BY BARRY GRANEK, LMHC, PAMELA MATTEL, LCSW, AND GERALDO RAMOS, MSW, MPA
Introduction
Pathway Home™ was launched in 2014 with a mission to provide essential care transition support to individuals navigating critical healthcare transitions. The Case Management Society of America Foundation is a non-profit organization advancing the practice of case management by promoting research and process improvement through grants and awards. The foundation has been making an impact on the practice of case management resulting in health improvements for individuals receiving services. In 2019, Pathway Home™ was honored with the 2019 Case Management Practice Improvement Award and accepted the honor in Las Vegas during the annual CMSA conference.
Along with accepting the CMSA Foundation Award at the 2019 CMSA conference, the Pathway Home™ program was featured in an article in CMSA Today titled, “2019 Case Management Practice Improvement Award Recipient: Pathway Home™ Program.” In that piece, we introduced readers to the innovative program model, which offers adaptable and flexible care transition case-management services to adults with severe mental illness, guiding them through the transition from institutionalization back to their communities. The article reported on the 400 graduates, including reductions in readmission rates, improved attendance at physical and behavioral health appointments and the establishment of long-term case management connections, as well as featuring firsthand testimonials from program members (Granek, 2019).
This article revisits Pathway Home™ to report on the program’s expansion since the initial feature. Here, we will spotlight the program’s growth, highlighting the enhancements it has undergone over time. Furthermore, we will offer additional feedback received from the program’s members, offering insights into their experiences.
Pathway Home™ Program Model
Pathway Home™ is a multi-phased short-term program, inspired by the evidenced-based Critical Time Intervention (CTI) model. Pathway Home™ focuses on essential healthcare tasks related to care transitions. It incorporates a range of techniques, including educational, supportive, interactive, member-driven and recovery-oriented methods. The program consists of four distinct phases, emphasizing the importance of building trust and rapport with members during critical care moments. Core values are common purpose and sense of urgency, radical collaboration, compassion, communication and inclusivity.
Key elements contributing to Pathway Home™’s success include small caseloads, assertive outreach, and individualized care plans tailored to each member’s unique needs. The program empowers members to optimize existing support systems and develop new ones, aiming to integrate them into the community-based fabric of services and social supports. The program adopts a multidisciplinary team approach, comprising licensed clinicians, peers, care managers and registered nurses. This approach aims to link members to behavioral health treatment, enhance their skills and facilitate engagement with social services. To address real-life problems, staff “start with what people care about” and put a focus on community integration, where members can progress in personal development outside of treatment.
Over the years, Pathway Home™ has become integral to the New York City community-based care system. Its success is attributed to extensive support provided by Coordinated Behavioral Care (CBC), a clinically integrated behavioral health Independent Practice Association and Medicaid Health Home, with experience and expertise orchestrating collaboration and driving system innovation. The CBC centralized hub leadership implement collaborative strategies connecting the system of care, incorporating multiple government layers, non-profit agencies operating Pathway Home™ teams, health, housing, and non-traditional partners, and people served. CBC brings its comprehensive network of behavioral health, primary care, social services, housing and care management to the effort. CBC acts as the Referral Hub, ensuring effective communication, marketing and relationships between teams, funders, referral sources and other stakeholders. Additionally, CBC maintains hospital relationships through ongoing hospital in-reach to support referrals and communication channels. For direct staff, CBC offers comprehensive training and ongoing technical assistance. Education and supporting individuals from their hospital stay has become a point of trust for many of the individuals served by Pathway Home. Many of these individuals had lost contact with family members and have no natural supports in place. The Pathway Home team has become their support system while working on re-connecting with the community at large.
The model represents a multi-year iterative process with agency leadership and staff, government stakeholders and funders, managed care organizations, people with lived experience and subject matter experts. The CBC Hub leverages its centralized infrastructure to generate sustainable connections across the coalition including the community at large, resolve communication gaps, and streamline workflows to secure community support. CBC as the Hub provides consultation for planning, implementation, ongoing management, team activities and overcoming barriers for sustainability. CBC adds value with providing job descriptions, staff recruitment/onboarding and technical assistance for fiscal management, clinical documentation and the program model.
Program Enhancements
Over the last decade, new features were incorporated into the model to improve effectiveness and success. Prominent strategies added were building team culture and branding, credible and accountable champions, designated points of contact, attention to cross-system literacy, cross-system meetings, a shared electronic case management record for the teams, monthly and quarterly data reports for government entities and participating partners, workforce satisfaction and consistent operational and clinical support.
