To ensure continuity of care and smooth patient flow between sites, all patients at ARMS are assigned a primary case manager who follows them throughout their course of treatment at ARMS and in the community. A comprehensive needs assessment is conducted and an individualized plan of care is established that addresses the comprehensive needs of the patient. Patients are screened for entitlement to public benefits (such as Medicaid, Medicare, SSI, SSDI, food stamps, etc.), assisted in completing required forms, in accessing ARMS’ transitional and permanent housing or other housing available in the community, and in arranging transportation. Any patient needs not met by ARMS providers are referred to other agencies and organizations for care and followed up by ARMS staff to determine outcomes and recommendations for continued care.