Partnership strengthens diabetes care for people with mental health needs
03 Nov 2025
The partnership, which piloted a mental health–type 2 diabetes case conferencing model, was showcased at the Diabetes Tech n Talk Conference held at the Macarthur Clinical School on 25 October. The event brought together around 60 GPs, diabetes specialists, and academics to discuss innovation and integration in diabetes care, self-management, and prevention.
SWSPHN’s Integration and Priority Populations Coordinator, Alyssa Horgan, and SWSLHD’s Mental Health Service Physical Health Coordinator, Isabella Sierra, presented the project, which addresses the high rates of physical health conditions—such as cardiovascular disease, respiratory illness, and diabetes—among people living with severe mental illness.
“Cognitive challenges and barriers to accessing regular care mean that people with severe mental illness can have a life expectancy shortened by up to 23 years,” Ms Horgan said.
Improving diabetes care for people with co-existing mental health conditions is a key focus in the South Western Sydney Diabetes Framework to 2026.
The Pilot Model
Initially, the model involved gaining consent from inpatients at Mental Health Units (MHUs) to participate in case conferencing with a ‘keystone’ GP, an endocrinologist, and a mental health coordinator acting as a care navigator. The pilot improved communication between medical officers across MHUs and endocrinology services and was well received by inpatient clinicians.
However, challenges such as inconsistent eligibility criteria and limited documentation in discharge summaries prompted refinements. The updated model now includes:
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Revised eligibility criteria
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Greater involvement of diabetes educators
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New referral pathways allowing community mental health services to initiate referrals
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Flexibility for patients to see their own GP or a keystone GP
Expected Outcomes
The refined model aims to deliver:
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Better coordinated, person-centred care
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Stronger collaboration between GPs and specialists
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Improved health outcomes for patients with complex needs
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Enhanced GP knowledge and confidence in managing diabetes
Other presentations at the conference included keynote speaker Professor Anthony Russell, co-creator of Diabetes Beacon Practices; Dr Dong Hua, who discussed improving diabetes care in general practice; and Rachel Hicks, who presented on NetHealth and the future of remote monitoring for gestational diabetes care.
For more information, visit the SWSPHN Diabetes – What We Do page.
Source: South Western Sydney Primary Health Network (SWSPHN)