Pathway Home™ teams have demonstrated a commitment to innovation and the implementation of creative approaches. Teams have embraced telehealth solutions to provide remote support, and a coordinated network technology platform connecting community partners to make closed-loop referrals addressing social care needs. This approach facilitates continuous monitoring, education and support, ensuring a smoother transition process.
Data and reporting enable the generation of external reports for various government entities and participating partners, and tells the story about the persistent, dynamic, complex and imperfect work of providing practical care for members. Data analytics, supported by Managed Care Organizations’ (MCO) gaps of care reports, have become instrumental in identifying individuals at high risk or in need of specific interventions. This data-driven approach empowers teams to intervene proactively, bridge gaps, enhance accountability, and refine their care activities based on collected data.
Teams enhance the scope of care by addressing social determinants of health (SDOH). In addition to the critical support around housing, transportation, and food security Pathway Home™ also recognizes the value of therapeutic activities around music, dance/movement, imagery and visual arts, writing/literature, drama, games and humor, animal assisted therapies, therapeutic horticulture and nature experiences.
Collaboration with non-traditional partners has become more common, including community organizations, government agencies, technology companies and housing providers building a more comprehensive and coordinated community care integrated system approach.
CBC upgraded its documentation platform to provide greater access to assessment tools and up-to-date member information. This democratization of data and streamlined documentation afford staff more time for direct member interactions and improved communication and coordination.
Finally, CBC embraces the expertise of peers (individuals with lived experience) and they “sit on the same side of the table.” The inclusion of peer specialists offers members support from those with lived experience in mental health or substance use leading to increased engagement and motivation among members. Similarly, mechanisms for ongoing member feedback have been established.
Ongoing Development
Pathway Home™ owes much of its success to a commitment of continuous program refinement and evolution. This process has been marked by a deliberate focus on accommodating the nuanced complexities of member needs, while preserving the program’s capacity for scalability and fidelity. This model has been formalized in the Pathway Home™ Program Manual and reinforced by a two-day Pathway Home™ Orientation for new staff and a standardized comprehensive curriculum training with ongoing learning forums. To ensure ongoing professional growth and development, CBC offers regular case conferencing opportunities that incorporate didactic learning and monthly staff specialty meetings that foster safe space to review successes, challenges and well-being.
Pathway Home™ success hinges on the preservation of program fidelity, a commitment upheld through the utilization of fidelity scales and the generation of regular quality reports. This data-driven approach equips Pathway Home™ teams to make systematic adjustments including resolving barriers. CBC plays a pivotal role overseeing quality and promoting continuous learning.
Challenges stemming from staff turnover and the diverse needs of the members have been addressed through comprehensive training, collaborative case conferencing and concentrating on staff wellbeing. The teams embrace continuous learning and a willingness to adapt treatment models through ongoing quality improvement.
Program Expansion & Adoption
Over the years, Pathway Home™ has grown in scope and become integral to the healthcare system. In 2019, CBC contracted with New York City’s public hospital system, Health and Hospital Corp., to fund four Pathway Home™ teams to serve members being discharged from psychiatric units at one of their 11 hospitals. In the same year, CBC contracted with Health First, a leading managed care organization, to fund a dedicated Pathway Home™ team. In 2021, CBC received funding from the New York State’s Office of Mental Health to pilot two teams for individuals using the New York City’s Metropolitan Transit Authority (MTA) public transit system as a temporary dwelling space; which includes over 500 subway stations and several terminals. CBC also piloted a Pathway Home™ team to serve members transitioning from rehabilitation and detox centers. This initiative lasting 18 months had produced positive results including 63% of members attended an appointment with their SUD provider and 43% of members attended an appointment with their primary care provider during the intervention.
Patients in state psychiatric centers often face extended institutionalization, leaving them susceptible to frequent returns. A gap in community follow-up services emerges for these individuals, leading to a dependency on structured support and missed life experiences (Tucker, 2016). Pathway Home™ addresses this with its two hospital-embedded teams in two state hospitals, proactively working with members well before discharge to build skills, create robust discharge plans and address community needs (Granek, 2019). Contrary to extended stays in the state hospital system, members are now provided solutions to enter the community with adequate support, which simultaneously addressed cyclical readmissions and inadequate hospital capacity.
As of 2023, Pathway Home™ comprises 13 teams, each dedicated to serving a diverse population. These teams cater to individuals with serious mental illness discharged from hospitals, those involved in the criminal justice system, adult home residents, high utilizers of inpatient services, the homeless and individuals with substance use issues.
