Introduction of a Psychosocial Post-Discharge Intervention Program Aimed at Reducing Psychiatric Rehospitalization Rates and at Improving Mental Health and Functioning

Abstract

Purpose: Based on the premises of assertive community treatment and intensive case management, we designed a program delivered by social workers that is targeted at transition to community treatments and social support.

Design and methods: Narrative review and qualitative analysis of three patients who participated in the program.

Findings: Case reports revealed that patients' social networks are small and their relationships are commonly conflictual and unstable.

Practice implications: Access to patients' social networks is a challenging task. Based on our preliminary experiences with the program, we suggest that more efforts should be made to enhance patients' social and interpersonal abilities.

Keywords: Community care; continuity of care; discharge intervention; network coordination; nursing; social support.