Primary Care Resources

What is stepped care for mental health?

Stepped care is a model of evidence-based mental healthcare delivery where the service intensity is matched to individual need/severity of the mental illness, ensuring that the right service is delivered at the right place, at the right time. The ideal intervention is the least intensive and least intrusive.

Importantly, the decision is driven by person-centred approach as opposed to one-size-fits-all. The continuum of care is self-correcting requiring monitoring of patient outcomes so that step-up or step-down may be implemented as appropriate.


The 10 stepped care principles

Stepped care is underpinned by ten comprehensive key principles for effective and inclusive service provision. These principles aim to provide flexible service delivery and referral pathways to a range of accessible integrated services which match individual need. 

Mental health supports (including psychological therapies) are evidenced-based and clinically governed. 

Crisis pathways are made available to those with urgent needs and services within the stepped care model, are also designed to target underserviced groups who are at risk and adaptive to the needs of the local community.

All services provided should include a recovery-oriented approach, which aims to equip consumers with the options and tools required to reach their goals.

1: Matched to choice and need 

Service intensity is matched to need. The ideal intervention is the least intensive and least intrusive, but most likely to lead to the most significant possible gain. Importantly, the decision is driven by client choice. The System where possible should align to the needs of the person, rather than the person having to align to the system. 

2: Flexibly adapt to change 

Stepped care approaches recognize that peoples’ needs can change over time and therefore services should have the flexibility to cater for these changing needs. 

3: User focused referral 

Flexibility is critical and allows an individual to move with ease across services without necessarily needing to be re-referred and re-tell their story. Assessment and review are embedded and ongoing. 

4: Service options provided 

PHNs will aim to commission and connect a broad mix and range of services to meet community needs. The goal being to address demand and provide individuals with choice and service options. 

5: Client led focus and plans 

Recovery plans and arrangements are led by the consumer, focused on their needs and goals and connect members of their care and support team including family and carers if desired. 

6: Crisis pathways 

Through regional integration, there is always a pathway available to those with high or urgent needs and access to specialist mental health services is fast-tracked. 

7: Flexible access 

Improved access is essential, and is supported by clearer referral processes, extended service hours, flexible modes of delivery, and readily available support to navigate services. 

8: Connected services and supports 

The focus is not only on the services commissioned by the PHN, but also includes informal supports, primary care, specialist supports, hospitals, NDIS, non-government, private and social supports.

9: Quality accountability 

Providers lead robust operational process, with clinical governance in place, quality management and improvement, reportable and measurable outcomes, evidence-based interventions- all of which have a meaningful and measurable impact on population health needs identified in regional needs assessments. 

10: Focus on underserviced groups 

The system is adaptive to changing local community needs and policy and service directives. PHNs focus on the populations and communities that are underserviced, at risk and who traditionally find services difficult to access.


Stepped Care diagram produced by Central and Eastern Sydney PHN, guided by the 2016 Australian Government framework, PHN Primary Mental Health Care Flexible Funding Pool Implementation Guidance: Stepped Care, available from the Department of Health website at


How South Western Sydney PHN adapted their mental healthcare needs

Following findings from the National Mental Health Commission’s mental health reforms, a renewed focus for low intensity and early intervention services has been introduced in South Western Sydney, including clinical and non-clinical services to capture a larger percentage of the population in our region. 

Low intensity services are designed to support individuals to manage day-to-day pressures and to limit potential mental health decline by supporting individuals to work towards practical goals for change whilst building resilience.

South Western Sydney PHN has adopted the stepped care model into their collaboratively designed suite of mental health programs to accommodate treatment for all levels of mental illness severity in the local community.

Our approved referrers and mental health central intake team will work with the client to determine the most appropriate service, supporting them to transition up and down as required.