RESUMO
To serve discharged state hospital patients from its catchment area, a mental health and retardation center established an ambulatory community service that has total responsiblity for the community care of those patients. The service is staffed primarily by mental health workers and nurses. They become members of the neighborhood-based teams on the state hosptial unit and take part regularly in discharge planning with patients and hospital staff. They also provide a range of continuing outpatient and support services, including medication review, development of housing placements and recreational activities, and psychiatric follow-up. The service operates as a specialized, autonomous unit, which allows it to shift staff resources in line with changes in patient and program needs, to allocate time for program development, and to pressure other agencies to develop needed services.
