Contact Us

Link-me+ for General Practitioners

What is Link-me+ and how does it work?

  • “Doing mental health care in general practice can be very rewarding, but there are challenges too. Link-me+ is a model that helps general practice engage and support people with common mental health presentations, especially depression and anxiety. It is an evidence-based, primary-care oriented, person-centred approach to mental health system navigation.”
  • Dr Caroline Johnson,
    General Practitioner and Associate Professor in the Department of general practice and primary care
    University of Melbourne

Link-me+ Journey

A Guide for General Practitioners

The Link-me+ Model of Care is designed to improve the management of mental health care in primary settings. The Link-me+ questionnaire is a clinical decision-support tool that enables General Practitioners (GPs) to identify and direct patients towards appropriate mental health services. It provides recommendations based on their specific needs. The questionnaire is offered to patients before their GP appointment.

Purpose of the Link-me+ Model of Care

  • The Link-me+ was developed to address challenges in mental health care, particularly the difficulty in matching patients with suitable services. Traditional approaches often fail to effectively stratify patients, leading to either over-treatment or under-treatment. The Link-me+ helps overcome these challenges by categorising patients into four groups. The Link-me+ model helps GPs match support intensity to each patient's needs, improving outcomes and reducing over-referrals.

Minimal prognosis group

Mild prognosis group

Moderate prognosis group

Severe prognosis group

  • Minimal prognosis group 
  • Patients who do not have current mental health concerns but may benefit from mental health promotion advice.
  • Mild prognosis group
  • Patients with milder mental health symptoms who have a higher likelihood of feeling better in three months' time and can thus appropriately be offered self-help resources or other low intensity interventions. 
  • Moderate prognosis group
  • Patients who may benefit from moderate intensity interventions, e.g.: talking therapies, additional support. 
  • Severe prognosis group
  • Patients who are most likely to still be experiencing symptoms in 3 months’ time and most likely to benefit from additional support in navigating and engaging with mental health and other services that are more tailored to their individual circumstances. 

How to use the Link-me+ model of care?

GPs can integrate the Link-me+ model into their standard consultations with patients. The process involves the following steps:

Administering the Questionnaire

Upon booking an appointment with their GP, the questionnaire is sent to the patient via a secure text message link, allowing them to complete it conveniently on their mobile device. 

01

Prognosis Stratification

Based on patient responses to the questionnaire, an algorithm categorises individuals into one of the four prognostic groups and provides support recommendations that are tailored to the issues that the patient nominates as most concerning for them.

02

Linking with the Patient’s Electronic Medical Record (EMR)

The questionnaire results and support recommendations are automatically integrated into the patient’s EMR, ensuring that the GP can review the responses prior or at the upcoming appointment that was initially scheduled.

03

Link-me+ Questionnaire Report recommendations

The questionnaire results provide tailored mental health support recommendations for the patient and GP to consider, including the option of additional support via a Care Navigator for patients with high mental health needs.

04

Ongoing Monitoring

The GP (and where applicable the Care Navigator) are responsible for ensuring appropriate follow up to assess patient outcomes.

05

The Link-me+ Model of Care is a valuable resource for GPs seeking to enhance their approach to mental health care. By facilitating targeted interventions, providing care navigation to identified patients, and offering person-centred recommendations, it ensures that all individuals receive the appropriate level of support, ultimately leading to improved wellbeing and more effective use of mental health services.

Where do the questions come from?

The Link-me+ model of care’s questionnaire is based on validated psychological assessment instruments commonly used in mental health care. These include:

  • The Patient Health Questionnaire (PHQ-9) – to measure depression severity. 
  • The Generalised Anxiety Disorder scale (GAD-7) – Questions about psychosocial variables that impact on symptom duration and severity to assess anxiety symptoms.

Additionally, the questionnaire includes demographic and identity-related questions that allow patients to identify themselves based on personal and social factors. This includes options for patients to indicate if they are:

  • A parent or caregiver 
  • An active military personnel or a veteran
  • A member of the LGBTQI+ community 
  • An Aboriginal or Torres Strait Islander person 
  • From a culturally and linguistically diverse background. Click here to see the established clinical guidelines that were used in the design of Link-me+.

Feedback Reports: Strengths and Support Needs

One of the key benefits of the Link-me+ Model of Care is the provision of a personalised feedback report, which provides valuable insights for both the patient and the GP. The report includes:

Areas Where the Patient Is Doing Well

Highlighting potential strengths that the patient has demonstrated in managing their mental health. This positive reinforcement encourages continued engagement with self-care practices. 

Areas Where the Patient Needs Support

Identifying specific challenges, symptoms, or stressors that require intervention, along with recommended support options.

Tailored Recommendations

Based on the patient’s responses, the report suggests the most appropriate level of care, such as self-help resources, psychological therapy, or specialist mental health services.

Goal-Setting Guidance

For patients receiving care navigation, they are encouraged to set achievable goals for improving their mental health. This balanced approach ensures that patients feel supported while also recognising their progress, fostering motivation and engagement in their care journey.

Why GPs should use the Link-me+ model of care?

Efficient Mental Health Care

The tool streamlines the process of identification and assessment, helping GPs more efficiently know which patients are likely to benefit from more intense support.

Personalised Treatment Plans

It enables patient-centred care by recommending interventions that align with the person’s mental health prognosis.

Promotes Inclusivity

By allowing patients to self-identify based on their personal and social circumstances, the tool ensures that diverse populations receive appropriate support.

Effectively Supports Patients with More Complex Mental Health Issues

The Care Navigation feature ensures that individuals with more significant mental health concerns receive ongoing, well-coordinated support.

Encourages Patient Engagement

The feedback report helps patients recognise their strengths while addressing their needs, making them active participants in their mental health care.

