OUR MODEL
The 3 months after psychiatric discharge carry the highest risk.
Our model is built for that window.
Research shows that the 3 months following psychiatric discharge carry the highest risk for crisis recurrence, re-hospitalization, and self-harm - yet structured support during this time remains one of the most significant unmet needs in youth mental health care. What happens in that window, and how youth and their families are supported through it, makes all the difference. Our model asks youth what they want their life to look like and how they want to get there. From that answer, youth and their families co-design a personalized healing journey anchored in local community organizations. Our approach is backed by evidence, built for scale, and designed to transform how the system supports youth at the moment they need it most.
HOW WE CREATE CHANGE
Youth-led recovery + people they trust + community organizations = healing takes root
My System of Care Hubs are a network of trusted, evidence-based community partners - brought together within a geography and activated through a dedicated space inside a hospital or residential treatment facility. That's where youth and their families take the lead, designing their own 8 to 12-week healing journey before discharge. Our approach is adapted from Resource Groups, an evidence-based, patient-centered model shown to significantly improve empowerment, quality of life, and personal recovery.¹
Every partner in our network, including our advisory board, brings evidence-based programming, lived experience, and deep expertise. Each healing journey is built on what works:
Supports everyone in a young person's world - families, educators, clinicians, and peers - not just one person in isolation
Connects youth and their families to trusted local organizations, peer supports, and cultural resources in their own community
Empowers youth to be the architects of their own recovery - choosing who is in their network, setting their own goals, and leading the plan
Stays engaged through the critical 8 to 12 weeks of transition post-discharge
When young people are the directors of their own care - choosing who surrounds them and what recovery looks like - outcomes improve across every dimension of wellbeing. We activate that power, anchor it in the local community, and sustain it long after the transition home.
¹ Tjaden et al. (2021). Effectiveness of Resource Groups for Improving Empowerment, Quality of Life, and Functioning of People With Severe Mental Illness: A Randomized Clinical Trial. JAMA Psychiatry, 78(12), 1309–1318.
MEASURING IMPACT
How we measure success
We know impact lives in everyday moments - a young person returning to school, a family that feels empowered, a clinician who has a trusted community partner to call.
And, we measure what matters most - to youth, to families, and to the systems that support them.
We work with Subject Matter Experts and our community partners to continuously evaluate and improve our model using best practices in participatory research.
“We don’t heal in isolation, but in the community.”
~ S. Kelley Harrell, Author and Healing Practitioner
YOUTH OUTCOMES
Youth move towards thriving
Reduced symptoms of depression and anxiety, back in school, re-engaged with peers, and moving forward in their lives
CRISIS PREVENTION
Crises prevented, not just managed
Fewer emergency interventions, reduced hospital readmissions at 30 days and 6 months, and greater stability during the critical transition home
FAMILY SUPPORT
Families who feel equipped
Caregivers who understand what their young person needs and feel confident supporting them at home
SYSTEM IMPACT
A more effective system
Reduced emergency healthcare utilization and cost, with resources directed toward early, effective support rather than repeated crisis response
YOUTH VOICE
Youth and families who feel heard
Satisfaction with care, sense of ownership over the healing process, and confidence in what comes next
COMMUNITY CAPACITY
Increased community capacity
Local organizations have a stronger, more connected ecosystem
Ready to go deeper into how our model works in practice?
Evidence-based and anchored in community programming, our process meets youth and their families where they are at, clarifies where they want to be, and establishes a personalized roadmap to get there.