Medicaid recipients hospitalized for psychiatric and/or substance use disorders have extremely high rates of readmission after discharge, as well as preventable visits to hospital emergency departments. The reasons have been well documented.  Very few receive help with the transition to community care and services are often not easy to access. The absence of appropriate community care also leads to unnecessarily long inpatient stays.

In addition to Pathway Home, CBC is developing new care transition services to address specific needs of high risk/high cost Medicaid populations throughout NYC.

Our interventions will facilitate access to CBC IPA’s network clinics, supportive housing, care management and ACT teams to more successfully transition participants 18 years and older to stable community care.  Care transition services will help ensure individuals engage with needed community services, are stably housed, and receive immediate assistance with any emerging issues, such as a problem with medication.

Key metrics of success for this intervention are to dramatically increase the numbers of individuals leaving inpatient care who complete their scheduled behavioral health outpatient visits within 7 and 30 days, and primary care visits within 45 days post-discharge.