Credentialed Mental Health Nurse Service

Ongoing therapeutic interventions and coordination of clinical services for those with severe and persistent mental illness.

Eligibility: Enduring and complex mental illness over a long period that significantly impacts social, personal and work life.

Services available: A team of Credentialed Mental Health Nurses across the South Western Sydney region will provide regular reviews, medication monitoring, physical healthcare information and liaison with carers and relevant mental health support services as required.

Referral pathways: Anyone can refer via central intake. A GP mental health treatment plan must be developed within one month of service commencement


Referral forms for this service can be found under Health Professionals > Practice Support > Forms and Templates

GPs can access the services through the Mental Health Central Intake number, and fax.


South Western Sydney PHN Mental Health Central Intake:

Enquiries: 1300 797 746 (1300 SWS PHN)

All referrals fax to: 4623 1796

Case study

Credentialed Mental Health Nurse Service (CMHNS)

Morpheus – Male – Age 52

Morpheus* is a 52 year old male who was referred to the Credentialed Mental Health Nursing Service (CMHNS) by his job search network. The CMHNS was launched in 2017 by the South Western Sydney PHN and has been allocated federal mental health funding. The program aims to provide ongoing therapeutic interventions and coordination of clinical services for those with severe and persistent mental illness.

Morpheus was initially referred for his depressive symptoms, but during the initial consultation, a long history of auditory hallucinations and paranoid delusional thoughts were disclosed. Morpheus stated he had been hospitalised a number of times since the 1980s and was diagnosed with Schizophrenia. He reported being on several medications, but could not recall their names apart from Methadone. Amongst his physical and mental health diagnoses are cervical, thoracic and lumbar spondylosis; asthma; and major depressive disorder. He stated being an intravenous drug user in his 20s and ceased by his 30s. He does not consume alcohol or illicit substances at the current time.

Morpheus applied for the Disability Support Pension (DSP) many times and was never invited for an interview; i.e. the application was rejected at the administrative phase. He had been asked to look for work, which has been extremely difficult due to his mental health, spending sleepless nights searching for cameras in his house; rearranging furniture to block windows and doors to prevent intruders, which he reports have stolen from him and have been after him for years.

A decision was made that I attend a GP appointment with Morpheus to ascertain some further information, and perhaps acquire some documentation, to assist him with another application for the DSP as he was unable to work in this state. After waiting two-and-a-half hours to see him, the GP informed us that another application for the DSP would likely be rejected. I informed the GP that I felt with his diagnosis of Schizophrenia alone (and symptomology), he would be eligible for the DSP. The GP stated that there is no record of Schizophrenia in the GP notes. At this point, Morpheus was extremely upset, stating that he had been in hospital for his symptoms, and the discharge summaries were usually faxed to the GP. It also appeared that he was not medicated for the Schizophrenia, except when he received prescriptions from the hospital shortly following his discharge. He had, however, been on antidepressant medication prescribed by the GP.

The GP stated that he could not confirm the diagnosis and a referral to a Psychiatrist was required. A referral was made to a private Psychiatrist, whose fee ranges around the $300 mark. Morpheus, already on limited income and unable to purchase medications and proper food, would not be able to afford this kind of fee.

Morpheus and I went back to my office where I called the local hospital and had them fax over his discharge summaries. I also contacted the Local Health District’s Community Mental Health team and they accepted his referral considering his presentation and that he was not medicated. Morpheus was relieved and stated that I was an angel (possibly delusional ��).

At that point, being only months working for the CMHNS, I realised that the need for the CMHN is extraordinary. Case coordination and clinical liaison is an important aspect of mental health care. Understandably, the GP can only do so much within the allotted timeframes and it is unfortunate to know some clients with severe and persistent mental health issues slip under the radar and are seemingly unaware of how the health system has failed them. The CMHNS is a long-awaited and urgently-required service to those in dire need.

*real name not used.


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