Follow-through
A Mobile Access Visit is useful only if the next connection keeps working.
MAV connects outreach to continuing support. The safety net is the process that keeps a person from falling back into the same gap after the Mobile Access Visit ends.
Six-stage continuity loop
Every stage has an owner and an exit condition.
Find people before crisis.
Community education, trusted hosts, events, schools, workforce, libraries, health sites and referrals make the front door visible.
Done when: the person knows a usable route into support.
Identify the actual barrier.
Separate communication, sensory, medical, behavioral-health, school, benefits, work, housing, transportation, diagnosis and caregiver needs.
Done when: there is a prioritized list rather than one vague “needs services” label.
Protect capacity.
Lower sensory and interaction demand when overload is blocking the next step.
Done when: the person can safely continue, pause with a plan, or transfer to an appropriate crisis/emergency service.
Do what can be done now.
Communication tools, appointment prep, resource search, safety plan, peer connection, Passport, benefits/workforce route or other immediate task.
Done when: the immediate problem is reduced or clearly handed off.
Get into the right continuing service.
Regional Dock, primary care, specialist, behavioral health, DHS, school, workforce, housing, clinical evaluation or other responsible route.
Done when: the receiving route is confirmed—not merely suggested.
Check whether the connection worked.
Failed referral, missed appointment, inaccessible communication or new barrier returns to navigation instead of closing the case as “referred.”
Done when: the person has a stable next route or chooses to end follow-up.
When a handoff fails
The system should show the failure.
No answer
Try another contact method, confirm office hours, use online/physical alternatives, or route to a navigator who can follow up.
Not eligible
Record the stated reason, explain appeal/alternate routes when applicable, and do not tell the person simply to “call around.”
Wait list
Create interim supports and a follow-up date instead of treating the wait list as completed care.
Communication/access failure
Document what accommodation or communication route is needed for the next attempt.
Transportation barrier
Look for telehealth, NEMT/transport benefits when eligible, a nearer site, a future MAV stop or a combined trip plan.
Crisis escalates
Transfer to the appropriate emergency or behavioral-health crisis pathway; MAV remains an access/prevention service, not a substitute for emergency response.
Follow-up cadence
Follow-up should match the risk of the handoff failing.
High-friction or urgent connection
Confirm that a scheduled urgent route, crisis transfer, medication/medical handoff or time-sensitive benefit/document action actually reached the receiving service.
Appointment or referral connection
Check whether the appointment was scheduled, whether the person can reach it and whether communication/access needs were conveyed.
Longer-term navigation
Review wait-list status, Passport updates, peer connection, benefits/workforce progress and new barriers without turning follow-up into surveillance.
Safety categories
Not every difficult situation is the same problem.
Overload / shutdown / meltdown
Reduce demand and input; protect communication; check for injury or medical concerns; do not automatically treat autistic distress as psychiatric danger.
Pain, breathing, injury, medication or acute illness
Use the appropriate medical route. Sensory accommodations can continue while medical needs are assessed.
Suicidal thoughts, severe psychiatric crisis or substance-related crisis
Connect to appropriate crisis services within policy and scope. MAV can support communication but does not replace the behavioral-health crisis system.
Unsafe housing, violence, exploitation or immediate social danger
Use the responsible safety, shelter, protective or legal support route while respecting the person’s communication needs and choices where possible.
Family/caregiver capacity is collapsing
Separate the person’s needs from caregiver exhaustion, identify respite/support options and avoid making one person’s distress the sole explanation for the other’s.
The service itself is causing the escalation
Change the communication or environment, document the barrier, and route the complaint/access issue when the receiving system will not accommodate.
Four-stage Safety Net
A simple view of the continuing pathway.
The expanded workflow can still be understood as four public stages: outreach, triage, expedited connection and continuous care.
Reach people earlier.
Identify people earlier, build local trust, reduce stigma, train community pillars, distribute useful sensory/communication tools and make the next access route visible.
Understand what is blocking access.
Review immediate needs, functional barriers, sensory risks, crisis risk, referral urgency, communication/AAC needs, executive-function load and caregiver strain.
Move into a real service.
Use telehealth review, regional clinic referral, adult diagnostic routes, early intervention, case management, benefits/workforce connections or another appropriate service, with the handoff prepared rather than merely named.
Keep support active.
Use the Access Passport, peer support, safety plans, resource navigation and regional follow-up so the connection does not disappear when the Mobile Access Visit ends.