Beyond the ER: A $1.8 Million Partnership Reshaping Emergency Room Services in Cook County

In an instrumental advancement of healthcare access and support for Cook County residents, Thresholds is proud to announce a new $1.8 million partnership with Cook County Health for enhanced emergency mental health services and aftercare called the Assertive Community Linkage Program. This transformative new program, funded over three years, will address the recurring instance of high Emergency Department (ED) utilization by individuals with mental health and substance use conditions in communities around Chicagoland. The funding is made possible through the American Rescue Plan Act (ARPA) and was allocated to Cook County Health by Cook County government.

Engagement Specialist Greg Sutherland, Team Leader Ariellah Goldbloom and Engagement Specialist Stacey Holmes

“We know that to improve the health of Cook County residents we must create more access points where people can get the care they need when and where they need it. Thanks to ARPA funding, we have been able to invest in patient-centered programs to bridge gaps in essential health care services,” said Cook County Board President Toni Preckwinkle.

Working with Cook County Health, Thresholds teams have identified gaps in care for individuals those who regularly seek medical and psychiatric care at EDs throughout Cook County, including Cook County Health’s Stroger Hospital on Chicago’s West Side and Provident Hospital on the South Side. These individuals, often experiencing homelessness and lacking essential resources, find themselves trapped in a cycle of repeated ED visits, a pattern known as the “revolving door syndrome.”

“We are thrilled to launch this new program with partners who share our passion and goals for equitable healthcare,” said Mark Ishaug, President and CEO of Thresholds. “This collaboration with Cook County Health builds on the existing success of our Crisis Team at Stroger Hospital, ensuring continuous care for clients, stabilizing their lives, and providing access to the essential care that everyone deserves.”

Thresholds and Cook County Health are committed to reducing the “revolving door” and changing lives. The Assertive Community Linkage Program will provide enhanced services beyond the ED for those in need.

“Cook County Health is pleased to expand our partnership with Thresholds to establish an Assertive Community Linkage team. Through this program, we are extending our ability to serve far beyond our emergency departments. We are offering patients in need not just immediate treatment but ongoing holistic support, understanding, compassion, and a lifeline to recovery,” said Dr. Erik Mikaitis, Interim CEO, Cook County Health.

The Linkage Team aims to reduce the number of ED presentations and 30-day readmissions, to connect people with stable housing, and to engage patients in community-based mental health, substance use, and primary care services. The new Linkage Team will work with individuals in partnership with the existing Crisis Team to create the best care plan for each client.

Ariellah Goldbloom, Team Leader for the new Assertive Community Linkage team has seen the impact of “revolving door syndrome” firsthand and is eager see these enhanced services break the cycle and offer more long-term solutions.

“When it comes to treating high-utilizers, immediacy and empathy are everything,” Ariellah shared. “The linkage team establishes contact with potential clients, reaching out before, during, and after their hospital stays and offering holistic support in a timely manner. The Assertive Community Linkage Program will now be able to step in to provide ongoing assistance, ensuring individuals receive the support they deserve from individuals they trust.”

The new Linkage Team will collaborate with Cook County Health and the existing Thresholds crisis team to offer mental health and care coordination services, including aiding in Medicaid and SSI/SSDI applications, connecting individuals with community-based primary healthcare, and psychiatry services. The Linkage Team will provide a seamless transition from the immediate care offered by the Crisis Team, engaging people in the community before and after they are discharged from the ED, helping with prescriptions, coordinating transportation for follow-up medical appointments, and ensuring access to short-term/emergency housing. Clients will be able to meet with their case manager frequently, offering flexibility and personalized support until permanent care is in place.

Another impactful addition will be the provision of no-cost cellphones for scheduling appointments and helping clients feel more connected. Ariellah added, “By taking both practical and emotional needs into account, our team is able to make an immediate and long-term impact.”

“The services and connections this team provides are not merely a program; they’re a lifeline—a testament to the power of timely, human-centric care,” said Ariellah. “By breaking down barriers and providing immediate support, we can make a meaningful difference for a healthier future.”

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