I would like to nominate the staff of the Behavioral Health's Community Psychiatric Nursing Program (CPNP) for the DAISY Team Award due to their dedication to evidence-based practice and improving the outcomes of the psychiatric population. In collaboration with the facility-based RCA group, staff from the inpatient unit, and team members of the CPNP, the framework of the program was refined in order to serve as a valuable resource as the first point of follow-up contact within 5-7 days of discharge for individuals identified as exhibiting a high risk for readmission. The improved framework for the program focused on improving patient utilization of positive coping skills, daily functioning, symptom management, and compliance with treatment and medication regimen. The improved framework assimilates principal components of transitional care into a single treatment model. Following discharge from psychiatric facilities, CPNP serves as an effective bridging intervention, providing patient education, medication reconciliation, assistance with scheduling follow-up care, continuity between inpatient and outpatient treatment settings, and medication monitoring through weekly home visits. Improving coordination, collaboration, and utilization of CPNP supports serves as an effective prevention intervention assisting the psychiatric population with safely transitioning from inpatient to outpatient care and reintegrating into a community setting with a goal of remaining hospitalization-free.