For many people living with severe mental illness, the path between homelessness, emergency departments, jail, and back to the streets can feel impossible to escape. The Field-Based Integrated Transition Team (FITT) formerly known as the Forensic Intensive Treatment Team, part of Lane County Behavioral Health, is working to change that by bringing intensive psychiatric care directly to those who need it most.
What is FITT?
FITT is a street psychiatry team that provides intensive, community-based services to people experiencing severe mental illness who are unhoused and acutely ill. Rather than expecting clients to come to a clinic, the team meets people where they are, often on the streets, in camps, or other places they are living. The multidisciplinary team provides wraparound support that includes psychiatric care, therapy, case management, peer support, medication management, addiction treatment, court advocacy, skills building, medical care coordination, and connections to housing and community resources. Many clients also benefit from long-acting injectable antipsychotic medications that help stabilize serious psychiatric conditions. FITT primarily serves individuals with repeated involvement in the criminal justice system, hospitals, or other crisis services. The team’s goal is to stabilize clients over several months and help them transition to long-term community care, breaking the cycle of homelessness, incarceration, and repeated emergency interventions.
How FITT Differs from Mobile Crisis Services
Although both FITT and Lane County Mobile Crisis Services work in the community, they serve different purposes. Mobile Crisis Services respond rapidly when someone is experiencing an immediate behavioral health crisis. Their focus is short-term intervention, safety planning, and crisis response, often alongside law enforcement when appropriate.
FITT, on the other hand, provides ongoing treatment and relationship-based care. The team works with a smaller caseload of clients over an extended period, often several months, providing psychiatric treatment, case management, and intensive support until individuals are stable enough to transition to long-term community services. Together, these programs complement one another by addressing both immediate crises and the longer journey toward recovery and stability.
A Life Changed Through Persistence
One recent success story highlights the impact of FITT’s long-term, relationship-based approach. An individual referred to FITT by HIV Alliance had spent more than 30 years unhoused. They experienced severe psychosis that caused them to hear threatening voices every day, leading to frequent screaming in public. Because of these behaviors, they had been repeatedly assaulted, robbed, and barred from several community services, including shelters and public transportation. Rather than giving up, the FITT team continued showing up. Through 27 separate outreach visits, they built trust while helping meet the person’s basic needs and supporting them through the winter. Eventually, the individual agreed to begin treatment with medication. Over the following months, they stabilized on a long-acting injectable antipsychotic medication, and the voices that had dominated their life nearly disappeared. Today, after experiencing homelessness since the age of 19, they have been stably housed for several months and are preparing to move into permanent housing. They have regained identification documents, reactivated Social Security benefits, made significant progress in addiction recovery, and reconnected with their mother for the first time in many years. FITT is now helping transition them to traditional outpatient behavioral health and primary care services, an important milestone on their path toward long-term recovery. Stories like this reflect the heart of FITT’s work. By meeting people where they are, building trust over time, and providing comprehensive, compassionate care, the team helps individuals reclaim stability, reconnect with their communities, and create new possibilities for their future.
