Project Summary People insured by Medicaid with a co-occurring serious mental illness (i.e., depression, schizophrenia, and bipolar disorder) experience persistent and growing disparities following medical hospitalizations and interventions that focus on their transitional care needs are lacking. Our study focuses on the adaptation of the THRIVE, an equity-focused evidenced based intervention that supports Medicaid-insured individuals with multiple chronic conditions transitioning from hospital to home. THRIVE services include coordinating care, standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital discharge. While evidence suggests robust improvements in post-discharge outcomes for THRIVE participants, it remains unclear whether the interventions equally benefit patients with and without SMI. The goals of this project are to adapt, implement and evaluate THRIVE to ensure suitability for all patients insured by Medicaid including those with co-occurring SMI. To meet this goal, we propose the conduct of a Type I Hybrid effectiveness-implementation stepped wedge cluster randomized controlled trial (CRCT)15 at a new site, the Hospital of the University of Pennsylvania Cedar Campus (HUP-Cedar). HUP-Cedar is a 100-bed minority serving hospital located in West Philadelphia where >50% of patients are Medicaid or dually Medicare and Medicaid-insured. This study represents a three-way partnership among health services researchers, community advisors, and health care leadership and staff at HUP-Cedar and Penn Medicine at Home and seeks as its primary objective to leverage participatory methods to adapt the THRIVE intervention and evaluate the context required for implementation. A second objective for this study is to examine differences in the utilization outcomes (e.g., readmissions) between THRIVE participants with SMI compared to those receiving usual care. Finally, we will employ mixed methods approaches through participant and clinician interviews and surveys to evaluate the acceptability, appropriateness, feasibility and cost of the intervention. Our study and engagement with community and health system partners is informed equity centered frameworks that will help to emphasize the systems, policies and delivery process from which inequities might arise. If our study hypotheses are supported, we will identify not only if an equity-oriented evidence-based intervention can be adapted and implemented to meet the needs of Medicaid insured patients including those with SMI, but we will also uncover the factors associated with those results. Our proposal is well-aligned with AHRQ's goal to develop and adapt EFEBI's that prioritize the voices and needs of the most underserved populations and change care processes to accelerate equity within healthcare systems. Collectively, the results of this study will provide the foundation for the next phase of our research, which includes a multi-site evaluati...