The document describes a pilot program between Abbott Northwestern Hospital and five community mental health agencies to improve care transitions for mental health patients. The program hired a Mental Health Navigator and Peer Support Specialist to enhance discharge planning and establish outpatient services. Initial outcomes include a 30% reduction in readmissions, increased engagement in recovery planning, and positive patient experiences and feedback. The success of the program is attributed to improved communication, care coordination, and a focus on patient engagement through trusting relationships and recovery-oriented services.