Also see:
Mental Health Team
Stepped Care Approach

What is Mental Health?

“Mental Health is a state of wellbeing in which the individual realises his or her own abilities to cope with the normal stresses of life, and can work productively and fruitfully.” (Mental Health Foundation)

Many things happen to us in life that make it difficult to cope with stress. Too much stress or without the skills, networks or resources to resolve problems can cause mild to moderate mental health problems.

Very often, we find our own solutions to work through life’s challenges - getting more exercise, reducing our workload, having more fun, or spending time with friends and family. However, there are times when we need additional support to work through things.  Primary Solutions/To Be Heard Programme is a support service available to assist you when things get difficult. Click here to see the services offered under the Primary Solutions/To Be Heard Programmes.

Equally Well

Equally Well

Compass Health PHO is committed to addressing the physical health of those with serious mental health illness, in addition to managing their mental health within primary practice. It is now becoming well know there is a disparity of health outcomes for this population and we aim to improve this in our region. The board at Compass Health PHO has endorsed the Equally Well programme and is committed to improving the health outcomes for this population.

Read more about Equally Well here.

Stepped Care Approach

With the growing rates of depression, anxiety, and other mental illness, primary care plays an important role in the delivery of mental health services. A key recommendation from the Ministry of Health’s Guidance Paper on Primary Mental Health Care (December 2009) is the implementation of Stepped Care by the primary mental health sector: “Stepped care is a system of delivering and monitoring treatments so that the treatment that is most effective yet least resource intensive is delivered to service users first. In a Stepped Care Model:

  • there are interventions of different levels of intensity available to the service user
  • the service user’s needs are matched with the level of intensity of the intervention
  • there is careful monitoring of patient outcomes, allowing treatments to be ‘stepped up’ if required
  • service users usually move through less intensive interventions before receiving more intensive interventions (if necessary)
  • there are clear referral pathways between the different levels of intervention
  • supporting self care is recognised as an important aspect of managing demand”.

This diagram outlines how a Stepped Care approach would deliver services to the general population, based on the level of need. It shows at which point an intervention is delivered, by whom and for whom and also encapsulates the psychosocial factors that are common across each step as they related to promoting mental health and wellness.

To assist general practice in navigating a Stepped Care Approach for the treatment of depression within primary care, the following tool has been developed as a guide. It is based on the Evidence-Based Best Practice Guidelines for the Management of Depression in Primary Care*. This tool is also intended for use by the general public as a way to navigate through the various interventions available to promote our mental well-being. Within each step there are four quadrants that comprise the different interventions that may be applied. By clicking on these quadrants you will be directed to the relevant resources, self-help information, provider details, assessment tools, websites, or guidelines that will aide in decision-making and facilitation of the appropriate intervention.

Click here to use the Stepped Care Approach.

*The guidelines on active monitoring are based on the decision-tools for treating and managing adults. For best practice clinical information related to the management of depression in youth click here.

For best practice guidelines related to Māori mental health, click here.

For information related to promoting Pacific peoples’ overall health, click here.


Primary Solutions Wellington - Nga Pu hera Atawhai /

To Be Heard Wairarapa

Primary Solutions/To Be Heard Programmes provide a range of support services that are available to patients enrolled in Compass Health practices, who have a mild to moderate mental health issue*, and meet one of the following criteria:

Primary Solutions Wellington To Be Heard Wairarapa 
All young people aged 12 to 25 years All young people aged 10 to 24 years
Community Services Card holders aged 12 years and over Community Services Card holders aged 10 years and over
Māori 12 years and above Māori 10 years and above
Pacific Island people 12 years and above Pacific Island people 10 years and above

*A mild to moderate mental health issue may mean a variety of things. In primary care, depression and anxiety are quite common, but what is important to consider is how stress impacts a person’s functioning. The severity of your difficulties is based on what you report, what can be observed and what can be measured. Everyone experiences stress, but for some individuals it is more difficult to manage.

Primary Solutions/To Be Heard Programme are:
  • Free of charge
  • Confidential and privacy is maintained
  • Respectful of different cultural and spiritual values
  • Considerate of the differing needs across the lifespan
How can I be referred to these services?
  • By your Doctor/GP
  • Self-referral
  • Or by direct referral within those primary practices where there are primary mental health practitioners based on a weekly basis.
What happens after I am referred?

