In general, the components of a community-based chronic illness support system consists of the following:
Patient identification and outreach: Chronic patients, who have not been compliant to treatment regimens, and admitted to multiple hospitalizations, will be selected for outpatient commitment.
A system for management and outreach - in order to accomodate a rapid and timely contact with patients in the community.
A transportation system: in order to facilitate the contacts between patients and the resource elements.
Mental illness treatment: Diagnostic evaluation: using standard evaluation protocols (Brief Psychiatric Rating Scale and the Global Assessment Scale) and for a measure of substance abuse. CAGE and CAGE, for adjustment levels, the SLOF, Specific Level Of Functioning Scale. Each of the rating scales will be administered at discharge from the hospital and every three months thereafter, for one year and for follow up.
Medication management - Supportive counseling - Substance abuse services.
Health and dental services: As needed for routine check-ups.
Crisis Response services: Crisis telephone systems - Walk-in crisis services (a network of mental health programs) - Mobile response teams for outreach and crisis - Crisis residential services - in patient services.
Housing: Supportive Housing programs - Group homes (but not a community hospital - size is crucial).
Income Support and Entitlements - Peer Support: Self-help and educational programs - Community consumer operated programs.
Family and Community Support: Support and assistance to families - Support and education to community.
Rehabilitation Services: Social rehabilitation and habilitation - Vocational rehabilitation
Protection and Advocacy
Case management and System Coordination
H.M. Visotsky, Prof., MD
Department of Psychiatry
Northwestern University Medical School, Chicago
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