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Findings suggest that the interpersonal skills of case workers; access to social support and housing; and continuity of case worker relationships throughout the pre-release and post-release period are key social and structural factors in program success.
According to some participants, the referral and feedback system enhances continuity of care of the patients; it provides them with a complete picture of post referral management and progress, for example, "I think referred for us as Family medicine for continuity of case is better" (FG2).
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In Zortman et al. (2016) participants cited the continuity of care from case managers as an important component in their progression through the program, sustained success and relapse prevention.
Because of the lack of continuity of care in case of referral, we expected that a referral would have the greatest negative effect in Belgium.
Three quarters of the protocols had no provision for ensuring continuity of care for cases not accepted by AMHS.
Personal continuity of care, in which case the midwife stayed until the end of labour, was highly appreciated but not always expected.
(Carer, A06) All stakeholders valued the continuity of care potentially offered by case management, especially since this was rarely provided by other services.
If the discharge letter and / or any comment on the ED visit in the follow-up chart had been found the case was defined as "a case with good continuity of care".
Absence of cardiac services affected cardiac patients' continuity of care; some participants described cases where patients refused treatment in town so they could return to their family in remote area communities.
This would create more stakeholder engagement in case finding and treatment and better continuity of care.
Practice Nurses are educated to act as case managers who aim to provide continuity of care.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com