Adoption of Pathway Home™ has occurred with the willingness of funders, governance bodies, agencies and program staff to support and deliver the program. Pathway Home™ now receives funding from various sources, including New York State Office of Mental Health, New York City Health and Hospital Corporation and a managed care organization, Health First.
Between November 2014 and August 2023, 9,050 referrals were received, of which 6,817 were eligible. 5,576 or 82% of those eligible referrals enrolled. The population primarily consisted of members with various psychiatric diagnoses, with the most prevalent diagnoses being schizophrenia disorder (28%), schizoaffective disorder (27%) and bipolar disorder (12%). The majority of participants were male (62%), identified as Black or African-American (60%), and aged between 18-44 years (50%).
In 2022, New York State introduced the Safe Options Support (SOS) program, closely modeled after the two piloted Pathway Home™ teams working with the homeless population, to provide outreach and care transition support to the street homeless population. Developed under the visionary leadership of New York State Governor Hochul and the Office of Mental Health, the SOS program has become a statewide initiative addressing homelessness. The governor’s active involvement in periodically joining the team underscores the highest level of support. Safe Options Support comprises 11 daytime and three overnight teams that have successfully enrolled over 1,700 homeless individuals and reached out to engage an additional 1,000 individuals who are currently experiencing street homelessness. The SOS program stands as a beacon of innovative, inclusive and effective care delivery with 330 housing placements, over 900 shelter placements and a remarkable 93% retention rate in permanent housing. This expansion is a testament to the success and adaptability of the Pathway Home™ model.
Pathway Home has been established as a community resource in NYC through a variety of funding models, including long-term government contracts, braided funding combining multiple funding sources, and contracts with a managed care organization. This demonstrates funders’ recognition of the program as an integral part of their care management continuum.
Success Story
Joseph (name changed for privacy) is a bilingual writer and poet with a BA in English and some published poems; and a diagnosis of schizoaffective disorder, bipolar type, and polysubstance use disorder with alcohol and heroin. His symptoms began during high school, and he experiences ongoing bouts of depression, including periods of suicidal ideation, both presently and in the past. Joseph described his depression as a “heavy cross,” worsening when his father died. When Joseph began working with Pathway Home™, he had difficulty keeping appointments and experienced multiple hospitalizations and inpatient detoxes with overdoses he described as accidental. Pathway Home sometimes discovered Joseph drinking 12+ drinks a day and using heroin on the street, once finding him passed out in the street nearby his home. After successful accompaniment to specialized medical appointments in the initial weeks in the Pathway Home program, Joseph received a diagnosis of liver cirrhosis and Wernicke Korsakoff syndrome and was informed he could have a life expectancy of just one year if he did not abstain from alcohol use. Joseph experienced strong helplessness, shame and despair, saying at one point to Pathway Home™staff, “just leave me to die.”
The Pathway Home is more intensive initially with increased visit frequency and duration, where the member benefits from extensive support and assistance connecting to a community network. For Joseph, Pathway Home showed up consistently and spent time building rapport, bearing honest witness to Joseph’s feelings and the pain of his situation, and easing his shame through demonstrating respect and compassion. Pathway Home’s RN accompanied Joseph to multiple medical appointments including the initial one a few days after program enrollment and provided health education on emerging cognitive and liver issues related to alcohol use. After multiple home visits encouraging attendance and offering accompaniment, Joseph was able to complete his intake appointments at a behavioral health clinic and started seeing a mental health counselor consistently for the first time in years, just a few weeks into his time in the program.
Joseph began talking about his painful experiences, particularly his grief surrounding his father’s death and his feelings of isolation from family. He attended his first group appointments with the accompanying presence of Pathway Home, sharing his feelings of shame and naming the ways he had stopped taking care of himself, including not remembering the last time he had drunk water, believing he did not deserve care or nourishment. His substance use, emotional struggles, and physical circumstances did not at this point prevent Joseph from attending his medical appointments; he became hopeful of a solution and increasingly committed both to receiving treatment and to taking action. Joseph decided to attend rehabilitation to address his substance use, persisting through withdrawal symptoms of severe tremors and seizures to self-admit and get help. Joseph has since been discharged and continues to work hard to move forward in his treatment. He has not used drugs or alcohol in the six months since and is participating in substance use treatment. He makes his appointments and is more active in caring for his mental and physical health. This positive movement and meaningful connections with providers have been pivotal and offered hope that felt intangible just a few short months ago. Joseph started writing again, sharing a moving poem with Pathway Home staff as a thank you for the care they provided. He also started volunteering teaching poetry, hopeful that he is steps closer to a life well lived.
