Institute of Mental Health1
Studies showed the efficacy of the linking up of services via a case manager (Fitzgerald et al, 1994). Therefore, a creation of support network for each client was developed withcommunity partners and AIC. Weekly home visits were made with community partners to understand clients (Lord et al, 1998). This study reports the outcomes of collaboration between IMH and Montfort Care in Kreta Ayer and Henderson regions for 2017 to 2020.
Data mining was done with Microsoft Excel. Consent from caregivers sought before including clients. They received regular updates on their condition during appointments.
125 clients in Kreta Ayer and Henderson areas. 50 co-managed with Montfort Care, 57 were monitored by the case manager and 18 transferred to Montfort Care. 956 telephonic management calls made to ensure treatment compliance. Clients met 289 times at the outpatient clinic and 92 times in wards when patient admitted. 50 linkages made to relevant agencies for financial/social issues. 180 home visits were done with Montfort Care.
Since the collaboration in 2017, readmission rates, emergency room visits rates decreased by 80%. Appointment default rates decreased by 90%.
Hospital and community carers understood their clients in a patient-centric manner (Audet et al, 2006). Clients were stable with regular follow-up in the community and medically compliant (Fitzgerald et al, 1994). Caring for clients in a supportive community ecosystem is an important strategy that requires hospitals to adopt fully in future.