落實去機構化運動與發展有效的社區精神復健模式已是現今精神醫療照護的重要方向，社區精神病患的照護與管理成為各地縣市政府衛生行政的重要課題。為有效提供社區中精神病患持續性的照護，中部某縣衛生局與某科技大學護理系共同合作，於96至97年間，嘗試以落實社區衛生所對精神病患的追蹤、進行溫暖社區關懷訪視、推展精神醫療機構的重症精神病患出院通報與加強相關資源聯繫整合的方式，對縣內社區精神病患提供持續性的照護。透過持續加強對訪視員與衛生所護理人員的訓練與支持，確實執行精神醫療院所的出院準備與通報，維護社區精神病患的訪視品質，有效連結整合相關資源，以建構社區精神病患的持續性照護。

Deinstitutionalization and the implementation of community psychiatry rehabilitation models define the future of psychiatric medical care in Taiwan. As such, managing and caring for psychiatric patients at the community level are increasingly important public health issues for county and city governments. A local public health authority in Taichung County established a collaborative relationship with a university-level nursing department during 2007 – 2008 in order to provide more effective
continuous community care for psychiatric patients. This cooperative arrangement provided continuous community care for psychiatric patients in the County by implementing aftercare for psychiatric patients that was delivered through community-level public health centers, which conducted patient visits, developed discharge notifications for severe psychiatric patients in mental health institutions, and strengthened connections among related resources. To establish continuous community care for psychiatric patients, it is necessary to enhance training and support for health recipients as well as nursing staff in public health centers through measures that include: implementing discharge preparations
and notifications in mental health institutions, improving the quality of community-based psychiatric patient visits, and connecting and integrating relevant resources effectively.