The Community Transition In-Reach Services will support adults, age 21 and older, who meet the access criteria for specialty mental health services, and who are experiencing or at-risk of experiencing extended stays in institutional settings in returning to the community.
- Participating Behavioral Health Plans (BHPs) will have the option to establish community-based, multi-disciplinary care transition teams.
- The In-Reach Team will provide intensive pre- and post-discharge care planning and transitional care management services.
- Comprehensive assessment and periodic reassessment of individual needs, to determine the need for any medical, educational, social or other services.
- Developing a comprehensive individualized care plan.
- Referral and related activities (such as scheduling appointments for the individual) to help the eligible individual obtain needed services.
- Monitoring and follow-up activities.
- Identifying and addressing other system barriers, including social and financial issues, and facilitating linkages to social supports necessary to support successful reintegration of Medi-Cal members into their communities.
- Services available for up to 180 days prior to discharge.
- Qualifying BHPs may provide Community Transition In-Reach Services in inpatient, residential, or subacute settings, including IMDs.
The Community Transition In-Reach Services BHP Readiness Assessment addressing these criteria is included as an Enclosure to this BHIN. Participating BHPs must complete and submit the BHP Assessment via DHCS’ website at
Opt-in-to-BH-CONNECT.
