Systems of Support (SOS)

Project Transition is partnered with TennCare, Amerigroup, Blue Care, United Healthcare, TN Department of Intellectual/Developmental Disabilities, and local provider agencies to deliver Systems of Support (SOS) services to children and adults with Intellectual and Developmental Disability 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 IDD and mental health diagnosis with behavioral challenges
  • Those who have been determined by their MCO orcare 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

SOS Services

  • 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 mentalhealth 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