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Patients with psychiatric illnesses require both medical as well as supportive psychosocial treatments in order to prevent a relapse (1). The Institute of Mental Health conducts an 8th week rehabilitation program to ensure successful transition and integration of patient to community living. This paper discusses the rehabilitation case manager Os(CM) role in the rehabilitation program and outcomes. Method: From Jan 2012 to Dec 2012, 307 patients were referred for rehabilitation. The CM performed bio-psychosocial assessments on patients suitability for the program. He coordinated and collaborated with the Multidisciplinary team(MDT) on the acute and rehabilitation ward on the transition of care and the discharge plan with the family. Outcomes of this input was collected and analyzed using Microsoft Excel program Findings 59% of the patients referred were accepted and with fairly equal numbers of males (55%) and females (45%). The majority (90%) were diagnosed with Schizophrenia. 80% were Chinese with 64% aged between 31yrs old to 40yrs old. Psycho-education, supportive counseling and linkages were done. 56% were successfully discharged home and 46% to step-down care. Conclusion: Together with the MDT, the case manager has an important role in the ensuring the successful transition and integration of patient to community living.

international journal of integrated care

Promoting successful transitions of care and community integration for patients with psychiatric conditions through a rehabilitation program: The case manager’s role