Improving continuity of care through a state hospital-CMHC liaison program

After several abortive attempts, a state hospital and a community mental health center located in the same county made a more successful attempt to improve continuity of care. A study of 78 discharged hospital patients identified several problems in the continuity-of-care system. A liaison team made up of a social worker from the hospital and a psychiatric nurse from the center was set up to carry out such tasks as contacting county residents admitted to the hospital, participating in treatment and discharge planning, and contacting patients who did not keep aftercare appointments. The program had several positive results; the authors believe they were related to such factors as an objective definition of the problems, administrative cooperation, and strong linkage, through a middle-management team, between the liaison team and top-level management and between the hospital and the center.