When discharge is complicated, we help make the next step possible.
Independent, person-centered transition support for individuals facing mental health needs, housing instability, low income, Medi-Cal and other social barriers.
We connect clinical discharge with the real-world support patients need to move forward safely.
Our team works alongside clinical staff to identify barriers early, connect individuals to resources, coordinate referrals, and create a practical, understandable discharge plan connected to care.
Identify the Barriers
- Homelessness or unstable housing
- Mental health and behavioral health needs
- Transportation, phone or access barriers
- Food, benefits, income and other basic needs
- Limited family or natural supports
Connect to the Right Resources
- Medi-Cal and low-income services
- Behavioral health and primary care
- Housing and shelter resources
- Benefits, food and transportation resources
- Community programs and supportive services
Strengthen the Discharge Plan
- Follow-up appointments and referral coordination
- Medication and care transition support
- Plain-language review and teach-back
- Warm handoffs when appropriate
- Clear next steps, contacts and locations
Stay Connected After Discharge
- Reinforce community referrals
- Help address practical barriers
- Support engagement with services
- Coordinate appropriate updates with the care team
- Escalate urgent concerns through clinical pathways
WHEN TO REFER: Consider our team early when social barriers, housing instability, behavioral health needs, limited income, or difficulty accessing services could affect discharge.