Pathway Home™ is a community-based care transition/management intervention offering intensive, mobile, time-limited services to individuals transitioning from an institutional setting back to the community.

A successful transition from inpatient care often demands navigating a complex and fragmented health system. Pathway Home™’s goal is to ensure uninterrupted and coordinated access to behavioral and physical health services while addressing the social determinants of health. CBC acts as a single point of referral to multidisciplinary teams at ten care management agencies (CMAs) in CBC’s broader IPA network. These teams maintain small caseloads and offer flexible interventions where frequency, duration and intensity is tailored to match the individual’s community needs and have the capacity to respond rapidly to crisis.

 
Please email PathwayHomeInfo@cbcare.org or call (646) 930-8841 to learn more and discuss a possible referral.

 

Services

Collaboration with community and familial supports to develop aftercare plan connecting multiple systems of care while delineating specific responsibilities;
Accompaniment home on day of transition having resolved immediate needs and assessed necessary skills for development;
Skills-building and engagement, with an emphasis on identifying goals that help provide the necessary motivation to improve or maintain health;
Advocacy for appropriate primary and specialty care, as needed;
Coordination with and accompaniment to initial behavioral health and/or primary care appointments, as well as linkages to other healthcare appointments;
Benefits and entitlements support from access to completion of relevant paperwork;
Expedited housing placement through existing in-network resources that circumvent barriers to community living;
Facilitated care management enrollment and engagement, including Health Home, Assertive Community Treatment, and others;
Wrap-around enhancement funds that subsidize activities or resources that help meet individual needs or goals;
Family conferences providing psychoeducation, support and social services; and
Ongoing assessments of health and social determinants needs.

 

Eligibility Criteria

Pathway Home™’s transitional care model serves individuals with significant behavioral health challenges or disabilities that make engaging in community care difficult. Additional criteria for enrollment require that participant:

    1. is 18 years of age or older;
    2. has a stable housing plan at time of hospital discharge within New York’s five boroughs;
    3. completes referral packet that includes the candidate’s signature consenting to voluntary acceptance of services and all applicable supporting documents, i.e. psychiatric evaluation and social history;
    4. is not enrolled with another program that offers duplication of services (e.g. Assertive Community Treatment/Mobile Integrated Treatment/Intensive Mobile Treatment);
    5. is referred from a State Psychiatric Center, State Operated Transitional Residence (SOCR / TLR) or from an Acute Hospital setting as a diversion to intermediate care in a State Psychiatric Center;
      1. For inpatient referrals, an upcoming discharge to the community (e.g. State Psychiatric Center, Article 28/31 hospital and or other inpatient setting); and
      2. For community referrals, referred from a State-Operated Residential Facility (TLR).

 

Teams

CBC Pathway Home™ teams recently expanded to serve several distinct populations. These include:

 

Adult Home Teams;
Embedded Teams (at Bronx Psychiatric Center & Metropolitan Medical Center);
OASAS Teams (referred from SUD detoxification/rehabilitation settings);
One City Health Teams (referred from Harlem, Metropolitan, Lincoln or Coney Island Hospitals);
Healthfirst Teams (Medicare, Medicaid Advantage Plus and dual eligible populations);

 

Care Management Agency Partners

CBC Pathway Home™ currently partners with ten of New York City’s leading community-based behavioral health providers to deliver care and coordinate services for its enrollees:

 

 

Presentations

Alcoholism and Substance Abuse Providers of New York State, Inc. (ASAP) and the Office of Alcoholism and Substance Abuse Services (OASAS) 2019 Statewide Prevention Conference. (April 16th, 2019) Poster board sharing successful outcomes of Pathway Home Embedded Team 730 project—Aja Evans and Monisa Lane

American Case Management Association 2019 Annual National Case Management and Transitions of Care Conference. (April 15th, 2019)—Mark Graham and Barry Granek

National Association of Case Management 24th Annual Conference: Start Your Engines, Leading the Race Towards Excellence in Case Management. (October 3rd, 2018)—Barry Granek and Nikenya Hall

The New York Academy of Medicine, Population Health Summit IV: Working Across Sectors to Address Social Determinants of Health. (December 12th, 2017)—Mark Graham and Barry Granek

NYS DOH Balancing Incentive Program BIP Innovation Fund Grants Results Meeting. (September 22, 2016)—Mark Graham and Barry Granek

NYS Care Management Annual Conference: The Bridge to Care, Wellness and Recovery. (May 8, 2016)—Barry Granek and Rika Gorn

 

Publications

Granek, B. & Frisco, J. (2019) Case Management Practice Improvement Award Recipient: Pathway Home™ Program. CMSAtoday Issue 5. pp 10

Petit, J. R., Graham, M. & Granek, B. (2018). Pathway Home: An Innovative Care Transition Program from Hospital to Home. Psychiatric Services, 69(8), pp. 942-943

Petit, J. R. & Granek, B. (2018). Virtual Pathway to Technology-Assisted Care Models: Keeping Up with New Technology in Behavioral Health Care. Behavioral Health News, 5(4), pp. 22

Mills, D. & Granek, B. (2017). Stopping the Hospital Revolving Door: A Pathway Home to Stable Community Life. Behavioral Health News, 4(4), pp. 29

OMH Newsletter (May 2018)

OMH Newsletter (February 2017)

 

Honors & Awards

Case Management Society of America (CMSA) Case Management Practice Improvement: Pathway Home (June 2019)
CMSA’s Award for Case Management Practice Improvement recognizes an organization that uses findings from a quality/performance improvement (QI/PI) project for innovation in the advancement of case management practice and/or improved client outcomes.

Crain’s Heritage Innovation in Healthcare Delivery Award (2019 winner, 2018 finalist)

Scattergood Innovation Award, presented by The Thomas Scattergood Behavioral Health Foundation and the National Council for Behavioral Health (2019 finalist)

NACM (National Association of Case Management) Innovation in Case Management Practice Awards (October 2018)

Benefits: Pathway Home

94% of all Pathway Home participants stayed out of the hospital during their first 30 days back in the community
89% of participants were not hospitalized at all during the duration of the program
91% of participants living in the community attended a behavioral health appointment within 30 days of hospital discharge
77% who completed the intervention had Health Home or ACT services in place.
75% attended an appointment with their primary care provider within three months of inpatient discharge