From Institution to Community: Implementing the Pathway Home Approach for High-Risk Members With Behavioral Health Needs Transitioning From an Adult Home.

PURPOSE/OBJECTIVE: Coordinated Behavioral Care began using its Pathway Home program to serve a subset of New York State Adult Home Settlement class members. Through its multidisciplinary team approach, Pathway Home is utilizing its multiphase model in assisting individuals with Serious Mental Illness leaving an Adult Home to successfully transition and remain in the community. PRIMARY PRACTICE SETTING: The Pathway Home program is a community-based service and serves class members wherever is needed to assist in their recovery and transition from an Adult Home. This includes meeting class members in Adult Homes and various settings in the community. FINDINGS/CONCLUSIONS: The New York State Adult Home Settlement presents a variety of systemic, care management, and individual member challenges. Adding the Pathway Home approach to an already existing, yet insufficient care management model strengthens the initiative's goal to transition and retain members safely into the community. Through the approach's adaptability and flexibility in providing community-based care, Pathway Home's successful cross-system collaboration is worthy of replication for other high need populations. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: A programmatic review for Pathway Home Adult Home+ teams gleaned the following key points for the field to consider in future care management practices. Class member self-efficacy and cross-system collaboration are essential in facilitating a class member's move into the community. Member choice and educating class members on their rights to move and options as well as community exposure prior to transition are important in assessing how a member fares outside of the Adult Home. Members determining their own care can reduce the risk of adverse outcomes and reinstitutionalization. Current low-touch care management programs are insufficient for members with complex needs living in institutions. These care management programs need to be augmented with a whole person approach, delivered by a multidisciplinary team.

The Effect of Time Spent With Participants on Program Outcomes.

PURPOSE OF STUDY: Little research exists on the correlation between time spent with participants in Critical Time Intervention-modeled programs, such as Coordinated Behavioral Care's (CBC) Pathway Home, and successful completion of the programs. This study explored associations between the total amount of time spent with participants in the initial 3 months of the program and positive program outcomes. METHODOLOGY AND SAMPLE: Data on total time spent with participants in their initial phase of the program were gathered from Pathway Home participants who were enrolled in the program from 2016 to 2019 and then were compared with program outcomes. RESULTS: The study found positive correlations between amount of time spent with participants and the attendance of a behavioral health appointment within 1 month of community entry, and positive disenrollment outcomes. This study did not find predictive significance of time spent. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Time spent with participants is a significant variable to study, yet more research is needed on its relationship to positive outcomes.

Pathway Home™ for High Utilizers of Psychiatric Inpatient Services: Impact on Inpatient Days and Outpatient Engagement.

OBJECTIVE: This study examined the impact of Pathway Home™ (PH) transition services for high utilizers of psychiatric hospitalization on inpatient days and outpatient engagement post-hospital discharge. METHODS: This case series study of forty PH graduates (5/22/2015-8/31/2018) used Medicaid claims to assess psychiatric inpatient days-per-month, average proportion of months with psychiatric emergency room, outpatient, and health home care management services. T-tests compared three time periods: the year prior, during, and after enrollment. RESULTS: Graduates had significantly fewer psychiatric inpatient days/month during (M = 1.84, p < 0.001) and after PH enrollment (M = 1.88, p < 0.001) compared to prior to enrollment (M = 7.1), while emergency services were stable. Outpatient visits increased from 45% prior to 76% during enrollment (p < 0.001) and was sustained on follow-up (67%, p = 0.008). A similar pattern emerged for health home services (32%, 60%, and 50%). CONCLUSION: PH is a promising approach for improving outcomes for high utilizers of psychiatric inpatient services, with sustained impact on follow-up.