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AIM OF THE STUDY Implementation and evaluation of a cross-sectoral complex care model for persons with severe mental illness (SMI). METHODS The care model was implemented at a psychiatric-psychotherapeutic specialized clinic. Within this patient-centered and needs-oriented complex care model, intensive case management was applied to transition persons with SMI between inpatient and outpatient mental health care. Evaluation was conducted using a matched control group design (n = 46/21). RESULTS According to clinical assessment, two thirds of the patients benefited from the care model. In the course of treatment, the patients showed a significant reduction in the use of inpatient psychiatric care structures and an improvement in clinical symptoms. CONCLUSION For people with SMI, there is a care gap in the in the transition from inpatient to outpatient care, which could be partially closed.