Systems of Support (SOS)

When an individual is identified to be at risk and/or in crisis, Project Transition steps in to bridge the gaps of care that may be contributing to the crisis events. SOS care is designed for:

• Individuals with an I/DD and mental health diagnosis with behavioral challenges
• Those who have been determined by their MCO or care team as someone in need of more supports
• Members who have providers and loved ones who need training and/or consultations to support them

• Assist the individual in achieving a better quality of life in the community
• Develop and/or support the individual’s support system (e.g., family, friends, mental and physical health providers) through training to recognize triggers, de-escalate crisis, etc.
• Decrease the frequency of crisis events (e.g., ER visits, inpatient hospitalization, behavioral respite)
• Reduce the use of psychotropic medications, as needed Increase one’s ability to remain safe in the community, and out of the hospital

• Crisis prevention and intervention services with 24/7, on-call support
• Identification of service gaps and assist with obtaining services needed to maintain safety and stability in the community
• Improve quality of life by supporting the existing service delivery system to effectively provide care and reduce crisis episodes
• Regular meetings with the individual, caregivers, and other providers to develop a crisis prevention and intervention plan
• Assist the individual’s team in developing skills to decrease crisis events that lead to hospitalization, law enforcement involvement, and emergency department utilization

• Intellectual or developmental disability and mental health diagnosis
• Significant psychiatric or behavioral symptoms that threaten the individual’s community placement
• Two or more crisis events within the past 180 days, with each event requiring at least one of the following: A call to mobile crisis or law enforcement (due to the crisis event), crisis stabilization services (i.e., behavioral respite), hospitalization in an acute psychiatric setting and/or ER intervention