Mental health care plans bring together a patient's concerns, treatment goals and next steps. For Australian GPs, that means making room for a sensitive conversation while documenting the assessment and meeting Better Access requirements. Questions about sessions, costs and expiry often arrive in the same consult. A clear explanation of the care pathway helps patients understand their options and helps you keep the plan, referral and follow-up aligned.

A mental health care plan is not emergency care. If someone is in immediate danger, call 000. Lifeline crisis support is available on 13 11 14, 24 hours a day.

What is a mental health care plan?

A mental health care plan is formally called a Mental Health Treatment Plan (MHTP). It is a written assessment and management plan prepared with the patient, recording their mental health needs, diagnosis or provisional diagnosis, agreed goals, treatment and follow-up.

Under Better Access, eligible patients can receive Medicare benefits for treatment from eligible mental health professionals. Three parts of the workflow have different purposes:

• The MHTP records the assessment and ongoing management of the patient's condition.
• The referral is a separate document requesting a defined course of treatment.
• The review assesses progress and whether further treatment or changes to the plan are needed.

The Better Access referral rules keep these distinct. Sending a plan alone does not create a valid allied health referral.

We support this workflow through our clinical AI platform, including MHTP and referral drafts. You remain responsible for the assessment, treatment decisions and clinical sign-off.

Who is eligible, and which GP can prepare the plan?

A patient can raise mental health concerns before they have a diagnosis. Better Access eligibility then depends on an assessment establishing a clinically diagnosed mental disorder, a need for at least a moderate level of support, and likely benefit from structured care. Distress alone does not automatically meet the patient eligibility requirements for Medicare-rebated treatment.

For GP MHTP preparation, referrals and reviews, the practitioner must be either:

• a GP or prescribed medical practitioner (PMP) at the patient's MyMedicare-registered practice; or
• the patient's usual medical practitioner, whether or not the patient is enrolled in MyMedicare.

The usual-practitioner route includes a GP or PMP who, or whose practice, provided most of the patient's care in the preceding 12 months, or is likely to provide most in the coming 12 months.

MyMedicare enrolment is not mandatory, and enrolment at one practice does not exclude a different practitioner who genuinely meets the usual-practitioner definition. The Medicare Benefits Schedule (MBS) requirements apply to all three services.

This is the usual community GP pathway. Hospital and residential aged care circumstances have separate eligibility and referral provisions. Eligible psychiatrist and paediatrician direct-referral pathways also exist, as set out in the official Better Access FAQ. These are distinct from GP MHTP preparation.

How does a patient get a mental health care plan?

When booking, a patient can tell their usual practice that they want to discuss their mental health and may need a treatment plan. A longer appointment allows room for assessment and planning. It can take more than one visit to understand the presentation and prepare the plan, as healthdirect's patient guidance explains.

Is a mental health care plan the same as a referral?

No. For Better Access allied health treatment, the referral must be separate, written, signed and dated. An electronic signature is accepted, and no particular Medicare form is required.

Include:

• the patient's name, date of birth and address;
• symptoms or diagnosis;
• current medicines;
• the number of treatment services requested; and
• whether an MHTP has been prepared.

These are the referral content requirements. The eligible treating professional must receive the referral by the first treatment consultation for the relevant Medicare benefit.

The referral can specify the profession or service type without naming an individual practitioner. A patient can change eligible allied health practitioners while using the remaining services. The MBS referral provisions preserve that choice.

Eligible clinical psychologists provide psychological therapy. Eligible registered psychologists, social workers and occupational therapists can provide focussed psychological strategies (FPS).

Appropriately trained, eligible GPs and PMPs can also provide FPS. Their treatment-provider requirements are separate from eligibility to prepare an MHTP.

Explain what information will accompany the referral and discuss sharing the full plan with the patient. A separate referral is required; routinely sending every detail of the MHTP is a different decision.

How many sessions does Medicare cover, and what does it cost?

Better Access provides Medicare benefits for up to 10 individual and 10 group treatment services per calendar year, from 1 January to 31 December, for eligible patients with a valid referral. These are maximum benefit allocations, rather than an automatic prescription for every patient.

If a patient uses six individual services, up to four remain in that calendar year. The initial course may be shorter than six.

Up to two eligible family or carer participation services can count towards the patient's individual allocation; they are not extra sessions outside that cap. The calendar-year claiming limits apply across eligible providers.

A plan does not guarantee free treatment. The GP and treating mental health professional set their fees and billing arrangements.

Bulk billing means accepting the Medicare benefit as full payment for that service; otherwise the patient may pay a gap between the fee and benefit. There is no single national gap price, as the Better Access fee guidance explains.

Practices can make this clearer by explaining appointment fees and Medicare benefits before the visit. Reaching the Better Access cap does not end a patient's need for care. Further management may involve other suitable services or privately funded treatment.

Does the plan expire, and when is a review needed?

An MHTP does not expire at the end of the year or when the referral's services have been used. It is a living document.

A new plan is not routinely needed for a new calendar year or referral. It should be clinically required and generally not prepared within 12 months, unless exceptional circumstances exist, such as significant clinical change or inability to obtain the existing plan. The plan continuity requirements distinguish updating an existing plan from creating another one.

Referral validity is different. Unused services on a referral can carry into the next calendar year, but services delivered then count towards that year's cap. For example, two unused services used in January count towards the new year's individual allocation, even though the referral was written the previous year.

After the initial individual course, review the patient before referring for another course. Bring together the treating professional's report, the patient's experience and your reassessment. Explain the review and record agreement, then:

• assess progress against the agreed goals;
• reinforce or expand relevant education;
• repeat the outcome measure used at assessment, unless clinically inappropriate;
• address crisis or relapse planning where appropriate; and
• amend the plan if needed, offer the updated copy to the patient and appropriate carer, and save it in the medical record.

