InvisALERT Solutions – ObservSMART

Stopping the Hospital Revolving Door: A Pathway Home to Stable Community Life

A not-for-profit organization formed by behavioral health (BH) community agencies, Coordinated Behavioral Care (CBC) operates one of NYS’s largest Health Homes (HH) and has formed an IPA to deliver integrated outcomes-oriented care. The many care managers who work with our HH members often face insurmountable challenges to support individuals after they are discharged from a long episode of inpatient care. There simply are not dedicated, flexible, time-limited services available in NYC to provide inpatient to community care transitions services.

In 2014, CBC created Pathway Home (PH), a care transitions program funded by the New York State Office of Mental Health, to fill this service gap. Operating in Brooklyn, the Bronx, Manhattan and Queens, three multidisciplinary teams comprised of licensed mental health clinicians, case managers, nurses and peers offer community-based time-limited services (average six months) 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.

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 after hospital discharge. The intensity, type and duration of services vary depending on the individual’s needs. By the time a PH participant is ready for “discharge,” they have engaged with appropriate outpatient providers and are following prescribed treatment. They are stably housed with benefits and adequate food, and have reconnected with family/friends and/or started to develop new social networks. Many have formed a trusting relationship with a HH care manager.

Literally, CBC’s Pathway Home bridges the divide between the 3 to 9-month post-discharge period when individuals are both vulnerable and face gargantuan challenges until they engage with community services. The program’s target population are adults with serious mental illness, many of whom are being discharged from State Psychiatric Centers. This group is at an extraordinary disadvantage navigating the complex and fragmented community care system. Fundamental independent living skills required to take care of basic needs may be lost or eroded during a long hospital stay. Yet how can a person survive, much less thrive, without the skills to use public transportation, buy food on a budget, prepare nutritious meals and maintain new housing? Additionally, the social determinants of health, if not adequately addressed, result in poor outcomes, avoidable readmissions and emergency department visits. Consistent and meaningful mental health treatment, along with adequate case management, is important to stabilization post-hospitalization.

The CBC Pathway Home model achieves positive outcomes by addressing four key areas:

  1. Pre-Discharge Engagement/Planning:

Early engagement is important to increase participation and build a therapeutic rapport. Many of the barriers and challenges that impact success at discharge can be identified, mitigated and resolved during the inpatient stay. As well, potential pitfalls and problematic issues can be preemptively addressed before they can undermine the individual after discharge. The CBC team begins developing a relationship before discharge that is critical to the success of the intervention. Simultaneously, the team collaborates with the care team (e.g. hospital, housing and support staff) to develop a discharge plan that connects multiple systems of care and establishes accountability. With input, the Care Plan better reflects the unique personality and immediate needs of each individual. If family is involved, CBC will engage them as a support during the transition.

Early engagement helps forestall some typical causes of community instability during the care transition. During the transition, unexpected and unanticipated challenges or barriers to community stability can occur. For example, appointments with clinics or doctors may not be scheduled by the inpatient discharge staff, or they may be made so far in the future that medication will be depleted. Pathway Home staff can problem-solve during the discharge process or advocate directly with the outpatient provider to address any issues.

The CBC team is available to accompany the individual home upon hospital discharge, allowing an in vivo assessment and resolution of any immediate needs that may pose potential barriers to care. In the first week, the individual has an appointment at a BH clinic, which Pathway Home will facilitate by either accompanying or meeting the individual there. The team visits several times a week and at times daily immediately post-discharge, depending on the needs of the individual. Medication management and reconciliation support is provided by nurses. If transportation is needed but not arranged, Pathway Home will arrange it to ensure attendance.

  1. Community Providers/Natural Supports Linkages: To prepare for long-term stability in the community, individuals are connected with various resources. Appointments are made with community providers of outpatient clinics and programs, as well as clubhouses, vocational, educational and other services that can lead to successful transitions. Pathway Home is an intense support that is meant to be temporary. A key priority is to facilitate enrollment and engagement with the CBC Health Home, so that care management services are in place after our care transition services end.
  2. Community Reintegration: Successful transition is not just about making appointments and taking medication. People need to feel productive and engage in meaningful activities, such as relationships and social networks that provide friendship, love and hope. The CBC Pathway Home team accesses both community resources and State-sponsored wrap-around funds to help address issues that may negatively impact success in the community (e.g. smart pill dispensers, clothing, or transportation). Family meetings are offered to provide psycho-education and support to both the person served as well as their family members. These types of activities not only support treatment goals, but imbue purpose and meaning into an individual’s life.
  3. Fostering Self-Efficacy: CBC Pathway Home ensures that the time-limited nature of the intervention is made known at beginning of the relationship. Self-efficacy and self-sufficiency are fostered by encouraging participants to be accountable for their own treatment. Individuals are expected to assume responsibility by making appointments, managing medications, and becoming productive in the community. Using Motivational Interviewing, the team shares tools that support skill-development and self-reliance. Participants are better prepared to function independently after the intervention ends.

Stopping the Revolving Door: Through Medicaid system redesign, NYS is seeking to reduce avoidable inpatient admissions and emergency room presentations. CBC Pathway Home is contributing to achievement of this goal with a person-centered, skills-building care model. In two years, we have helped participants achieve better health outcomes: 93% attended a BH appointment within 30 days and 82% attended a medical appointment within 90 days of inpatient discharge; and 79% enrolled in a Health Home prior to Pathway Home discharge.

CBC Pathway Home is a Hospital to Home intervention that is stopping the revolving door by improving health outcomes and reducing avoidable costs. It successfully addressing treatment-related issues and social determinants of health that are drivers of preventable readmissions and/or emergency room visits. As important, many participants are now thriving in their communities, connected to care, and living healthier, happier lives. In 2017, CBC seeks to build on this model of care for similar vulnerable populations, including individuals who are justice involved, have medically co-morbidities and/or are long-term chronic State hospital patients.

Danika Mills is the Executive Director of Coordinated Behavioral Care, Inc. & Coordinated Behavioral Care IPA and can be reached at 646-930-8803 or . Barry Granek is the Program Director of Pathway Home at Coordinated Behavioral Care and can be reached at 917-242-2090 or For more information, visit

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