Mobilising community-managed organisations: A call to action to confront physical health inequities in people living with complex mental health challenges

Abstract

Australia is failing people with complex mental health challenges, who experience poorer physical health and a reduced life expectancy of 15–20 years. This inequity is driven largely by preventable physical illnesses, many linked to lifestyle-related behaviours including physical inactivity, poor nutrition, smoking and sleep disturbance. Evidence shows integrated physical health and lifestyle interventions are feasible and effective. Yet translation into routine care remains fragmented, with most initiatives failing to scale beyond pilots. As a cornerstone of Australia’s mental health system, community-managed organisations (CMOs) are central providers of recovery-oriented and peer-led psychosocial care to adults with complex mental health challenges. This uniquely positions CMOs to tackle such physical health inequities, yet they are under-resourced and underfunded, and their capability remains insufficiently recognised within national health policy frameworks. This Perspective presents a case for harnessing the capacity and capability of CMOs as a pathway for system reform, enabling better access to interventions that improve health outcomes and minimise health disparities. We outline opportunities for structured models of intervention, integrated care pathways, workforce development and policy and research priorities – all critical levers to enable sustainable, equitable physical health outcomes. It is time to elevate CMOs within mainstream health policy and strategically invest in their capacity to lead a systemic response to the physical health inequities of people living with mental health challenges.

Keywords

Community-managed organisations physical health mental health services complex mental health services call to action integrated care

Introduction

The Lancet Psychiatry Commission on Physical Health highlighted a stark 15- to 20-year life expectancy gap among people living with severe mental illness, here described as ‘complex mental health challenges’ (Teasdale et al., 2025). This disparity is driven largely by preventable cardiometabolic disease, respiratory illness and cancer (De Hert et al., 2011). Evidence-based preventive interventions – including physical activity, nutrition, sleep, smoking cessation and metabolic screening – are essential but remain inconsistently integrated into routine mental health care, limiting population-level impact (Teasdale et al., 2025). Beyond the moral and clinical imperative, there is also a compelling economic case, with every dollar invested in preventive health saving an estimated $14.30 in healthcare and other costs (Australian Government Department of Health, 2023a).

In Australia, successful examples of integrated lifestyle initiatives have been implemented within state-funded mental health settings. These include the Keeping the Body in Mind programme in South East Sydney Local Health District, NSW (Curtis et al., 2024), and the Move Your Mind Exercise Physiology service at Fremantle Hospital, WA (Furzer et al., 2021), which demonstrate that embedding lifestyle interventions into routine practice is possible and can improve health outcomes. Despite their success, such initiatives remain few and limited in scale and depend on engagement with clinical services, thereby restricting access to individuals who are already actively engaged with mental health services. In contrast to the public sector, far less efforts have been directed to community-managed organisations (CMOs).

CMOs, known internationally as community mental health, third-sector, voluntary or non-government organisations, have long been central to deinstitutionalisation and mental health reform, often driven by consumer leadership and advocacy. Although their size, structure and workforce composition vary internationally, CMOs typically emphasise strengths-based, recovery-oriented, trauma-informed and peer-informed approaches, often with a mix of clinically trained staff and peer workers. As illustrated in Figure 1, CMOs sit at the intersection of community and hospital-based services, providing psychosocial support, housing and community connection for people living with complex mental health challenges.

Figure 1.

Australian mental health service overview.

This unique positioning enables CMOs to bridge gaps in fragmented health systems and support people who may not otherwise access clinical care (Whiteford and Buckingham, 2005). As the National Mental Health Workforce Strategy (2022–2032) (Australian Government Department of Health, 2023b) emphasises:

The CMO workforce is central to the provision of psychosocial supports, playing a critical role in prevention, early intervention and recovery-focused care. The shift from institutional care to community-based models has been underpinned by the growth of CMOs, who continue to support people to live independently, reduce reliance on hospital care, and deliver cost-effective services (p. 46).

Despite their central role in psychosocial support, CMOs continue to face substantial gaps in physical health capability and workforce capacity. Addressing these gaps is an urgent priority for policy reform, targeted training and sustainable funding to enable equitable, integrated care for people living with mental illness.

