Transitions of Care Team

Smoother Transitions • Reduce Re-Admissions • Improve Client Outcomes

Do you see the same clients cycling in and out of hospitals or ERs? Do you have a client that never seems to stabilize in the community? Do you want to provide more support but are unable to do so for a client who needs it?

LSSI's Transitions of Care Team works with individuals who are discharging or have already discharged from an inpatient setting remain engaged, access needed services, and get connected to long-term treatment options. Our team works together with the individual and acts as a support for a period of 90-120 days while they are getting established with outpatient services.

Our hope is that by creating smoother and stronger transitions, we are improving the client's outcomes and success.

For More Information or to Make a Referral, Please Contact Natalie Matos:

Natalie.Matos@lssi.org
224.283.2694224.283.2694

The Transitions of Care Team Will:

  • Receive a coordinated warm hand-off from the discharge planner
  • Work with the individual in implementing their discharge plan
  • Continue to engage the client post-discharge
  • Help the person access community services (food, clothing, utility assistance, etc.)
  • Provide assistance in signing up for benefits (healthcare, disability, social security)
  • Ensure linkage to providers such as Primary Care Physician, Therapist, Psychiatrist, etc.
  • Help sign-up for housing and/or obtain temporary housing
  • Provide counseling and community support services while client is waiting for services to begin
  • Develop a crisis plan with the individual and link them to community-based crisis services

This Program Is for Adults Who Will Be or Have Already Discharged From a Hospital or Inpatient Program and Who:

  • Have a serious mental health diagnosis
  • Have repeated psychiatric hospitalizations
  • May struggle with addiction
  • Need continued engagement in order to be successful
  • Have been put on a waiting list for treatment
  • Need help getting medications
  • Need assistance following their discharge plan

How Are These Services Covered?

  • Medicaid
  • Managed Care
  • Eligible for Medicaid but do not currently have benefits

For More Information or to Make a Referral, Please Contact Natalie Matos:

Natalie.Matos@lssi.org
224.283.2694224.283.2694