Transition To Recovery

The Transition to Recovery program (TRec) is an intensive community outreach mental health program that aims to assist people to transition to the community following an acute episode of mental illness and to prevent relapse.

The program works with people to maximise their potential for recovery and independence following discharge from hospital or who require additional support in the community to manage sub-acute symptoms to prevent hospitalisation.

recovery-resizedPeople are eligible and can voluntarily access the program if they:

  • Live in the area currently serviced by Mental Health Justice Health and Alcohol & Drug Service
  • Have an existing functional limitation due to a mental health issue
  • Are clinically managed by Community Mental Health Teams
  • Are aged between 18 – 64 years and have no significant age related issues
  • Would benefit from additional clinical management and psychosocial support in a community setting.

The program runs for 12 weeks offering intensive outreach support, including evenings and weekends.

Referrals to the program are made by a Clinical Manager in one of ACT Health's Mental Health Teams:

  • City, Belconnen, Tuggeranong or Woden Mental Health Teams
  • Early Intervention Team
  • Adult Mental Health Unit
  • Calvary 2N
  • Forensic Mental Health Unit.

Download: Information for Clinical Managers

Participants

If you are currently in the Adult Mental Health Unit at Canberra Hospital or 2N at Calvary Hospital, TRec may be able to assist you. Alternatively if you have a Clinical Manager and are at home but feel you need additional support to prevent hospitalisation we are also able to assist you through the program.

The program can:

  • Provide outreach for up to seven days a week in your community. This will include visits and access to phone support until 9.00pm
  • Link you with services and provide social support and assistance to attend medical appointments and community based programs
  • Talk through any concerns you may have about managing mental health symptoms and your day to day living needs
  • Provide psychosocial education to support you to manage mental health symptoms so that you can do the things you enjoy.

If you have a Clinical Manager and are at home but feel you need additional support to prevent a hospital admission, we can provide all of the above.

Download: Information for Participants

Carers

Carers are often the first people to recognise early warning signs of a mental health episode of those close to them. TRec works best when a person recognises and seeks assistance as early as possible.

If you are concerned about a family member please talk to TRec about options for early intervention.

Download: Information for Carers

This Program is an ACT Government funded initiative.

ANU Evaluation of the Transition to Recovery Program – TRec

WCS implemented the Transition to Recovery Program (TRec) in 2011 after identifying a clear need and gap in local service provision for people leaving hospital following a period of psychiatric care.

WCS met with the ANU Centre for Mental Health Research (CMHR), now the National Institute for Mental Health Research in November 2011 to commission an evaluation to examine the effectiveness and acceptability of the program and to ensure the suitability of the model of care for this client group.

Professor Kathy Griffiths designed and supervised the evaluation as CHMR Director and the Final Report was completed on the 21st May 2015.

The data and findings found that the program was acceptable to consumers and consistent with recovery oriented principles.

Key findings attributed to TRec’s 12 week intensive outreach intervention

  • Most participants reported that the program was highly acceptable to them and would recommend the service to others.
  • Participants reported that they felt emotionally supported, accepted and understood.
  • Lower psychological distress and higher functioning in life skills was reported by participants.
  • The program showed reduced relapse and (re-) admission to hospital and overall reduction in the use of emergency services.
  • There were high levels of participant satisfaction with the service in the following areas:
    • Providing the right kind of support when needed – 7 days a week, face to face and phone support, practical help and assistance with daily tasks;
    • Providing assistance that reduced isolation and increased access to community resources and support;
    • Providing support and information that assisted people to feel more confident in self-managing their mental health.
  • Mental Health staff reported a high level of satisfaction with the service particularly around the high intensity and flexible support available to those in the program.
  • The Recovery Self-Assessment Scale (RSA) questionnaire identified Trec a service that provides individualised, optimistic and person centred support.

All recommendations identified in the evaluation to improve the service have been implemented. They include:

  • Extending timeframes in the program if needed - the service now has capacity to extend beyond 12 weeks for participants who need extra support.
  • Increasing resources to the program to expand reach - additional capacity in the program (from 15 to 35 participants) has now been supported by ACT Health.
  • Building on the collaboration between clinical services - an identified Referral and Liaison staff positon has been established and there are now weekly liaison meetings with all referring clinical teams.
  • Addressing additional support needs for participants in their relationships with friends and family – TRec revised policies and practice to ensure that the needs of participants to connect with family is a focus for Key Workers.

We hope you enjoy reading the detailed evaluation report.

Click to Download Report

Want to know more?

For more information, please contact the TRec Manager on (02) 6221 9511 or email This email address is being protected from spambots. You need JavaScript enabled to view it.

Acknowledgement of Country

"Woden Community Service acknowledges the Ngunnawal people as the traditional owners of this land and their continuing connection to land and community. We also acknowledge Aboriginal and Torres Strait Islander peoples who have come from other nations to live on Ngunnawal land. We pay our respects to their cultures, ancestors and elders past, present and future."