In Izumo City,Shimane,Japan,the Public Health Center has been organizing multidisciplinary outreach team to serve patients with severe mental illnesses since 2006. This team has been providing supervision and second-opinion services to cover the needs of patients, their families and local hospitals,and is composed of approximately 18 people; psychiatrists, mental health professionals and nursing staff.
 A dispatch of the service is regarded as a work at the affiliated institution and is offered free of charge to the consumers. The Public Health Center gathers appropriate persons upon the emergence of the case; the team is usually composed of 3 to 4 people to discuss the case. An individualized plan takes into action after a thorough discussion, but the actual practice is not necessarily provided by the team members. Most of referrals are concerned about untreated cases, and an emphasis is placed to respect patients’requests and to establish mutual trust, in order to guide them to psychiatric treatment.
 Since 2011, our outreach services are trying to especially target those who voluntarily stopped treatment, who are supposed to have serious mental illnesses, who need multiple admissions and who are withdrawn but left untreated. Each referral is carefully evaluated and necessary information gathered for acceptance into our service. Individualized support meetings take place once the referral is accepted and the team is established.
 Each team shares information on the case and decides individual role to play within it. The goal is to monitor the progress and to guide the consumers to the specialty treatment. In this paper, by sharing actual cases, we report on our efforts and future perspectives in Izumo City.