<p>U.S. healthcare systems struggle to provide needed services for those with mental health needs, particularly those with serious mental illness who may have difficulty connecting and/or continuing in traditional outpatient care. The lack of adequate mental health care is related to numerous negative outcomes. Often people who have difficulty connecting to adequate care are caught in a ‘revolving door’ of emergency or crisis care even when adequate outpatient care is available. In this work we describe the development and clinical monitoring of a unique, prevention-focused, low-resource pilot intervention designed to foster a longer-term outpatient treatment connection for people who were not connecting with outpatient care despite demonstrated need. Results indicate positive impact on symptoms as well as successful connection to and utilization of longer-term outpatient care post-discharge. Key strategies that promote successful assessment/monitoring that can increase sustainability for clinically-focused interventions are provided.</p>