CBC Pathway Home is a Care Transitions Program that offers mobile, time limited services in NYC for adults with serious mental illness transitioning from the hospital to the community.
A successful transition from inpatient care often demands navigating a complex and fragmented health system. Those with extended stays, for example at a State Psychiatric Center, are exposed to additional challenges as they often have not been effectively connected to ambulatory care and are frequently ill prepared for community living.
CBC is breaking this cycle with Pathway Home (PH), an innovative care transitions program funded by the New York State Office of Mental Health. PH uses the evidenced-based Critical Time Intervention (CTI) model, providing intense services beginning shortly before hospital discharge to build trust and continues with the individual into the community for six to nine months after hospital discharge. Operating in Brooklyn, Manhattan, Queens, and the Bronx, four multidisciplinary teams comprised of Licensed Mental Health Clinicians, Case Managers, Nurses and Peers offer community-based time-limited services for adults with serious mental illness who have experienced long-stays in psychiatric inpatient care. PH staff address a host of issues—housing, food, economic security, medication adherence, linkage with outpatient providers, family conflict, and social isolation–faced by individuals transitioning to the community.
Pathway Home teams offers:
• Hospital engagement beginning on the unit, involvement in discharge planning, and a needs assessment of community transition supports essential to stabilizing the individual;
• Health education and connection to primary care to address physical health issues that impact a patient’s ability to successfully live in the community;
• Peer support from individuals with shared experiences;
• Short term counseling (substance use, coping skills, trauma informed, decision making);
• Discharge medications and post discharge medication management and reconciliation support including financial support when indicated;
• Patient navigation by accompanying to first behavioral health and medical appointment, travel training, reengagement in community care, referral to services;
• Linkages and appointments with community providers of outpatient clinics and programs for individuals with serious mental illness (SMI) and substance use disorder (SUD), clubhouses, vocational and educational programs, and other services that are paramount to successful transitions;
• Facilitate enrollment and engagement with Health Home or ACT services;
• Wrap-around enhancement funds are utilized to address any individual issues that may negatively impact success in the community (e.g. individual comes home from hospital to empty refrigerator and SNAP benefits not in place yet, transportation to appointments, season appropriate clothing);
• Skills-building and engagement, with an emphasis on identifying goals that help provide the individual with the motivation to take care of their health and learn the skills needed to be successful in community housing;
• Timely access to Crisis Intervention services once in the community including respite referrals and other diversion and stabilization services; and
• Community Reintegration through developing relationships and social networks that provide support, friendship, love, and hope. Inpatient family conferences will be offered when indicated to provide psycho-education and support and promote reunification.
Outcomes have shown that Pathway Home decreases hospital readmissions, shortens lengths of stay and reduces emergency department use for Medicaid-eligible patients with serious mental health disorders. Pathway Home is now funded by the New York State Office of Mental Health (OMH).
To find out more or to make a referral, please contact us at (646) 930-8841 or email PathwayHomeInfo@cbcare.org.