This Perspective challenges policymakers and health system leaders to recognise the critical role of CMOs in improving the physical health of people with complex mental health challenges. CMOs are uniquely positioned to lead this transformation, but their potential will remain unrealised without targeted investment, updated national practice frameworks and formal recognition within policy and planning processes.

CMOs: a missing link in physical health care

CMOs remain a missing link in improving the physical health needs of people living with complex mental health challenges despite some progress. Their role in mental health reform, and their history of consumer leadership and advocacy, positions CMOs to extend this leadership into physical health. Systematic mapping identified 29 studies of CMO interventions across Australia, the United States and Europe, suggesting potential improvements in health outcomes and implementation; however, most studies were of low methodological quality, highlighting the need for more rigorous evaluation (Bartlem et al., 2020). Importantly, this mapping revealed that the contribution of CMOs to this shared agenda is often overlooked, resulting in a workforce with considerable but under-recognised potential to enhance physical health outcomes for people living with mental illness.

In the following paragraphs, we highlight six strengths of CMOs, supporting their role in physical health care. These strengths form a foundation for targeted investment and capacity-building.

First, CMOs prioritise person-centred practice, promoting choice, agency and empowerment. These principles are central to behaviour change and motivational theory and help individuals engage meaningfully and sustainably in health-promoting behaviours such as physical activity (Vancampfort et al., 2015). Second, CMOs recognise that social connection is central to mental health recovery (Holt-Lunstad, 2024). Lifestyle-focused group programmes, like cooking groups or exercise classes, create safe and supportive environments that reduce isolation, foster belonging and build functional capacity and independence (Ahn et al., 2024). Third, CMOs operate across both clinical and non-clinical settings, serving as vital connectors within the health system. They work alongside general practitioners (GPs) and other professionals through structured referral pathways, wellbeing checks and lifestyle support to promote early detection, continuity of care and recovery-oriented outcomes. Fourth, their recovery-oriented, strengths-based and trauma-informed approaches create psychologically safe, person-led environments consistent with the Australian Commission on Safety and Quality in Health Care’s National Safety and Quality Mental Health Standards for Community Managed Organisations (Australian Commission on Safety Quality in Health Care, 2022). Extending these principles to lifestyle behaviour change enhances accessibility and engagement, particularly for people with trauma histories (Darroch et al., 2020; Mauritz et al., 2013; Substance Abuse Mental Health Services Administration, 2014). Fifth, CMOs have a workforce ready to act. When trained and resourced, staff can successfully embed preventive health strategies and identify unmet needs (Jones et al., 2016). CMOs represent around one-quarter of the NSW mental health workforce, with 19% of staff identifying as having lived experience and peer workers comprising 12.3% (Ridoutt et al., 2023). This lived experience fosters trust, reduces stigma and can model healthy behaviours (Stubbs et al., 2016). Finally, CMOs meet people where they are at. They provide accessible and non-confronting, and often non-clinical, entry points to care while sustaining long-term, trusted relationships with those they support. Because consumers often engage in residential, vocational and day programmes or through outreach, CMOs can embed health-promoting practices (such as smoke-free environments, healthy food choices and structured daily activity) directly into everyday routines. This creates consistent opportunities to raise and address health concerns in familiar, supportive settings. Their accessibility, recovery-oriented ethos and community reach mean people with a psychotic illness are more likely to use CMO programmes (22.4%) than government services (14.5%) (Morgan et al., 2012), extending support to the approximately 493,600 Australians with moderate-to-severe mental illness currently without psychosocial care (Health Policy Analysis, 2024).

The path is paved, so why no action?

National frameworks, such as Australia’s Being Equally Well Roadmap (Calder et al., 2022), position CMOs as critical partners in preventive and lifestyle care, calling for shared-care, removal of financial barriers to essential medications (e.g. metformin, nicotine replacement therapy), dedicated research investment and workforce training. Consistent with this, CMOs have piloted integrated approaches, such as embedding oral health promotion and chronic disease management within routine support, that improve service uptake and staff confidence, with success linked to partnerships with healthcare providers, co-production, peer involvement and tailored interventions (Bartlem et al., 2020). Recent evidence further highlights that CMOs play a vital and under-recognised role in supporting the physical health of people living with complex mental health challenges, often addressing health risk behaviours such as smoking, poor nutrition, alcohol use, physical inactivity and poor sleep (Dray et al., 2022). However, the provision of such care remains inconsistent and not routinely delivered across all risk factors, underscoring the need for structured models of care and implementation strategies to support behaviour change in these settings (Love et al., 2025). Qualitative research in Australian CMOs shows that, although consumers and staff value nutrition and physical activity programmes and other health behaviour supports, access and delivery are constrained by funding, organisational policies, staff capacity, consumer circumstances and the degree of collaboration with external health services (Dray et al., 2022; Mucheru et al., 2020). The consistency and quality of care are further shaped by organisational culture, staff training, funding and external partnerships (Dray et al., 2022).

