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Continuity of Care with Transition Specialists Program (CCTS) Transitioning from Colorado Mental Health Institutes

Continuity of Care with Transition Specialists Program (CCTS) Transitioning from Colorado Mental Health Institutes. 
Program Background: 

The current behavioral health system lacks adequate capacity to deliver intensive community-based behavioral health services for clients who have been committed/certified/ or are voluntarily receiving emergency-stabilization behavioral health treatment services.


The Office of Behavioral Health identified the need for an increase in service capacity to more seamlessly address the service needs of those individuals who have been committed/certified/ or are voluntarily receiving emergency stabilization behavioral health treatment services. 


Program Description:

The program created positions for Transition Specialists and Peer Bridgers that assist clients and communities statewide in managing the transition from hospitalization to less restrictive alternatives, employing a wraparound services approach.


The Transition Specialists will assist adult and juvenile clients in accessing services and benefit acquisition, coordinating various services and funding sources, identifying and strengthening formal and informal community resources, and mobilizing helping networks.  


The supports provided by the specialists will complement and enhance the services provided by Assertive Community Treatment (ACT) providers. 


The Transition Specialists will facilitate community reintegration and manage funds (Money Follows the Individual) for wraparound services which are not otherwise supported with insurance or other funding sources for persons transitioning from the two state mental health institutes.

Population Served:

The priority for the service will be for individuals who have been hospitalized at either the Colorado Mental Health Institute at Pueblo or the Colorado Mental Health Institute at Fort Logan. The service will mainly focus on individuals on the discharge barrier wait list, but will also provide a service for any clients at the Institutes that meet the following criteria:


  • Individuals who have been hospitalized in the Institutes for one year or more
  • Individuals who have a demonstrated past history of significant barriers which have prohibited them from a successful transition into their home community. 
  • Individuals who have had 3 or more inpatient psychiatric readmissions at any hospital within the previous 12 months
  • Defendants pleading not guilty by reason of insanity (NGRI)
Program Services:

Transition Specialists will coordinate of ongoing, individualized care planning and  will work to ensure the provision of all wrap around services including, but not limited to, the following:


  • Transportation costs to promote engagement in treatment and community integration;
  • Necessary assistive technologies;
  • Independent living skills training including structured daily activities (e.g. recreation centers, continuing education and training), assistance with management of finances, transitional specialized rehabilitation and client-directed attendant support;
  • Home delivered meals if necessary (Project Angel Heart, Meals on Wheels, Volunteers of America and various regional food banks);
  • Residential placements that may include enhanced Assisted Living Residences (ALRs) or other residential placement options;
  • Vocational/occupational rehabilitation and therapy (that is not funded by Medicaid or Division of Vocational Rehabilitation);
  • Academic educational services; 
  • Home modifications;
  • Personal care; 
  • Sex offender management board approved treatment; 
  • Polygraphs; 
  • Surveillance equipment such as electronic monitoring devices;
  • Personal needs such as work uniforms and costs associated with volunteer activities; 
  • Individualized peer mentoring;
  • Smoking cessation/nicotine patches; 
  • Respite care for family members caring for individuals; 
  • Guardianship and payeeship fees and sservices;
  • Any other client centered expense that will support a successful and permanent transition into the community.


Program Contacts:
Katie Herrmann, LCSW
MHI Transition Program Manager
Behavioral Healthcare, Inc.
Direct line: 303-361-8124
Fax: 720-490-4395

Jagruti Shah, M.A., LPC, CAC III
Manager, Offender Mental Health Programs
Colorado Office of Behavioral Health
3824 West Princeton Circle
Denver, CO 80236-3111
(303) 866-7504