Schizophrenia Stories from People on the Front Lines: The Importance of After-Care Plans

Despite a myriad of challenges, these people within the network of care have been able to make a meaningful impact.

Hospital discharge planning — Hear Eric’s story

As a hospital discharge planner for over 5 years, Eric works with each person to create an after-care plan that ensures they have the support they need to follow up and attend appointments. Hear about what he thinks is the most important aspect of an effectively managed transition.


My name is Eric, I’m a discharge planner for adult patients living with schizophrenia. Young man came to us, dealing with schizophrenia, repeated has been a recidivist at the hospital. And upon switching of doctors, the doctor and I discuss it with him and explain to him what was going on with him and we were able to move him from supportive living to independent living, where he gets his own apartment and is attending college—I think he’s about a junior in college by now. The illness is gonna be a continued care. It’s not a laceration where you put a band-aid on it and it’s fixed.

Patients look forward to getting rideshare home upon discharge because oftentimes they might not have made it to their destination to pick up their meds and then make it home, so with rideshare they’re able to complete both assignments within the day of discharge.

The caregiver becomes an essential part of that patient after-care plan. And this is where the network come in, in terms of following up on patients after care. My ideal group is first and foremost we have to have the psychiatrists. Clinicians and staff would be central which would be a master level clinician support group who would come in there and be able to provide the information to the patient dealing with their after care, family members we ask them that they show up. There could be a foster parent not defined by the state, but as somebody of a support that is a parent figure within the organization. When you call a caregiver you try to establish a communicative relationship with that caregiver, and you oftentimes, you may follow up and say Hey did Johnny went to his appointment? He was due an appointment. Or you try to notify him 24 hours ahead Hey Johnny remember you have an appointment on the 7th coming up so don’t be late, the doctor’s expecting you, he’s looking forward to seeing you and hope all is well. In that scenario, a person who doesn’t have that family support, we generally recommend them to a personal care home because there are several others there who are living with similar illness and therefore they’re able to support each other, as well as the operator of the personal care home will be actively involved in the patients care, or after care. So we work close with law enforcement, whether for transport, or just the fact that they have identified patients that are generally come to our hospital and see them out there and can return them for treatment.

As we all know, the fear of the unknown generally scares anyone, so if somebody could become —a public official can become a voice of reasoning that talks about it, then for people in the public will get a better understanding of how to deal with it, and don’t perceive it as something scary but as something that can be treated. In successful discharge, a patient committed to his or her after care is the most vital part.

Effective management of transitions in mental health, including schizophrenia, can be critical to reducing hospital readmissions1

Many people living with schizophrenia do not have successful care transitions from inpatient to outpatient settings.2,3

  • In a study of 229 patients with a primary psychiatric diagnosis, including 48% of patients having schizophrenia, nearly 2 out of 3 people did not attend their first outpatient appointment2
  • Additionally, in a 2003 retrospective claims analysis of Medicaid patients, approximately 40% did not receive any outpatient follow-up care within 30 days of discharge3

Some hallmarks of successful care transitions for people living with schizophrenia include:

  • Before discharge, scheduling a follow-up appointment within 7 days with a mental health provider4
  • Facilitating the connection between patients and any new provider referrals4
  • Within 72 hours of transition, contacting the patient to review the care transition plan and answer questions or concerns4

Poor transitions of care have been shown to increase the risk of hospital readmission1

  • In a 36-month study of 323 patients diagnosed with psychosis, including 85.1% with schizophrenia, 63.8% of patients were readmitted during this timeframe5
  • In 2011, the cost of 30-day readmissions for Medicaid patients with schizophrenia and other psychotic disorders was $302 million6