Outcomes Achieved and Member Feedback
Pathway Home™ has consistently demonstrated its effectiveness through positive outcomes. Several studies have explored the effectiveness of Pathway Home™ at improving post-discharge outcomes. We summarize the key findings from these studies and highlight the impact of program interventions on reduced hospital readmission rates, improved attendance at behavioral health and medical aftercare appointments, utilization of case management services, and ultimately empowering individuals to navigate critical healthcare transitions successfully (Petit, 2018, Petit, 2021, Granek, 2021, & Ernst, 2022). See Table 1 Study Title and Year with Key Findings for details.
Table 1: Study Title and Year with Key Findings
| 2018 study findings in Psychiatric Services (Petit, 2018): |
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| 2019 study on hospital embedded teams in Collaborative Case Management (Granek, 2019): |
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| 2021 Case Series Study using Medicaid claims data in Community Mental Health Journal (Petit, 2021): |
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| 2021 Study on Using an Innovative Staffing Approach to Enhance Engagement and Enrollment: Rethinking the Traditional Referral Process (Granek, 2021): |
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| 2022 Study on Time Spent with Members in Professional Case Management (Ernst, 2022): |
|
Pathway Home program is actively leading the way by incorporating innovative technology solutions aimed to enhance member engagement and use technology-assisted care, for example ridesharing applications, phones with text and video technology, and applications using behavioral economics to build habits around healthcare tasks (e.g. taking medications) (Granek, 2021). Unique partnerships particularly with hospital systems, such as embedding teams directly into hospitals, have helped ensure members receive seamless and timely support during their critical care transitions (Granek, 2019).
Moreover, the feedback received from graduates and referral sources highlights the program’s positive impact on members’ lives. Graduates of Pathway Home have expressed appreciation for the program’s efficiency, quick response times and friendly interactions during the referral process. Referral sources feedback is gathered through regular surveys and meetings, and referral sources have expressed that the referral process is easy, seamless and user-friendly. These sentiments underscore the program’s success in delivering effective care transition support. The program continues to receive extensive feedback from program members sharing how the program helped in their recovery.
- “Pathway Home would check up on me three times a week and connect me to resources that would help me. Being released from the hospital and suffering from mania, I was not able to do things for myself and they helped me with everything. They were absolutely amazing.”
- “Pathway Home connected me with a peer specialist. She would talk to me about bipolar disorder and would check in on me to see how I was doing. Being able to speak with a peer specialist was critical when it came to my rehabilitation. Being able to speak to someone who is also bipolar gave me such deep insight and advice on how I should move forward with my life. She was warm, genuine and really wanted to help.”
- “Pathway home gave me the tools, resources and support to help rebuild my life. I am back at work and I have a stable life. If it wasn’t for the resources and support given by Pathway Home, it would have been a much more difficult journey getting back to normal.”
- “Being in the psych ward was not easy, and when I was released, I was in a damaged state of mind. You helped rebuild me when I was released from the psych ward.”
Collaboration with hospital system staff is integral to the success of the program. The program regularly receives feedback from hospital staff.
- “I had an amazing experience with the Pathway Home™ team. They assisted me in connecting a vulnerable individual—a little ‘out of the box’…and since connecting us, the team has been responsive, interactive, and really stepping up to the plate. This individual has limited resources, and they have been such a great support for her, and I am sure will prevent future hospitalizations and support her to remain in the community.” – hospital social worker
- “I am touched by his (Pathway clinician) willingness to take her all the way back to her apartment, which she had been dreading since leaving it in her former deteriorate state, and said just having him there to accompany her made it so much easier. So we can see how the Pathway Home model works and can really make a difference!” – hospital social worker
- “Pathway Home has gone above and beyond. She has no supports in the community after her mother died, and it is so great to know that she has the Pathway Home team there for her.” – hospital social worker
Conclusion
Within the current healthcare system, the absence of flexible services to support transitions between different care settings has been a longstanding challenge. This gap is pronounced for vulnerable individuals facing significant barriers when transitioning into the community after prolonged inpatient stays. These challenges include symptom relapse, social determinant of health barriers, heightened risk of homelessness and potential for violent behavior or suicide.
The Pathway Home model addresses these needs by offering flexible, transition-focused care that coordinates services and integrates formal and informal networks. The CBC Centralized Hub serves as a crucial point of contact, bringing together fragmented providers and systems to improve access and quality through collaboration. By reducing administrative burdens and increasing resource accessibility, the Hub empowers care providers to focus on delivering high-quality services efficiently and effectively.
