Despite its significance, ensuring continuity of care demands substantial resources, which might not be readily accessible in many public healthcare systems. Studies indicate that continuity of care remains uncertain in numerous healthcare systems.

This study aimed to assess the effectiveness of a continuity-of-care model for patients with severe mental illness (SMI), providing seamless treatment from discharge from a closed ward to subsequent psychiatric, psychological and rehabilitation services.

Data from patients discharged before (1 January to 31 December 2018) and after (1 June 2021 to 31 May 2022) full implementation of the model were analysed and compared in terms of average duration of hospital stay, emergency department visits within 90 days of discharge, readmission rate within a year post-discharge and initiation of rehabilitation process.

In the post-implementation period (n = 482), the average admission time significantly decreased from 30.51 ± 29.72 to 26.77 ± 27.89 days, compared with the pre-implementation period (n = 403) (P = 0.029). Emergency department visits within 90 days following discharge decreased from 38.70 to 26.35% of discharged patients (P < 0.001). The rate of readmission decreased from 50.9 to 44.0% (P = 0.041) for one readmission and from 28.3 to 22.0% (P = 0.032) for two readmissions in the year following discharge. Additionally, the proportion of patients entering formal rehabilitation increased from 7.94 to 12.03% (P = 0.044).

This study highlights the effectiveness of a continuity-of-care model spearheaded by senior psychiatrists and involving paramedical personnel. These findings underscore the significant potential of the model to substantially enhance mental health services and outcomes. Moreover, they emphasise its relevance for patients, clinicians and policy makers.

尽管具有重要意义，但确保护理的连续性需要大量资源，而许多公共医疗保健系统可能不容易获得这些资源。研究表明，在许多医疗保健系统中，护理的连续性仍然不确定。

本研究旨在评估连续性护理模式对严重精神疾病 (SMI) 患者的有效性，该模式提供从封闭病房出院到随后的精神科、心理和康复服务的无缝治疗。

对模型全面实施之前（2018年1月1日至12月31日）和之后（2021年6月1日至2022年5月31日）出院患者的数据进行分析和比较，包括平均住院时间、出院后90天内的急诊就诊时间，出院和开始康复过程后一年内的再入院率。

实施后( n =482)与实施前( n =403)相比，平均入院时间从30.51±29.72天显着缩短至26.77±27.89天( P =0.029)。出院后 90 天内急诊就诊的患者比例从 38.70% 下降至 26.35%（P < 0.001）。出院后一年内，一次再入院的再入院率从 50.9% 降至 44.0%（P = 0.041），两次再入院的再入院率从 28.3% 降至 22.0%（ P = 0.032）。此外，进入正式康复治疗的患者比例从7.94%增加到12.03%（P =0.044）。

这项研究强调了由高级精神科医生牵头并涉及辅助医务人员的连续性护理模式的有效性。这些发现强调了该模型在大幅增强心理健康服务和结果方面的巨大潜力。此外，他们强调其与患者、临床医生和政策制定者的相关性。