Many partnerships within the MindMatters Plus GP initiative begun by mapping the local services available to support young people. This is a more complex task than it appears as the list of potentially relevant services is large and diverse, and there must also be a supportive environment for the referrals within the school.

Referral pathways - A referral pathway is a series of steps, including clinical interventions, to be taken by schools and local health providers in response to young people with high mental health support needs. A referral pathway is a process as much as a product or tool. Ideally it is developed via a comprehensive and inclusive approach between the school and relevant health agencies to establish relationships and a shared understanding and agreed ways of working together to better address the mental health needs of young people. Resource 14: Key elements of a referral pathway  shows some of the key elements required for effective referral pathways.

Young people with high support needs may require the support of a number of different services and sectors. This may involve referral to specialists and the establishment of multidisciplinary teams.⁴  It is essential to identify all these different services and sectors and to ensure that there is a consistent and co-ordinated response that has at its centre the young person and his/her needs.

Some of the services that may be involved in provision of care to young people are listed in Resource 15: Mapping local services that support young people . For each of these types of services, it is useful to determine whether they are available locally (and if not how are these types of services delivered in the community), the name of the service, contact details, and also the referral processes they use. [Note that undertaking this mapping process can also help establish where the service gaps are within your community].

It is especially important to be able to clearly determine the target groups of each of these services and their referral processes. Most services have specific entry criteria and access processes. Understanding these boundaries and processes is essential to being able to access the appropriate services quickly and effectively.

Roles and responsibilities

A clear understanding of the roles and responsibilities of all the parties involved in providing care to a young person with high mental health needs must be established. The roles and responsibilities of different service providers will vary depending on the needs of the student, the types of resources available in the community, and the types of supports and services that the student needs to access.

GPs are in a unique position within the primary health care system to coordinate the multidisciplinary care that a young person with high needs may require. The school will also be integrally involved with ongoing care and support, and the roles of the staff within the school need to be determined in terms of their responsibilities within the multidisciplinary team.

There may also be other service providers involved. There are several ways that the GP can be involved with high support need students.

These can include:

• providing shared care in collaboration with allied health professionals, youth services and specialists
• formulating care plans and case conferencing under Medicare CDM item numbers to facilitate collaborative care
• facilitating referral to other services
• acting as a point of contact and advocate for the young person and their family in dealing with the health system
• providing case management by coordinating the input of other professionals and facilitating the young person's access to health services
• ensuring that a young person receives optimal care.

The GP's role must be clearly expressed and clarified, when necessary, as changes occur. A review process is required to update on a regular basis.

The roles of school staff, in particular school counsellors, welfare staff and classroom teachers are considered on page 24.