Specific CMO-led initiatives, including structured exercise programmes, nutrition interventions, smoking cessation support and health cheques, demonstrate promise. For example, the ‘Healthy Bodies, Healthy Minds’ programme, developed and implemented across NGOs and Health and Hospital Services, engaged over 600 participants (Kugelman et al., 2025). This initiative demonstrated measurable benefits for quality of life, motivation and recovery among people with mental health challenges (Seymour et al., 2022; Whybird et al., 2022). Taken together, the evidence suggests CMOs should be resourced to deliver flexible, co-designed interventions, supported by sustainable funding, staff training and infrastructure, while also linking with broader health and social systems to address barriers beyond CMOs’ direct control.

National guidelines broadly support such approaches in community settings, but they do not explicitly acknowledge the distinct role of CMOs. As a result, these organisations are often overlooked within reactive mental health funding cycles. Consequently, CMO-led efforts remain fragmented, small in scale and at risk of staying peripheral rather than becoming a systemic solution.

The problem of an undefined role

While national standards for CMOs exist (Australian Commission on Safety Quality in Health Care, 2022), their articulation of physical health responsibilities is unclear. These standards reference promoting health and wellbeing, minimising harm through risk screening and medication safety, which can reasonably be interpreted to include chronic disease prevention and management of cardiometabolic side effects of antipsychotic medications. However, they stop short of clearly defining the role of CMOs in preventing and managing physical health, including through structured lifestyle interventions. This challenge is compounded by the fragmentation of the Australian CMO sector, which operates across funding structures and policy contexts, and by the finding that no single body is able to mandate or enforce consistent standards of care. Greater clarity is needed to ensure CMOs are supported to play a defined role in addressing physical health inequities.

State-based guidelines in NSW (NSW Health, 2021) and Queensland (Queensland Health, 2022) provide strong frameworks for public mental health services, emphasising metabolic monitoring, lifestyle interventions and integrated care planning with CMOs. However, these recommendations do not consistently extend to the CMO sector despite CMOs often being the long-term point of contact and support outside tertiary care. Consequently, expectations and implementation are likely to vary considerably between services and jurisdictions. CMOs frequently initiate and deliver beneficial programmes in the absence of equivalent minimum standards, investment and resources. However, these programmes too often remain unfunded, short-lived, unevaluated and unsustained. Sustainability is further undermined by the lack of dedicated commissioning streams, workforce training and outcome monitoring, increasing the risk that effective initiatives fade without systemic support. Addressing this will require greater consistency and collaboration across federal, state/territory governments and peak bodies.

Responding to this need is essential, as CMOs are often the first to identify and respond to physical health issues such as poorly managed diabetes, obesity or uncontrolled hypertension. Yet without appropriate training, clear referral pathways or integration with primary care and health services, these critical opportunities can be missed, compromising care. In contrast, CMO workers are already trained and mandated to act when a consumer’s mental health deteriorates, including referral to crisis services or hospitalisation. Physical health must be addressed with the same urgency and structure. Staff encountering physical health crises, such as uncontrolled diabetes, obesity or hypertension, need training and clear escalation protocols, along with tools for referral, monitoring and interagency communication.

What exactly should CMOs be resourced and supported to do?