Seamless Integration with EMRs

The tool streamlines the process of identification and assessment, helping GPs more efficiently know which patients are likely to benefit from more intense support.

Reduces GP Workload

The structured approach aims to minimises the burden on GPs by providing more tailored care, additional resources for patients to try and care navigation for those eligible for additional support. 

Improved Patient Outcomes

Early identification and appropriate treatment leads to enhanced patient outcomes.

For patients identified as severe-prognosis, the Link-me+ model provides an essential care navigation component. The Care Navigator, a trained allied health professional, complements usual GP care by providing additional support to the person, via motivational interviewing, and social prescribing to tailor recommendations to that person's unique circumstances. The Care Navigator collaborates with the patient and the GP to find the types of services best suited to that person's needs, and continuity of care is ensured through the scheduled check-ins and tailored sessions focused on supporting the patient. By implementing care navigation, the Link- me+ model of care has been shown in a randomised-controlled trial to improve patient outcomes

FAQs

The Link-me+ Model of Care supports General Practitioners (GPs) in addressing the mental health needs of their patients. It features a patient-facing digital questionnaire that categorises patients into mental health needs based on the predicted severity of their anxiety and depression symptoms over time. This model enables patients to be offered tailored and effective, evidence-based interventions. Link-me+ is a Model of Care grounded in patient experience. It has been developed through extensive consultation and research over the last 20 years. This includes a Randomised Controlled Trial (RCT) involving 23 general practices in three PHNs across three states. 

At the time of booking patients (18 years old and over) will receive an SMS with a link to the Link-me+ questionnaire. Patients interested in taking part can complete the questionnaire or opt out of receiving further SMS about Link-me+. Patients who have not completed the questionnaire will be sent a reminder SMS within 24 hours of their appointment.

After completing the questionnaire, the patient immediately is shown their results, including tailored feedback and recommended supports. These results also state that the GP will review their results either before or at their appointment.

GPs will receive the patient’s questionnaire outcome and a summary report in their Clinic’s Electronic Medical Records shortly after the patient completes the questionnaire.
Only eligible patients identified through the Link-me+ questionnaire can have access to Care Navigation

Patients identified as having a severe prognosis by the Link-me+ questionnaire will first meet with their GP for a consultation to review their results, discuss clinical treatment options, and explore access to care navigators. 

GPs can access the patient results via their clinic’s electronic medical records.Care Navigators will also be able to access the results via the clinic electronic record records, if patients are eligible for the Care Navigators Program. 

Patients who fill out the Link-me+ questionnaire will be provided with feedback and resources upon completion of the survey. Patients at higher risk of harm will also be provided with additional crisis and emergency contact numbers while awaiting their GP appointment. Studies indicate that inquiring about suicidal thoughts does not heighten the risk of suicidal behavior. In fact, discussing suicide may decrease suicidal thoughts and contribute to better mental health outcomes. 

GPs will receive continuous support and training in Link-me+ to ensure they deliver best-practice mental health care. They will have access to a local service directory, capacity building opportunities through in-house clinical education on key mental health topics, and special interest support networks. 

Link-me+ Model aims to enhance and support GPs’ and clinics’ mental health care workflows. Prototyping and testing practices are used in Link-me+. With these practices we can identify and resolve any potential issues in collaboration with GPs and other clinic staff before implementation. These sessions are a key part of the co-design process, allowing clinics to share concerns and help tailor the model to fit their own context, ensuring any foreseeable challenges are addressed early on.  

Once implemented, the Link-me+ model of care is designed to support GPs in their day-to-day work without adding extra burden. It is expected that care navigators will ultimately decrease GP workload by providing an additional care option that meets patients’ needs in a personalised way.

Patients will receive one SMS with a link to the Link-me+ questionnaire before their appointment. They will receive another SMS with a reminder if they do not complete the survey. The timing of these messages will be agreed upon with each practice to ensure it aligns with their context and workflow. Patients will be able to opt out of further messages by clicking on the link or by letting their practice know that they do not wish to receive messages. Patients of participating GPs will only be sent an invitation to take part in Link-me+ Model of Care.  

 Only patients who complete the questionnaire and choose to participate in the evaluation of Link-me+ will receive a follow-up message. Patients will have full control over providing their contact information upon completion of the questionnaire. 

Patient data is handled within the clinic. FHT does not send or retrieve identifiable information outside of the practice. The code generated for the patient cannot be connected to the patient outside of the FHT infrastructure. FHT uses secure mechanisms throughout the whole process, from identifying eligible patients to getting their results back into the clinic’s EMR. These mechanisms have been approved by the University of Melbourne. 

Patients interested in participating in a research survey to evaluate the implementation of the Link-me+ Model of Care can express their interest by accessing a separate link provided at the end of the Link-me+ questionnaire. This is the only instance in which patients provide identifiable information (i.e., name and email address) outside the practice. The data collected follow the standard research ethics regulations stipulated by the university, to ensure it is securely stored and handled. 

Text messaging patients with the Link-me+ questionnaire will be aligned with the GP clinic’s privacy collection notice. Patients who have not consented to receive SMSs from the clinic or have opted out will not receive the link to the questionnaire in their phones. GPs can still recommend that patients complete the questionnaire by providing them with a QR code during the appointment.   

Patient’s personal data remains at the practice in the clinic’s management software (such as Best Practice Premier or Medical Director). Care Navigators may also store patient personal data necessary for administrative purposes on Access Health and Community software. Anonymous data drawn from patients completing the Link-me+ questionnaire is stored on the University of Melbourne servers. Data handling for Link-me+ purposes comply with privacy obligations.

© 2025 Linkme+. All rights reserved.

Cookie Policy | Privacy Notice | Terms of Use

Menu

Contact Us