A Primary Mental Health Practitioner will contact you to assess the factors impacting on your wellbeing and to identify the supports you require. Primary Mental Health Practitioners follow a Stepped Care approach to service provision by matching the level of intervention to the level of need. Services offered by the Primary Mental Health Coordinator may include:

  • Face-to-face needs assessment and discussion that explores the different areas in your life where you might be struggling as well as focussing on your strengths, preferences and resources, occasionally this may be via telephone
  • Assessments will be held either in your primary practice or the Compass Health counselling rooms which are based in Wellington, Porirua, Kapiti and the Wairarapa
  • Information and links about support services available in your community and how to access these services, including making referrals to other agencies
  • Actively monitoring your progress should you undertake a self-management or e-therapy programme to work through your difficulties
  • Brief intervention, therapy to help you manage issues that are affecting you
  • Working with you to plan a flexible package of care to meet your individual needs, which might include:
    • Assessment and short term therapy with the mental health practitioner
    • Seeing your GP or practice nurse for followup appointments which can be funded
    • Access to external providers for those with more complex mental health issues

Mental Health Liaison Programme

What is the Mental Health Liaison Programme?

This Programme was set up to provide free health care both mental and physical for people who have experienced mental illness. It is hoped that increasing the role of GPs who work with these patients, enables the needs of the individual to be met within their community and also reduces dependence on specialist services.

The Mental Health Liaison Programme has been jointly developed by:
  • Capital and Coast Mental Health Services
  • General Practitioners in Wellington, Porirua and Kapiti
  • Compass Health
  • Wellington Mental Health Consumers Union
  • A team of people who have experienced mental illness.
Ways of being referred to the Programme:
  1. From Mental Health Services to General Practice. Either:
    • Full transfer to the GP, or Shared Care - clients retain a case manager in the Mental Health Services
  2. From General Practice - for clients who are currently looked after by their GP and have previously been diagnosed with a mental illness by a Mental Health Service.
Key features of this Programme are:
  • Removal of the cost barrier which prevents some people who use mental health services from visiting their GP.
  • Development of a personal health plan between client, their support network and the doctor.
  • A Primary Mental Health Liaison Nurse, who works in the Community Mental Health Team, can assist with Transfer and Shared Care.
What are the costs to the patient?

Provided all the following criteria are met, there are no costs with the possible exception of referral to other services:

  • Patients have been assessed by the Mental Health Service (MHS) as having an ongoing mental illness. Brief referrals to the Community Mental Health Team may be excluded.
  • Possession of a valid community services card/high user card.
  • Identified need of regular GP or practice nurse input.
  • Have seen a psychiatrist within the last six months. This criteria is flexible for individuals that are referred by their own GP under the scheme.
  • The patient must reside within the CCDHB geographical area, and be enrolled with a practice in this area – live between Wellington and Waikanae.

Eligibility for funding will be reviewed as circumstances change in terms of residence or criteria.

What is funded?

Where the financial situation of the client is a barrier to exit from MHS

  • A capitation fee may be paid to the GP on behalf of the client. In this instance each visit to the GP or nurse will be free to the client up to 12 visits per annum.
  • The Mental Health capitated payments will be made by CHWT to the GP quarterly and in advance.
  • There will be an annual audit of the funding necessity for each client.
  • The payment covers both mental and physical health visits
  • Patients are entitled to a maximum of two after hours appointments per quarter under the scheme.

Also included in the mental health liaison programme is the Primary Mental Health Community Navigation/Coordination Service

The Primary Mental Health Community navigator/ Coordinator can help you with information and support in the following social areas, which may be impacting on your mental health status:

  • Benefits: Making sure you receive the benefits you are entitled to
  • Employment: Assistance with finding training and work
  • Finance: Helping you access budgeting and financial advice
  • Health: Access to health services
  • Housing: Linking you with assistance for any housing issues
  • Recreation: Finding activities for your spare time
  • Social: Support to meet people
The mental health navigator/ coordinator does this by:
  • Networking with community groups and social service agencies
  • Being available to work with you 1:1
  • Supporting you to build networks
  • Helping you recognise your own strengths and abilities
  • Working together with you on goals you want to achieve
  • Assisting you to access other agencies
Who can ask for support and information?
  • Referrals from GPs and other health professionals
  • Social and community agencies
  • And who lives in the area from Tawa to Waikanae
The service is:
  • Free of charge
  • Confidential
  • Acknowledges and respects different cultural and spiritual values
  • Recognises the differing needs