To realise this potential, CMOs need clarity on which interventions they should deliver, and at what level of intensity. The Sax Institute review (Bartlem et al., 2020) highlighted that CMOs should be resourced to deliver multi-strategy lifestyle interventions addressing physical activity, nutrition, smoking and other risks. Co-design, tailoring and peer support worker involvement were key features of effective programmes. CMOs also need sustainable supports to embed routine screening, referral pathways and integration with primary and specialist care, as these mechanisms are consistently linked to positive outcomes. Importantly, implementation success depended on dedicated staff training, practice change support and adequate infrastructure. This evidence suggests CMOs should be funded and supported not only to deliver flexible, consumer-centred health programmes but also to act as connectors and navigators across health and social care systems, reducing barriers and enabling holistic support for people living with complex mental health challenges.

A useful framework to guide this thinking is the Inter-Agency Standing Committee (IASC) mental health and psychosocial support (MHPSS) pyramid (Rosenbaum et al., 2025), which describes interventions across layered levels of support, from broad, community-based approaches to more specialised care. Although originally developed in the context of humanitarian displacement, the logic of tiered supports is readily transferable to the Australian CMO sector. CMOs already occupy a central place in psychosocial care, and this layered model can help define the scope of their contribution to physical health. The tiered approach presented in Table 1 draws on this framework and aligns closely with emerging stepped-care models proposed for preventive physical healthcare in mental health settings (Mareya et al., 2025). In stepped care, the intensity and expertise of support are matched to an individual’s needs, risks and complexity. Table 1 adapts and integrates these complementary frameworks to illustrate how CMOs may contribute across different levels of physical healthcare support.

Table 1.

Tiered model for CMO-delivered physical health interventions.

Tier	Definition	Examples	Implementation requirements
Tier 1: Universal health-promoting environments	Creating supportive settings that make healthy choices easier and embed physical health into everyday CMO practice.	• Provision of healthy food options in supported accommodation and other support settings • Smoke-free policies and proactive smoking-cessation support • Embedding physical activity into daily programmes (e.g., structured walks, group exercise)	Staff training and resource provision Practice change in personnel Assessment of barriers to implementation Strategic operational support
Tier 2: Health coaching and behaviour change	Equipping CMO staff with skills and tools to support individual behaviour change around lifestyle risk factors.	• Training staff in motivational interviewing, brief interventions and health coaching for physical activity, nutrition and smoking cessation • Practical tools such as pedometer challenges, cooking groups or nicotine-replacement starter kits	Underpinned within a trauma-informed approach Programme and resource co-production with consumers and staff Referral pathways to healthcare providers Tailored evidence-based interventions Staff training in behaviour change strategies
Tier 3: Integrated allied health roles	Embedding specialised allied health expertise within CMO services to deliver targeted interventions and enhance continuity of care.	• Placement of AEPs, APDs and other allied health professionals within CMO teams • Co-location models where CMO psychosocial staff work alongside health professionals	Implementation strategies including training, practice support and resources Clear role delineation and responsibilities Information technology infrastructure Clinical supervision arrangements and frameworks

CMO, community-managed organisation; GP, general practitioner; AEP, Accredited Exercise Physiologist; APD, Accredited Practising Dietitian.

Such a framework can provide consistency and clarity across the sector, while still allowing CMOs to adapt interventions to the cultural and local needs of their communities. Critically, it echoes the stepped-care principles that CMOs already apply in mental health programmes, adjusting the type and intensity of supports as needed, and extends them into the domain of physical health promotion and disease prevention. Targeted funding, strategic support and training in physical health–related interventions will further enable the peer workforce to support physical health by drawing on lived experience to foster trust and encourage engagement in preventive cheques and healthy lifestyle changes. While the peer workforce and other staff can play an important role in providing support, encouraging engagement and referral, more intensive behaviour-change interventions may require additional training and clearly defined scope.

Building workforce capacity

Strengthening CMO capacity to protect and promote physical health requires targeted, practical strategies that can be scaled nationally. The Sax Institute review found that effective initiatives were those supported by multi-component implementation strategies, including staff training, practice change to support personnel, provider resources and audit–feedback systems, rather than single strategies alone (Bartlem et al., 2020). Importantly, these supports were most effective when combined with co-production, a strong peer workforce and tailoring interventions to the needs of people with complex mental health challenges.

Six key opportunities to support capacity-building for physical healthcare within CMOs are described below:

Training psychosocial and peer support workers in health coaching – equipping the workforce with skills in physical activity, nutrition and smoking cessation to integrate physical health into everyday support, while recognising when more intensive behaviour change support or referral to appropriately qualified internal or external providers (e.g. counsellors, psychologists or specialist smoking cessation services) is required.

