ABSTRACT
To describe a home care service developed in Roozbeh Hospital for patients with bipolar disorder and schizophrenia and report baseline and 6-month follow-up data. Roozbeh Home Care Program consists of home visits by multidisciplinary home care teams, including general practitioners, nurses, and social workers who are supervised by psychiatrists. Home visits are scheduled as biweekly for the first three months following discharge and then on a monthly basis and the care includes biopsychosocial assessments and interventions. Baseline and 6-month data were extracted using a chart review. After 10 months of the Program development. 53 patients were enrolled and a total of 349 home visits were made. Of these, 29 were followed for at least 6 months. More than 86% of the patients remained in the community throughout the follow-up period, most in full remission and a small minority [4 patients] with a mild to moderate relapse that was overcome with interventions made by the home care teams. A home care service is a feasible mode of community-based aftercare for patients discharged from the hospital. Its effectiveness should be assessed by a randomized controlled trial