A Community Outreach program, based on a Health Home Service Model (IHH) and Assertive Community Treatment (ACT), offering specialized clinical care and comprehensive care coordination for adult individuals diagnosed with severe and persistent mental illness in Rhode Island. Ocean State Outreach is an open-referral program that utilizes the DLA-20 to determine program eligibility. As part of a network of programs Ocean State Outreach supports individuals through these service categories: Comprehensive Care Management, Care Coordination, Health Promotion, Comprehensive Transitional Care, Individual and Family Support Services, and Referral to Community and Social Support Services. Programming centers on recovery and resiliency with an emphasis on rehabilitation and person- centered care to manage co-occurring behavior health needs, improve activities of daily living, and increase independence in order to transfer to a lower level of care. OSO workforce members work with individuals and their stakeholders through a combination of community-based and office-based services indicated by their comprehensive assessment and person-centered plan.