Transicare's PATs program is an intensive community based wraparound service utilizing teams composed of LPHA’s, QMHP’s and PEER’s to provide specialized engagement and support services to behavioral health populations evidencing recidivism or vulnerable to becoming revolving door individuals. Services typically begin in institutional settings with assessments to identify the phase specific needs of individuals which create the best opportunity to facilitate engagement in recovery and sustainable linkage to lower cost care settings. Phase tailored intervention is grounded in the evidence based practices of Critical Time Intervention and Prochaska & DiClemente’s Stages of Change in an effort to identify the unique continuity of care development needs of the individual. Services include transportation, case management, medication assistance, system advocacy and navigation intensively supported in the community in conjunction with stagewise motivational development and recovery engagement. System advocacy and navigation represents a dynamic need that requires PAT’s teams to proactively identify provider challenges in meeting an individual’s needs and collaborate with providers to find creative solutions to unique continuity of care issues.