose, HbA1c, Vitamin D.  Dietetic and Exercise Physiology interventions are individualised based on assessments so clients can achieve optimal physical health outcomes.  Regular follow-up monitors progress and provides support.


  • Total clients: N=24.


  • AusDRisk-screen scores– 14 (58%) =high-risk, 4 (17%) =moderate risk, 6 have diagnosed diabetes (25%).


  • 17 lost weight (71%), between 1.0-14.8kg. Median number of Dietetics appointments: 5, EP appointments: 4.


  • 5 (21%) attended YMCA gym integration program– 3 completed the existing 8 week program (13%), 2 currently completing/attending (10%), 6 will begin the program (25%). 4 are ineligible and referred for further medical investigations (17%).


  • Waist circumference change–17 (71%) lost between 1cm-19cm, average loss: 6.6cm.


  • Qualitative– 4 referrals to Endocrinology (17%), 5 referred for investigation of cardiovascular issues (21%), 3 referred to DNE (13%), 2 referred to women’s health nurse (10%).


Significance of the findings to allied health:

Clients receiving services from a PVCH Dietitian and Exercise Physiologist through this innovative partnership with the NAMHS Physical Health team have improved health outcomes and reduced risk factors for chronic disease.