Including lifestyle experts within models of care – embedding allied health professionals with expertise in lifestyle interventions, such as Accredited Exercise Physiologists (Lederman et al., 2026) and Accredited Practising Dietitians (Teasdale et al., 2018), within CMO teams to deliver in-house evidence-based services and support staff managing more complex needs.

Embedding shared-care protocols – providing clear guidance on when and how to escalate physical health concerns, or refer when needs exceed staff training or scope, aligned with existing mental health–escalation pathways, anchored in supported decision-making.

Establishing supervision and co-design structures – where necessary, linking CMO staff to clinical expertise (e.g. Accredited Exercise Physiologists, Accredited Practising Dietitians, Registered Nurses) for ongoing guidance, while involving consumers in co-design to ensure training is acceptable, relevant, trauma-informed and culturally safe.

Identifying physical health staff champions – supporting motivated staff to lead by example, promote physical health initiatives and encourage uptake of new approaches within teams.

Creating dedicated physical health leadership roles – ensuring CMOs have recognised positions that drive policy, training, a positive culture and integration of physical health across programmes.

Crucially, these opportunities must be underpinned by dedicated, sustained investment, as CMOs cannot be expected to carry this responsibility alone. Funding mechanisms, particularly those from the Commonwealth, National Disability Insurance Agency (NDIA), Primary Health Networks (PHNs) and state governments, should explicitly support workforce development focused on physical health within the CMO mental health sector.

Research and policy priorities

For CMOs to fulfil this role, research must move beyond efficacy trials in clinical services to evaluating pragmatic, real-world and CMO-led interventions, at scale. Evidence calls for systematic, theory-based assessment of barriers and enablers before new models are implemented, advocating frameworks such as the Consolidated Framework for Implementation Research to tailor rollout to each organisational context (Damschroder et al., 2022). Given the limited evidence base for what works within CMOs, there is also a need for hybrid effectiveness-implementation studies that concurrently examine consumer health outcomes, implementation processes and feasibility of scale-up. Priority areas include co-design with people with lived experience, their advocates and allies and communities to ensure interventions reflect lived experience, cultural priorities and local contexts; implementation studies of CMO-delivered health coaching and referral pathways (Love et al., 2025); economic evaluations of integrated CMO-health service models to inform sustainable funding and longitudinal research examining consumer outcomes when CMOs embed physical health into routine psychosocial practice. National implementation will additionally require understanding how barriers and enablers differ across jurisdictions, funding arrangements, workforce capability and organisational readiness.

At the policy level, national guidelines should set clear standards for CMO involvement in physical health. Updating the National Safety and Quality Mental Health Standards (Australian Commission on Safety Quality in Health Care, 2022) for CMOs to embed explicit responsibilities for physical health promotion and management would be an important step. The Being Equally Well Roadmap (Calder et al., 2022) provides an important foundation, but it must be operationalised with explicit expectations, funding and training for CMOs, while mandating participatory approaches to ensure strategies are acceptable, equitable and tailored to the diverse communities that CMOs serve.

If not CMOs, then who? If not now, when?

The case for closing the 15- to 20-year life expectancy gap for people living with complex mental health challenges is clear and urgent. What remains less clear is how to achieve this in practice. Although essential, reforms within public mental health services and primary care alone are insufficient to meet the scale of need. Elevating CMOs as leaders in health promotion, prevention and early intervention offers a practical pathway to scalable, sustained change. People living with mental health challenges do not experience their lives in silos: mental health, physical health and social determinants are interlinked. A defined role for CMOs in physical health has the potential to complement mental healthcare, reduce preventable morbidity and ultimately improve outcomes for people living with complex mental health challenges. The question is not whether CMOs can contribute, but how we structure, fund and support them to do so safely, effectively and at scale. In this Perspective, we have highlighted key opportunities and priorities. To enable these opportunities, a clear and coordinated agenda is needed. A summary of the key actions required across consumer, service and system levels is outlined in Table 2.

Table 2.

Recommended actions to strengthen the role of CMOs in physical health care across micro, meso and macro levels.

