Project Transition is partnered with TennCare, Amerigroup, Blue Care, United Healthcare, the TN Department of Intellectual/Developmental Disabilities (I/DD), and local provider agencies to deliver Systems of Support (SOS) services to children and adults with I/DD who also experience behavioral challenges that pose a risk to their safety and stability in the community.
Project Transition collaborates with SOS members, their supports, and with state-wide mobile crisis teams to improve their lives and ability to self-regulate and thrive in the community.
The SOS Mission: Building integrated systems of support through innovative partnerships and collaboration to empower Tennesseans with I/DD to live the lives they want in their communities.
Who is SOS Designed for?
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
Systems of Support Goals
- 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
Admission Criteria for SOS
- 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