CBC Pathway Home: A Care Transitions Intervention for Individuals with Serious Mental Illness

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This educational webinar explores how to leverage technology to improve outcomes in a high-risk population, featuring real-world results experienced by Coordinated Behavioral Care (CBC), the fastest growing health home in the state of New York.

The current service system has not been able to effectively engage and treat adults with serious mental illness (SMI) discharged from inpatient care to communities. This has resulted in dismal treatment and recovery outcomes, as well as high levels of Medicaid expenditures for avoidable readmissions and emergency department visits. This webinar discusses how Coordinated Behavioral Care (CBC) used care intervention to improve outcomes for individuals with SMI.

Pathway Home is a Care Transition Program of CBC that offers mobile, time-limited services in Brooklyn, Manhattan, Queens, and the Bronx for adults with serious mental illness. The program includes a multidisciplinary treatment team to enhance the system of care for those transitioning to the community from the hospital. Pathway Home uses a Critical Time Intervention Model that facilitates community integration and continuity of care by ensuring that an individual has support systems and enduring ties to the community during the critical period following discharge.

Since the start of the program, Pathway Home has been shown to have several beneficial effects:

  • 94% of all Pathway Home participants stayed out of the hospital during their first 30 days back in the community
    • Compared with 87% of 2013 NYC psychiatric hospitalization readmissions within 30 days to any NYC hospital (June 2016 DOHMH Policy Brief)
  • 91% of participants living in the community attended a behavioral health appointment within 30 days of hospital discharge
  • 75% of participants graduated with a Health Home or ACT services in place
  • 74% of participants attended an appointment with their primary care provider within three months of discharge

Pathway Home is now funded under a New York State Office of Mental Health (OMH) grant.

This webinar discusses how CBC improved outcomes with its SMI population, and how to leverage technology to support efforts like this.


Danika Mills, LCSW, LCAT
Executive Director, Coordinated Behavioral Care, Inc. & Coordinated Behavioral Care IPA

Mark Graham
Associate Executive Director of Operations, Coordinated Behavioral Care, Inc. & Coordinated Behavioral Care IPA

LeRoy E. Jones
Founder and CEO, GSI Health