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.
Please email PathwayHomeInfo@cbcare.org or call (646) 930-8841 to learn more and discuss a possible referral.
• 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.
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:
- is 18 years of age or older;
- has a stable housing plan at time of hospital discharge within New York’s five boroughs;
- 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;
- is not enrolled with another program that offers duplication of services (e.g. Assertive Community Treatment/Mobile Integrated Treatment/Intensive Mobile Treatment);
- 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;
- For inpatient referrals, an upcoming discharge to the community (e.g. State Psychiatric Center, Article 28/31 hospital and or other inpatient setting); and
- For community referrals, referred from a State-Operated Residential Facility (TLR).
• 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
• Catholic Charities Brooklyn & Queens
• Community Access, Inc.
• Institute for Community Living, Inc.
• The Jewish Board of Family & Children’s Services
• Postgraduate Center for Mental Health
• Samaritan Daytop Village
• Services for the Underserved, Inc.
• Visiting Nurse Service of New York
• WellLife Network
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
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)