Care Transition Teams

This project will follow the evidence-based ‘‘Critical Time Intervention’’ (CTI) approach to providing care at staged levels of intensity to patients with serious mental illness during transitions from the hospital setting to the community. It is designed to prevent readmissions to acute care, inappropriate use of the ED, and recurring homelessness.  Under CTI, a multidisciplinary team follows a three-phase approach to assisting individuals with transitions out of the hospital, including veterans, people with a history of homeless, and formerly incarcerated individuals.