San Francisco Behavioral Health Services (BHS) requests funding through the SAMHSA FY 2021 Community Mental Health Centers (CMHC) Grant Program to implement the Care Coordination and Transitions Management (CCTM) Project, an innovative, collaborative intervention designed to support, restore, and enhance the delivery of community mental health center services that have been severely impacted by the COVID-19 pandemic. CCTM services will be specifically directed to persons living in the City and County of San Francisco who have diagnosed SED, SMI, and/or COD, and who have an unmet need for mental health and/or substance use disorder treatment. The two-year initiative will utilize a highly qualified, multidisciplinary CCTM team to provide centralized intake, assessment, referral, linkage, and engagement and retention support services on behalf of the entire community mental health center network in San Francisco. The overarching goal of CCTM is to significantly increase the number of persons with unmet or under-addressed behavioral health conditions who are successfully supported, stabilized, and anchored in mental health services and substance use treatment. CCTM will incorporate extensive peer support and involvement, wide-ranging telehealth and telemedicine strategies, and pro-active efforts to inform, educate, and link persons with qualifying conditions, with an emphasis on low-income and underserved populations, including homeless persons, persons recently released from incarceration, active substance users, and low-income persons of color. Following a 3-month project start-up phase, key outcomes of the program include: a) Providing multidisciplinary, team-based, centralized behavioral health engagement, assessment, referral, linkage, service planning, and retention support services for a minimum of 600 persons living with San Francisco with identified SED, SMI, and/or COD; b) Providing one-on-one peer based support services for at least 150 project clients with complex needs and/or co-occurring conditions; c) Conducting regular drop-in telehealth support groups co-facilitated by project staff and peers, using frameworks that include Wellness Recovery Action Plan (WRAP) and Seeking Safety; d) Achieving a six-month GPRA follow-up rate of at least 80% for enrolled clients (n=480); e) Documenting self-reported improvements in mental and physical health, family and living conductions, education and employment status, and/or social connectedness for at least 75% of clients who participate in CCTM services for a minimum of 3 months; and f) Documenting increased satisfaction with behavioral health service referrals, linkage and service coordination among public and private community mental health center staff as measured through surveys and key informant interviews. In addition to a half-time Project Director, the core CCTM team will consist of a Clinical Supervisor / Social Worker, two Behavioral Health Clinicians / Social Workers, and two Health Workers / Client Navigators. The project will also employ five half-time Peer Specialists with lived experience of mental health and/or substance use issues who provide provide ongoing support for CCTM clients, including through informal one-on-one counseling, system navigation / linkage support, and drop-in group facilitation services. A part-time Nurse Practitioner Medications Manager will monitor, prescribe, and evaluate medication treatment regimens for clients, including Medication Assisted Treatment (MAT). A highly qualified consulting firm, Hatchuel Tabernik and Associates, will oversee project evaluation and quality improvement activities.