Individuals served may experience serious mental illness, co-occurring substance use disorders, histories of trauma, homelessness or housing instability, repeated psychiatric hospitalization or crisis utilization, difficulty maintaining consistent treatment engagement, limited natural supports, transportation barriers, financial instability, medical needs, and other social determinants that interfere with successful community living. Responsibilities include coordinating access to behavioral health treatment, psychiatric and medical services, substance use treatment, housing, benefits, transportation, employment, peer support, and other community resources; conducting assertive outreach; assisting with transitions between levels of care; monitoring participant needs and progress; and maintaining communication with the multidisciplinary AOT team.