Care as usual; no intervention.

CSC 2.0 arm will be offered 1:1 peer support, digital outreach, care coordination, multi-family group therapy, and cognitive remediation (if applicable).

• The study staff clinician will review all medical issues for each patient and reach out to primary care providers (PCP), dieticians, and other medical providers as needed.
• The study staff clinician will serve as point person for communication with emergency departments and inpatient providers if the patient requires those levels of care.
• The clinician will communicate with outside providers to provide background and ensure health decision making by those providers, visit and support patients as appropriate, access outside records and share with rest of the care team, and most critically ensure that a proper discharge plan has been made for the patient including care appointments, access to prescriptions and any new referrals made during hospitalization.

Number of months each participant had ≥4 visits in a 12-month period

Total number of clinic visits in a 12-month period

Numbers of different types of visits (eer provider, psychotherapy, psychopharmacology, group therapy, etc.) in a 12-month period

Exploratory analysis of variables collected by EPINET CAB by arm