Barry Granek, LMHC Program Director CBC Pathway Home 123 William Street, 19th Floor New York, NY 10038 bgranek@cbcare.org Rika Gorn, MPA Quality and Evaluation Specialist rgorn@cbcare.org

Today’s Goals Need For a New Approach To Care Management CBC Pathway Home Program Model Review The Evidence-based Practice of Critical Time Intervention (CTI) Share Program Outcomes Best Practices for a Care Management Team

The Revolving Door Problem Between 15-20% of adults discharged from a State Psychiatric Center between July 2013 and April 2015 were readmitted within 30 days. 22.9% of the 22,868 adults who were discharged from a NYC inpatient psychiatric facility in 2014 were readmitted within 30 days. Number of past hospitalizations increases the risk of readmission within 30 days. Long-Term Stay Community Short-Term Inpatient Shelter Crisis

Systemic Challenges: A Person’s Journey Benefits Reconciliation Inpatient Housing Medication Management Community Reintegration Hospital Discharge Linkages to Outpatient Care

CBC Pathway Home is a Care Transitions Program that offers mobile, time limited services in NYC for adults with serious mental illness transitioning to the community from the hospital.

Pathway Home Program Rationale Reduce Hospitalizations Facilitate Housing Placement Diversion from State Forensic Diversion Focus services on assisting recipients in transition from a State PC or TLR to a community setting For individuals being discharged from an acute care hospital to provide more intensive support 730.40 Initiative Invest in community services and supports

Critical Time Intervention (CTI) Model PRE-CTI 01 02 03 Develop relationships with providers and hospital staff Present program and model to referral sources Tailor program to population needs 0-3 months Provide support & begin to connect individuals to people and agencies that will assume the primary role of support Problem-solving obstacles preventing engagement in outpatient services 3-6 months Observe operation and strengthen of support network and skills, modifying care plan or network accordingly Encourage increased responsibility 6-9 months Terminate CTI services with support network safely in place Step back to ensure supports can function independently Hold meeting with supports marking transfer of care Relationship Building Transition to Community Trying Out Transfer of Care

Bridge to Intensive Services Program Outcomes 91% 69% 12% 92% 84% Are not readmitted to the hospital within 30 days of entering the community 94% HH Enrollment Bridge to Intensive Services BH Appt Med Appt Are not readmitted to a State Psychiatric Center

Key Factors for A Flourishing Care Management Team Ongoing Assessments and Feedback Process Engaging in Meaningful activities, family, social networks Fostering Self-Efficacy Linkages to Community Providers and Natural Supports Systems Accompaniment Home and To Initial and Follow-up BH and PCP Appointments Pre-Discharge Engagement and Discharge Planning 01 DISCHARGE PLANNING 02 03 05 ACCOMPANY TO APPOINTMENTS COMMUNITY LINKAGES 04 COMMUNITY REINTEGRATION SELF-EFFICACY

Best Practice: Operationalizing your Team Team Makeup Multidisciplinary team approach Workflow Speedy referral and enrollment process (approximately 2 days) Start Early Engagement begins inpatient Mobility and Flexibility Community Based (vs office based) R Case loads compared to reg case management Team – connected but also each team has flexibility, community health crisis such as k2, can bring that to the attention, there own expertise, Relationship with CBC and Cm – client has specific need, we can assign that client to that team, moves boroughs, Targeted Case Loads Focus intensive services on most critical Technology Using technology to manage and communicate across teams

Best Practice: Continuity of Care “continuity of care means that the patient will be able to receive all the different services that he or she needs, even though the service system is fragmented and even though many different service delivery agencies must be involved in his or her treatment” (Leona Bachrach, P.h.D) “pinch hitting, trouble shooting, smoothing transitions, creating flexibility, speeding the system up, and contextualization” (Norma Ware, P.h.D, Associate Professor of Global Health and Social Medicine at Harvard Medical School) The assurance that individuals are provided with uninterrupted and coordinated mental and physical health services over time Services will endure past the (CTI) Intervention

Best Practice: Step in and Step Back Let individuals try and manage routine activity and crisis events Remain accessible and ready to step in for needed support Crisis Response Reminders (Appointments, medication)

Best Practice: Health is More Than Absence of Disease Improv Classes Trauma Informed Yoga Art Classes Barber Supplies Boot Camp Lunch To Facilitate Socialization

A Person’s Pathway Home Revisited 05 Community Integration 04 Medication Management and Benefits Reconciliation 03 Post-Hospital Discharge and Housing 02 Hospital discharge 01 Inpatient

Any Questions? Pathway Home in the News: https://www.omh.ny.gov/omhweb/resources/newsltr/docs/february-2017.pdf http://www.mhnews.org/back_issues/BHN-Summer2017.pdf Contact Us: Barry Granek Pathway Home Program Director 123 William Street, 19th Fl. New York, New York 10038 E-Mail: bgranek@CBCare.org Tel: 917-242-2090 Fax: 877-418-5421 Rika Gorn Quality and Evaluation Specialist 123 William Street, 19th Fl. New York, New York 10038 E-Mail: rgorn@cbcare.org Tel: 646-930-8816 Fax: 877-418-5421