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CBC project Pathway Home providing personalized CTI in New York City

Pathway Home, a new program of Coordinated Behavioral Care (CBC), is using CTI to provide supportive care to individuals who are transitioning from state psychiatric centers, state operated community residences, and acute inpatient hospital settings in Manhattan, the Bronx, and Brooklyn in New York City. The program, which has been operating since October of 2014, includes a treatment team of peers, LPNs, RNs, social workers, and a nurse practitioner who provide community support services six days a week, with additional support offered through a 24 hour emergency call line. Project Director Mark Graham states, “Our program allows for our clinicians to assess clients and provide personalized treatment, so our clients get the intervention that is needed rather than something prescribed. We can address individual needs, and this results in a high level of buy-in and engagement.” Graham also says that his team has begun analyzing the data and they are starting to see a reduction in readmission rates, higher rates of attendance to primary care appointments and outpatient programs, and shorter lengths of hospital stays. Graham believes that Pathway Home’s success can be attributed to a particularly strong emphasis on the pre-CTI phase, which commences in the hospital setting. “Our workers try to visit clients at least twice while they are still in the hospital, and work in collaboration with hospital social workers to create more personalized discharge plans that include appropriate post-hospital placement and community resources.”

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