The MBS review requirements also recommend review at least annually. Unless exceptional circumstances exist, an MHTP-specific review should not occur more than once in three months or within four weeks of preparation. Most patients generally need no more than two such reviews per calendar year.

Those routine review limits do not mean a patient should wait for care when their condition worsens. Arrange clinical follow-up according to need and distinguish that ongoing care from the MHTP review service.

How GPs assess, document and prepare the plan

For you as the GP, the work starts with assessment and agreement. The document follows those decisions.

Explain the service and assess the patient

Before preparing the MHTP, explain the service and its steps, and record the patient's agreement to proceed. Involve a carer where appropriate and with the patient's permission.

A clinical assessment includes the presenting concerns, relevant biological, psychological and social history, current and previous medicines, mental state examination, coexisting conditions and risk. The General Practice Mental Health Standards Collaboration (GPMHSC) assessment guidance includes the severity of distress and thoughts of suicide, self-harm or harm to others. These clinical assessment principles sit alongside the MBS service conditions.

Record your formulation, including a provisional or formal diagnosis. Preserve diagnostic uncertainty where it exists; a completed questionnaire does not establish a diagnosis by itself.

Use an appropriate outcome measure

Use an evidence-based outcome measurement tool unless it is clinically inappropriate. The Kessler Psychological Distress Scale (K10) and Depression, Anxiety and Stress Scales (DASS-21) are examples, rather than compulsory instruments. The choice remains yours under the official template requirements.

Record the instrument, result and relevant clinical interpretation so progress can be assessed at review. An outcome score does not replace a risk assessment, and the MBS does not prescribe a universal numerical suicide-risk score.

Agree goals, treatment and follow-up

Discuss treatment and referral options, appropriate support services and relevant education about the condition. Agree what the patient wants treatment to achieve and what actions they will take. Include a crisis-intervention and/or relapse-prevention plan and arrange treatment, referrals, review and follow-up.

These are MHTP preparation requirements.

Make goals specific enough to revisit. For example, a patient whose anxiety is affecting work might prioritise managing anxiety during meetings and returning to activities they have been avoiding. Record their priorities, agreed actions and how progress will be discussed.

Record the assessment and management decisions in writing. Offer the patient a copy of the completed plan, offer a carer a copy where relevant and appropriate, and add the plan to the medical record.

No particular MHTP template is mandated. Our mental health plan template provides a documentation example; its example content is not a treatment recommendation or a substitute for the current service requirements.

Which MBS items apply to GP preparation and review?

The Better Access changes that took effect on 1 November 2025 retained GP preparation items and removed the dedicated GP review and ongoing mental health consultation items. Reviews, referrals and ongoing management now use appropriate time-tiered general attendance items.

Item 2712 is no longer the GP MHTP review item. The MBS change factsheet sets out the changes.

Accredited mental health skills training is strongly recommended, but it is not a prerequisite for a GP to prepare a plan. Training status determines the preparation item family:

PMPs have separate item numbers. The MBS preparation item families distinguish both practitioner type and training status. Duration alone does not establish that a service meets an item descriptor, and a drafted document does not establish claiming eligibility.

Video preparation also needs to meet the applicable telehealth relationship requirements. The patient's MyMedicare practice is one route; otherwise the established face-to-face relationship rule applies, subject to its listed exemptions. Meeting the usual-practitioner definition alone does not remove that separate telehealth requirement.

How we support MHTP drafting and write-back

Your clinical judgement gives the plan its substance. Lyrebird can organise the consult content into an MHTP draft and draft a separate referral, leaving you to review, edit and sign off each document.

Through our Bp Premier integration, patient context can inform the draft. You can invite patients to complete DASS-21 before the consult, with their responses populating a structured plan.

You can also complete DASS-21 during the consult with the patient on your computer. The results are calculated and written back to the Notepad and Bp Premier patient file.

You choose whether that instrument is clinically appropriate. Scores from other tools or external forms need to be accurately documented; they should not be assumed to have been automatically imported.

Before filing, reconcile the draft with the assessment and agreed decisions. Pay particular attention to diagnosis, medicines, risk findings, the patient's own goals, referral service count and follow-up. Remove unsupported findings and correct omissions or contradictions.

Template customisation can adjust headings, section instructions, order, format, length and tone; use de-identified examples when uploading documents. Customisation does not establish clinical validity.

After reviewing and approving the documents, select Save to Bp. Care-plan documents save to Correspondence Out, and Bp Premier remains the medical record of truth. This is a clinician-confirmed save, rather than automatic MHTP write-back into structured fields.

Keep consent and confidentiality part of the workflow

Explain the intended AI-scribe use and the practice's information-handling process before capture, and obtain and record the consent required for that workflow. The Therapeutic Goods Administration (TGA) digital-scribe guidance places responsibility for informed consent and record accuracy with the clinician. Patients can withdraw consent and ask for another recording method.

A consent setting or timestamp does not replace that conversation. You can pause or stop recording, and you may decide an AI scribe is inappropriate for a sensitive consult. Our patient consent guidance addresses the distinction between workflow controls and a meaningful consent process.

Our Privacy Policy sets out data handling. Australian server location alone does not determine whether Australian Privacy Principle 8 applies: the Office of the Australian Information Commissioner (OAIC) cross-border guidance concerns disclosure to overseas recipients, with scope and exceptions that depend on the circumstances.

For a GP workflow that keeps assessment, separate referrals and clinician review connected, talk with us about MHTP drafting in your practice.

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