关键词: 精神残疾人, 社区精神卫生服务, 康复

Abstract: Background　As an important pilot project of National Mental Health Comprehensive Management，this study formed a muti-disciplinary team to provide occupational rehabilitation based on “hospital-community integration” service model for people with mental deformity in the Changning District of Shanghai.Objective　To analyze the standardized building of occupational rehabilitation based on “hospital-community integration” service model.Methods　We described the situation from four aspects：team organization，service path，training module and daily operation，and evaluated rehabilitation rate，accident rate and satisfaction rate.Results　The model gained social support from government departments and towns，received technical support from institutions，colleges and universities，acquired professional guidance from mental health multifunctional team，and promoted participation from social organizations，mental health social services and family members of patients.This model established rehabilitation paths and training modules，provided occupational rehabilitation training and comprehensive intervention.As of 2017，the comprehensive service modelhas received 62 patients with severe mental disorder and serviced2 124 visits annually.The statistic results of two consecutive years（from 2016 to 2017） showed the satisfaction rate of patients increased from a baseline of 96.7%（60/62） to 99.3%（142/143），meanwhile the satisfaction rate of their families increased from a baseline of 95.1%（78/82） to 98.6%（140/142），the annual standard rehabilitation rate reached 99.5%（4 227/4 248） ，the average rate of palindromia and rehospitalization per year reached 4.8%（3/62） and the accident rate remained unchanged at 0.Conclusion　“Hospital-community integration” model in Changning complements the existing system，meets various rehabilitative needs for patients with mental disability due to severe mental disorder and their family members，creates auxiliary jobs and provides policy basis for the standardization building of occupational rehabilitation.

Key words: Mentally disabled persons, Community mental health services, Rehabilitation