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Community Integration


Community Integration

Wednesday, March 15, 2017

Oregon State Hospital has launched a new, innovative and interdisciplinary initiative called the Person-Directed Transition Team.

We've put together a dynamic team of mental health professionals – a mix of clinicians and peer recovery specialists – to help people who have been civilly committed transition back to the community.

A collaboration between Social Work, Rehabilitation, Peer Recovery and OHA's Health Systems Division, the demonstration project puts a strong emphasis on person-directed planning and community integration. This team collaborates with patients to:

  • Support independence through skill building and education opportunities
  • Identify and secure the right housing, with a "key to their own front door" as appropriate
  • Learn about neighborhood resources, such as local retailers and healthcare providers
  • Build relationships with like-minded people with shared experiences, such as peer, vocational and personal support groups
  • Assist with employment efforts, such as filling out job applications and practicing for interviews
  • Conduct assessments for community readiness
  • Track metrics regarding patient and program success

All of these things will help patients build the skills and knowledge they need to successfully transition to life outside thehospital.

Program Goals

  • Connect Patients With Community of Choice

This includes familiarizing themselves with the features of the community, such as public transportation, grocery stores, libraries etc. Knowing one's way around the neighborhood and where its resources are are key to success.

  • Develop a Strong Support System

By connecting patients with the peer groups in their community, patients learn from people who have walked a similar path to overcome mental health and substance use challenges.

  • Find Employment

A huge piece of independence is being able to support one's self. Through vocational rehabilitation services, the project team works with each person to help them find jobs for which they are qualified AND that they find fulfilling.

Person-Directed Plans

One of the most important aspects of the demonstration project is to collaborate with patients to develop their own "person-directed plan." Where a treatment care plan is based on clinical goals, person-directed plans focus on the personal goals people want to achieve in their life.

Often these goals have nothing to do with their illness. Person-directed plans provide opportunities for people to define themselves beyond their diagnosis or clinical setting and can motivate patients to seek stabilization to achieve life goals.

Choice Model Program

The Person-Directed Transition Team is paid for through funding from the Choice Model program, formerly known as the Adult Mental Health Initiative,or AMHI, from OHA's Health Systems Division (HSD).

The Choice Model is focused on the development of housing resources, peer delivered services, supported employment and vocational rehabilitation. This will continue the work started by the Demonstration Project after patients have discharged to the community.

For more information on the project, email, or contact Rebecca Curtis, Person-Directed Transition Team (PDTT) manager, at or 503-945-2860.


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Community Integration3/15/2017
Introducing the new Person-Directed Transition Team3/6/2017

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