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Tia Burroughs Clayton, MSS
Learning and Community Impact Consultant

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Alyson Ferguson, MPH
Chief Operating Officer

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Vivian Figueredo, MPA
Learning and Community Impact Consultant

Derrick M. Gordon, PhD
Learning and Community Impact Consultant

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Georgia Kioukis, PhD
Learning and Community Impact Consultant

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Samantha Matlin, PhD
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Director of Learning & Community Impact

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Joe Pyle, MA

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Nadia Ward, MEd, PhD
Learning and Community Impact Consultant

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Bridget Talone, MFA
Grants Manager for Learning and Community Impact

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Hitomi Yoshida, MSEd
Graduate Fellow

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Ashley Feuer-Edwards, MPA
Learning and Community Impact Consultant

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Pathway Home

Coordinated Behavioral Care

Pathway Home Logo

Program Website
New York
Winner Status:
Program Type:
Symptom Management and Treatment Adherence
Target Population:
Individuals with Serious Mental Illness

Nature of the Problem

Across the United Sates, high hospital readmission rates within 30 days of discharge and non-urgent emergency room usage are consistent factors in high health care costs. Individuals with behavioral health conditions, particularly Medicaid beneficiaries, are even more likely to be readmitted due to poor connections with community providers and limited daily living skills. Readmissions drive up avoidable health care costs and this cycle of readmission prove traumatizing for individuals and their families. Despite NYC having an array of community care programs, behavioral and medical clinics, and health homes services that offer adequate support needed to treat and care for people in the community, services remain difficult to access. Individuals with long psychiatric hospital stays therefore face insurmountable challenges as they transition back to the community. Dedicated and flexible community-based case management and support services have not been easily accessible or readily available in New York City. Poor discharge planning, communication breakdowns, inadequate follow up, mean NYC’s readmission rates are reflective of the national average. To address these challenges and issues, CBC created a care transition program called Pathway Home aimed to improve the reintegration of individuals after a hospital stay, improving health outcomes and life satisfaction.

Program Description

CBC is breaking this cycle of hospital admissions with Pathway Home (PH), an innovative care transitions program funded by the NYS Office of Mental Health. Using the evidenced-based Critical Time Intervention model, PH provides intensive and flexible services during the critical time of community transition. The intervention begins shortly before transition with engagement and active involvement in the aftercare planning. Early engagement allows for increased participation, rapport building, and identifying, mitigating, and resolving barriers that may impact successful reintegration. The intervention continues into the community facilitating integration and continuity of care by ensuring support systems are in place and enduring ties to the community. Flexibility differentiates this approach compared to traditional case management. PH see individuals’ multiple times each week, for several hours at a time during the first few months. This ensures engagement to the most appropriate and accepted long-term services and that any anticipated or unanticipated challenges are immediately identified and resolved. This high touch service facilitates a relationship where participants feel invested in and become more involved in treatment. Over time, individuals take responsibility for their care needs, and services are stepped back. This flexible and holistic approach ensures clinical, social and wellness needs are fully addressed.


PH stands out from traditional models with these key features. The ability to leverages a wide-array of community-based health and human services essential to ensure all aspects are cared for. Incorporating technology-delivered interventions – through texting, video-conferencing, medication reminder machines, and one that combines behavioral economics and mobile technology to keep track of health activities – have increased engagement, trust, access, and the communication necessary to know what is happening and provide personalized support. A rapid response and easy access recognize that helping people with chronic illness lead longer and healthier lives begins by addressing symptoms early with quality and comprehensive care. This also leads to a unique relationship among hospital and community providers forming collaborative aftercare planning processes. A ‘conversational’ assessment enables discussion and relationship building. Emphasis on employee work satisfaction results in low staff turnover and thereby consistent care from experts in providing care.


PH developed a conceptual framework using key programmatic elements, focusing on clinical and wellness components of care to facilitate the adoption of an innovative care transition approach. PH created the conditions for translating an evidence-based transitional care model into mainstream practice. As a result, PH has become a well-known program and model, recognized by NYS and throughout the healthcare delivery system, and synonymous with the best practice in hospital to community transitional care. Program staff teach on the model at local social work schools, in hospital systems and to community care workers. Recognizing how impactful the model is, a Pathway Home Training Institute has been funded to provide training and technical assistance and guide the replication of the program. An outcome was the positive impact on the hospital discharge process and the development of strengthened partnerships with CBOs. This led to improved care coordination and connection to local neighborhood supports.


The PH program has grown since operationalizing in 2014. Two teams have grown into eight teams, adapting to new populations; Criminal Justice involvement, homeless, long-term stayers at State Hospitals, and Adult Homes. The quickness of this recognition is due to demonstrating impressive outcomes, both from healthcare perspective and in improving the wellness of those with behavioral health and SUD. In a healthcare system fraught with inefficiencies, excessive paperwork, confusing data, PH has eliminated frustration and inefficiency, streamlining case management delivery. This replicable model has garnered interest among many branches of the healthcare delivery system including MCOs, hospital systems and other government bodies, to develop and expand to additional populations. These teams will serve individuals with substance use, people with chronic health conditions and youth transitioning from foster care. CBC launched a Pathway Home Training Institute that provides training on the PH model and operationalizing teams in different regions.


PH has served over 1,200 individuals since inception and produced robust outcomes. Metrics that demonstrate connection to care and reduction in costs are tracked during the intervention. These include attendance at behavioral health and medical appointments and hospitalizations. Of 153 individuals who graduated from PH in 2017, 89% (N=136) had not been readmitted to the hospital 30 days after an inpatient discharge and 100% had not been readmitted to a state psychiatric center at the time of completion of the intervention. Within the first seven days in the community, 77% (N=117) attended a behavioral health appointment; by day 30, 88% (N=135) had attended; and at completion of the intervention, 100% of individuals had attended their follow-up appointment and 88% (N=135) had attended medical appointments. To maintain success post intervention, ongoing case management is essential, and 73% (N=111) of individuals have been enrolled in health home care coordination.