Lead intervention team for each PS, comprised of a combination of Outreach Worker(s), Nurse, Housing Coordinator, Addictions Recovery Counselor, Peer Specialist, Community Connector, Employment Coordinator and/or Family Connector based on specific needs of PS.• Oversee service delivery to all assigned PS, including participation in services, treatment and support skills planning and implementation of recovery goals, peer and family support, readiness for discharge, and support through service and life transitions, including acute care and housing transitions. Promote healthcare and employment services access for PS.• Promote engagement, safe housing, community tenure, achievement of greater self-sufficiency and successful completion of service for all PS.• Assign and direct Outreach Workers to deliver specific skills training and supports needed for Treatment Plan success for PS living in independent settings.•