This project is evaluating the feasibility of an online shared care plan supporting communication between GPs, specialist services, consumers, carers and other care team members  for clozapine treatment,  preventive care and behavioural change in the long-term shared management of people with a lived experience of severe mental illness. The care plan sets out the tasks required, when they need to be completed and who is  responsible. This intervention is being implemented with the My GP & Me shared care program currently running in the SESLHD, Eastern Suburbs Mental Health Service.

The project is one of 4 clinical pathways projects funded by Mindgardens Neuroscience Network.

Chief investigators

Mark Harris, Ben Harris-Roxas Catherine Spooner, Jane Taggart


SESLHD: Mike Gatsi, Patrick Bolton, CESPHN: Mariam Faraj, Mindgardens: Jackie Curtis, Drug & Alcohol: Nicholas Lintzeris

Project Rationale

Mental health and drug and alcohol services are often fragmented, have multiple service providers and are difficult to negotiate access. Services are spread across primary care settings (e.g. GPs, Allied Health in the community), private specialists in the community, specialist services in the, and increasingly a range of online and telephone support services. Patients have different types and severity of mental health and substance use problems, and it can be extremely difficult for patients, carers and service providers to find the ‘right’ service.

There are around 217 consumers attending the clozapine service at the Euroa Centre, POWH and the demand for clozapine therapy is increasing. The current model of care is restrictive and intensive and the workflow at the Centre is congested. There is a move for a more holistic model of shared care with GPs. GPs are able to prescribe Clozapine if they are registered with a Clozapine Provider and have a key role in the prevention and management of physical health conditions.

Research with other long-term conditions suggests that effective sharing of care requires an interactive information  system allowing team members to confirm acceptance of their roles, notify when tasks are due, track that tasks are completed and share information and results. Online shared-care systems can improve appropriate health service use and reduce hospitalisations and have been demonstrated as feasible for conditions such as cancer and diabetes. Their adaptation to shared care of people with a lived experience of mental illness has not yet been demonstrated.

Project Aim/s

  1. To develop a web based shared care plan that links GPs with specialist services (mental health and drug and alcohol) in the long-term management of people with a lived experience of severe mental illness.
  2. To implement this for consumers on clozapine therapy where there is agreement for this to occur (by patient, GP, mental health services).
  3. To evaluate the feasibility, acceptability and experience of patients with clozapine shared care using an e-care plan.

Project Design and Method

This is a qualitative feasibility study that will recruit up to 20 consumers, their usual GP, their Mental Health care providers and other agreed members of the care team.

The intervention is a model of shared care that uses an e-care plan for sharing the tasks and responsibilities and for communicating results and monitoring care between the Mental Health Service, GPs, other care team members and the consumer. The e-care plan is integrated with general practice clinical information systems.


Mark Harris Email:


Mindgardens Neuroscience Network

Project lead centre


Project stream

Prevention and Management of Long Term Conditions | Informatics and eHealth