Level	Key issue	Recommended action	Key stakeholders
Micro (consumer/staff)	Limited staff confidence and capability	Train mental health staff, including peer workforce in brief physical health support, screening, referral and health coaching.	CMO staff
Micro (consumer/staff)	Need for more intensive behaviour change support	Develop referral and escalation pathways to appropriately trained clinicians and specialist services.	Health professionals trained in behaviour-change counselling
Meso (organisation/service)	Unclear role of CMOs in physical health	Embed physical health into routine CMO practice using the Tier 1–3 stepped-care model outlined in Table 1.	CMO managers, service leaders
	Limited workforce expertise	Embed lifestyle experts such AEPs, APDs and nurses within or linked to CMOs.	CMOs, PHNs, public health institutions
	Fragmented care	Establish shared-care protocols and formal referral pathways with primary care and specialist services.	CMOs, GPs, public health institutions, allied health
	Limited monitoring and evaluation of programmes	Implement routine outcome monitoring, audit-feedback systems, quality-improvement processes. Where possible, engage internal research supports or partner with external research institutions to sustain and evaluate effective initiatives.	CMO staff, CMO managers, researchers
Macro (system/policy)	No consistent national expectations	Update national standards to explicitly define the role of CMOs in physical health.	Government, peak bodies, standards agencies
	Decentralised and inconsistent funding	Create dedicated commissioning and funding streams for physical health within CMOs	Commonwealth, states/territories, NDIA, PHNs
	Lack of national coordination across jurisdictions	Establish collaboration between state and territory peak bodies, national organisations and governments to create consistent expectations while allowing local adaptation	Community Mental Health Australia, state and territory peak bodies, governments
	Weak evidence base	Fund hybrid effectiveness-implementation trials, scale-up research and partnerships between CMOs and research institutions to strengthen the evidence base and support national implementation.	Researchers, governments, CMOs

Abbreviations: CMO, community-managed organisation; PHN, Primary Health Network; GP, general practitioner; NDIA, National Disability Insurance Agency; AEP, Accredited Exercise Physiologist; APD, Accredited Practising Dietitian.

National guidelines must articulate the role of CMOs in screening, intervening and referring for physical health. Given their established roles in policy leadership, legislative reform and workforce development, state and territory peak bodies representing CMOs are well positioned to contribute to national guideline development and implementation. Working collaboratively with these peaks provides a direct mechanism to ensure that the perspectives and needs of CMOs are embedded within system-level reform and practice guidance. Funding mechanisms through PHNs, NDIA and state governments must resource CMOs to build health-informed environments and train their workforce in evidence-based health coaching. Integration pathways must ensure CMO-led interventions link seamlessly with general practice, allied health and specialist services, avoiding the pitfalls of fragmented care. Finally, research must focus on evaluating these models at scale, including their cost-effectiveness, cultural safety and long-term impact.

Mobilising CMOs as key partners in holistic mental health care demands more than goodwill; it requires policy clarity, sustainable funding and structural investment that recognises them as important contributors within the health system. National frameworks must explicitly articulate their role in preventive and lifestyle health and establish clear pathways connecting CMO-led initiatives with primary and specialist care. With the right mandates and resources, CMOs can drive a transformative shift in Australia’s response to the physical health inequities faced by people living with complex mental health challenges.

Footnotes

Author contributions

OL led the conceptualisation, drafting and revision of the manuscript. SR, HF, ET, JCh, MO, AW, GW, RL, PW and JCu contributed to manuscript development and critical revisions for important intellectual content. All authors reviewed and approved the final version of the manuscript and agree to be accountable for its content.

Declaration of conflicting interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MO is the Chief Executive Officer of the national community-managed organisation Flourish Australia. ET is the Chief Executive Officer of the Mental Health Coordinating Council (MHCC). SR is supported by a National Health and Medical Research Council (NHMRC) Emerging Leadership Fellowship (APP2017506). The contents of the published material are solely the responsibility of the individual authors and do not reflect the views of the funding bodies. All other authors declare no conflicts of interest in relation to this work.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Oscar Lederman

Hamish Fibbins

Evelyne Tadros

Justin Chapman

Mark Orr

Philip B. Ward

Andrew Watkins

Gemechu Wirtu

Regan Lamble

Jackie Curtis

Simon Rosenbaum

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