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A 42-year-old single man who had a long history of chronic paranoid schizophrenia with marked functional deficit was receiving a disability support pension and living in a shared rented flat; his elderly mother lived nearby. He had been hospitalised four times in the last three years. He saw his general practitioner regularly, receiving depot fluphenazine decanoate 25 mg intramuscularly every two weeks. However, he was lost to follow-up by the general practitioner for two weeks, his condition deteriorated and he was admitted to hospital via the police.

Collaborative care after discharge

After a period in hospital, his condition improved. The general practitioner, area psychiatric service psychiatrist and case manager planned for his discharge from hospital in a five-minute conference call.

During this consultation, the responsibilities of the general practitioner, case manager, psychiatric service and psychiatrist were defined, and a case review was arranged for three months later.

The psychiatric service obtained the patient's agreement to the management plan and he was discharged from hospital. For the first few days a clinic worker (a nurse) visited the patient at home to assist with basic living needs and medication. He was then assisted to visit the general practitioner every two weeks for continuation of medication; the general practitioner also reviewed physical state, side effects and mental state.

After seven weeks the patient was able to attend the general practitioner by himself and also attended the service psychiatrist for review.

The general practitioner noted the development of akathisia and called the psychiatrist, who recommended reducing the dose of fluphenazine decanoate and introducing propranolol (which can be useful for control of akathisia) for short term therapy of about two weeks.

The case manager continued seeing the patient frequently to help sort out problems, including finances and rent arrears, preventing a psychosocial crisis. The patient was still living in the community and continuing to receive care two years later, despite fluctuations in his illness.

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