James Plastiras Director of Public Information New York State Office of Mental Health 518-474-6540 james.plastiras@omh.ny.gov

October 19, 2017

New York State Office of Mental Health Announces Expansion of Program Helping Individuals Transition from Inpatient Hospitalization to Community-Based Services

‘Pathway Home’ Program Reduces Readmissions, Length of Hospital Stays, and Emergency Room Visits; Helps to Improve Health Outcomes and Reduce Avoidable Costs

The NYS Office of Mental Health today announced the expansion of the transitional program, Pathway Home, into two New York City hospitals.  This innovative program which helps individuals with mental illness transition from inpatient care to community-based services, has started accepting referrals at Bronx Psychiatric Center and Metropolitan Hospital Center. This expansion is funded through an $880,000 grant award from the Office of Mental Health (OMH).

Coordinated Behavioral Care, Inc. (CBC) created the Pathway Home program in 2014 to help individuals who are discharged after a long episode of inpatient psychiatric care successfully transition back to their community.  Pathway Home helps these vulnerable individuals address issues that can be overwhelming, such as housing, economic security, medication adherence, linkage with outpatient providers, dealing with family conflict and overcoming social isolation.

OMH Commissioner Dr. Ann Sullivan said, “Pathway Home has been proven to reduce readmissions to psychiatric hospitals and to shorten the stays for those patients who are readmitted. It focuses on individuals who are considered likely to have difficulty maintaining community care, and provides them with stability, greater independence and enhanced care.”

CBC’s CEO, Dr. Jorge Petit said, “The Pathway Home program is an innovative intervention that helps bridge inpatient to community services with proven improvements in outcomes as well as tangible decreases in subsequent inpatient hospital days, readmission and avoidable emergency room visits. The Pathway Home program offers high-touch, personalized and intensive level of services by staff that are anchored in the community and work with the patients to get them the services they want and need in their community in order to deliver a truly person-centered, recovery-oriented treatment plan.”

Pathway Home teams are comprised of licensed mental health clinicians, case managers, nurses and peers, who provide community-based time-limited (nine months) services to adults with behavioral health conditions who have experienced long-stays in psychiatric inpatient facilities. The program emphasizes the importance of initial engagement and assessment prior to discharge. Active team involvement during the discharge process ensures connection to the extensive array of community based services offered by CBC.

CBC has been operating three Pathway Home multidisciplinary teams in New York City where they have been shown to reduce preventable readmissions, inpatient hospital days, and emergency room visits, improving health outcomes and reducing avoidable costs. Over the past three years, Pathway Home has helped 856 individuals to successfully transition to more independent lives in the community.

The newly funded teams will focus on the development of each patient’s daily living skills and coping mechanisms through group and individual work on the hospital units. The teams will work closely with hospital staff to help improve communication between the hospital, community services, and providers. The new Pathway Home teams will consult on questions of readiness for community living, address barriers to discharge, provide peer support, and teach the activities of daily living needed to ensure a smooth transition.

The Pathway Home teams will work collaboratively with hospital staff to:

  • Determine readiness for discharge;
  • Identify which community services and supports will lead to a more successful discharge, and address the barriers to maintaining such services, such as insurance, proximity, transportation, etc.;
  • Ensure patients leave the hospital with active medical insurance and related financial benefits;
  • Provide life skills training including shopping, cooking, travel training, or cleaning to help patients’ live successfully in the community;
  • Ensure continuity of care by coordinating with outside providers, accompanying the patient to appointments before and after hospital discharge, and establishing community linkages;
  • Work with families and social support networks to involve natural supports into the discharge plan. For example, the team may request a family meeting to help foster the relationships that will determine a successful transition;

The new Pathway Home teams at Bronx Psychiatric Center and Metropolitan Hospital Center recently completed orientation and have begun accepting referrals.


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