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

Abstract

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. 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. 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. 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.