Moreover, Pathway Home contributes to behavioral health interventions compatible with alternative payment methods, emphasizing value-based care and addressing social determinants of health. This approach not only enhances member satisfaction but also demonstrates cost savings over time, aligning with evolving payment models that prioritize value over volume.
The program has garnered positive feedback from its graduates, and its positive impact on community outcomes, including mental health, treatment engagement, and overall quality of life, underscores its effectiveness and adaptability. As Pathway Home continues to evolve and expand, it serves as a beacon of innovation and collaboration, ensuring that individuals transitioning from behavioral health institutions receive the support needed for dignified, autonomous living.
The Pathway Home program exemplifies the value of flexible, person-centered care in meeting the diverse needs of patients during critical healthcare transitions. Its commitment to innovation and collaboration underscores its role in facilitating dignified, self-directed lives for those it serves.
References
- Granek B, Frisco J. (2019) Case management practice improvement award recipient: Pathway Home™ program. CMSA Today. 5:10-2.
- Granek, B. (2020) CBC’s Pathway Home Response to COVID-19 and Future Implications. Behavioral Health News. 8 (1), 29
- Mattel, P., Ramos, G., Granek, B. (2023) Safe Options Support: Charting a Path to Stability for Homeless Individuals through Coordinated Care. Behavioral Health News. 11 (1), 22
- Tucker, W. (2016) Narratives of Recovery
- Granek, B., Evans, A., Lane, M. (2019) A Review of Effective Collaboration Between Hospital and Community-Based Teams: Partnership Between Pathway Home Hospital Embedded Team and Bronx Psychiatric Center. Collaborative Case Management, ACMA: Collaborative Case Management. 71 : 13-17
- Petit JR, Graham M, Granek B. (2018) Pathway Home: An innovative care transition program from hospital to home. Psychiatric Services. 1;69(8):942-3.
- Petit J, Graham M, Granek B, et al. (2021) Pathway Home™ for high utilizers of psychiatric inpatient services: Impact on inpatient days and outpatient engagement. Community Mental Health Journal. 16:1-5.
- Granek B, Boenisch J, Graham M. (2021) Using an innovative staffing approach to enhance engagement and enrollment: Rethinking the traditional referral process. Professional Case Management. 1;26(2):113-7.
- Ernst A, Granek B. (2022) The Effect of Time Spent With Participants on Program Outcomes. Professional Case Management. 1;27(3):141-9.
- Granek, B., Evans, A., Petit, J., James, M. C., Ma, Y., Loper, M., … & Schmidt, R. (2021). Feasibility of implementing a behavioral economics mobile health platform for individuals with behavioral health conditions. Health and Technology, 11(3), 505-510.
- Granek, B., Evans, A., Lane, M., James, M. (2019) A Review of Effective Collaboration Between Hospital and Community-Based Teams: Partnership Between Pathway Home Hospital Embedded Team and Bronx Psychiatric Center. Collaborative Case Management, 71, 13-17.
Barry Granek, LMHC, is a senior healthcare leader with expertise in clinical operations, program development and oversight and strategic management. Barry joined Coordinated Behavioral Care (CBC) in 2015 and is currently the vice president, systems of care, where he has been integral to the design and expansion of 30+ community-based care management teams, including Pathway Home and Safe Options Support. He is committed to improving healthcare outcomes, enhancing patient experiences, and advancing the field of behavioral health. Barry maintains a psychotherapy private practice in New York City and teaches Critical Time Intervention at Hunter College.
Pamela Mattel, LCSW, is a highly qualified senior leader with 38 years of nonprofit experience, 15 years in executive positions advancing high quality healthcare integration and innovation in behavioral healthcare, primary healthcare and housing. Ms. Mattel’s leadership and management have consistently delivered on the promise of integrated care, multiplying reach and ensuring financial sustainability. She graduated from Columbia University with a master’s degree in social work and holds certificates in several post-graduate programs.
Geraldo Ramos, MSW, MPA has shown exemplary leadership during his 30 years of non-profit clinical and administrative experience. He is a “hands on” leader, going the extra mile to achieve success. Mr. Ramos focuses on improving systems of care, working collaboratively with member agencies, and championing initiatives across the enterprise with funders and other human service agency partners. He is guided by recovery-oriented, trauma-informed and person-centered theory. Mr. Ramos also extends himself by training others in evidence-based practice models such as Critical Time Intervention, crisis management, and motivational interviewing.
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