Samaritan Daytop Village Among Four Providers for New Pathway Home Program

Reference press release from NYC Health + Hospitals
September 3, 2019

Link to Press Release

NYC Health + Hospitals’ Office of Behavioral Health, in partnership with OneCity Health, today announced the launch of Pathway Home, an innovative care transition program created by Coordinated Behavioral Care (CBC), to help individuals with mental health needs transition from short-term health services to ongoing community-based care. The Pathway Home program will provide multidisciplinary care transition services to patients 18 and older transitioning from psychiatric inpatient units who have had four or more mental health inpatient visits in the past 12 months. Pathway Home teams will actively participate in aftercare planning and perform a transition needs assessment, accompany patients home and arranging for any immediate needs, such as food and filling prescriptions, accompanying them to primary care visits, and meeting with them regularly for six to nine months post-discharge. In addition to reducing avoidable readmissions, Pathway Home aims to strengthen community-based care and improve connections to outpatient services post-discharge, shortening length of stay and increasing participation in treatment.

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Stock photo credit: NYC Health + Hospitals

“By bridging the high-quality clinical care provided by NYC Health + Hospitals in the acute and outpatient setting with the support and resources available in the community, our goal is to create a comprehensive and coordinated service for patients. Through this innovative partnership, NYC Health + Hospitals, Coordinated Behavioral Care and OneCity Health aim to make transitions between care settings and providers seamless for patients”, said Israel Rocha, CEO of OneCity Health and Vice President, NYC Health + Hospitals. “OneCity Health continues to invest in innovative care models that will result in improved outcomes and a better experience for patients.”

“Patients with behavioral health needs often struggle to navigate health care systems and to connect with outpatient services, especially after prolonged or multiple hospital admissions,” said Charles Barron, MD, Deputy Chief Medical Officer, Office of Behavioral Health at NYC Health + Hospitals. “Practice-based evidence programs like, Pathway Home, reach out and support patients during the transition from acute care to our ambulatory programs in the community, helping them to establish strong therapeutic alliances with NYC Health + Hospitals Behavioral Health outpatient service providers.”

“Too many individuals transitioning from psychiatric inpatient care have difficulty connecting and reintegrating back into their communities. The necessary supports needed to reintegrate back into community living are often lacking. The Pathway Home model has proven effectiveness in breaking the cycle of readmissions and helping these individuals successfully re-connect,” said Jorge Petit, MD, President and CEO of Coordinated Behavioral Care.

OneCity Health is investing over $4 million in the Pathway Home program and providing technical assistance as part of its effort to implement new models of care that will reduce avoidable hospital utilization under New York State’s Delivery System Reform Incentive Payment (DSRIP) program. The investment will help fund the new services for NYC Health + Hospitals’ mental health patients through a contract with Coordinated Behavioral Care and additional partnerships with community-based organizations (CBOs). Pathway Home will launch at four NYC Health + Hospitals acute care facilities. Each site will work with one Pathway Home team and will enroll up to 150 patients over a 15-month period. The four sites are:

  • NYC Health + Hospitals/Coney Island
  • NYC Health + Hospitals/Harlem
  • NYC Health + Hospitals/Lincoln
  • NYC Health + Hospitals/Metropolitan

The Pathway Home team consists of registered nurses, licensed clinicians, case managers and peers who help address clinical and social issues. Team members meet with patients at least once a week for the first one to three months, and accompany them on the day of discharge, as well as to subsequent clinical appointments. By initiating engagement before discharge from an acute care setting, this team-based model will provide high risk patient populations with support within the community to connect with outpatient clinical services as well as social services. Four CBC Network CBOs will provide the Pathway Home services in the community. The CBOs are: Services for the UnderServed, The Jewish Board, Visiting Nurse Services of New York, and Samaritan Daytop Village.

“The partnership between NYC Health + Hospitals and Coordinated Behavioral Care is an important step in providing integrated services to New Yorkers with mental health needs,” said Assembly Health Committee Chair Richard N. Gottfried. “It’s critically important that patients transitioning from inpatient psychiatric settings have access to combined physical, behavioral, and mental health care. I commend NYC Health + Hospitals and Coordinated Behavioral Care for this initiative, which should be a model for other providers.”

“This partnership will provide a much needed continuum of care and support for individuals to ensure they are transitioning smoothly into their communities,” said Assemblyman Robert Rodriguez. “This program will not only save lives but will improve the lives of thousands of New Yorkers. I thank NYC Health + Hospitals, OneCity Health and Coordinated Behavioral Care for their work and this innovative partnership to bring Pathway Home to New Yorkers.”

“I want to commend the leadership of NYC Health + Hospitals and Coordinated Behavioral Care for their efforts to provide resources to individuals with mental health needs through the Pathway Home program,” said Councilmember Mathieu Eugene. “I believe that the city of New York must continue to expand its healthcare services so that members of the community can have access to the specialized care that they require. The treatment of mental illness is not only difficult for the patient, but also for family, friends, and the healthcare professionals involved in the treatment process. It is my hope that by working together we will continue to improve our ability to provide necessary mental health resources to those who need them.”

“The healthcare system is difficult enough to navigate – especially for patients who need continuous care once out of the hospital,” said State Senator Diane Savino. I am thrilled to see a wraparound program within NYC Health + Hospitals to provide continuous care for our patients with the greatest needs.”

Many patients with behavioral health needs are high utilizers of acute care services and are often not engaged in ongoing ambulatory behavioral health care. Pathway Home aims to support adult patients with behavioral health needs navigate health care services during the transition from inpatient psychiatric care or the emergency department treatment back into the community, and connects them with the community-based services available. Pathway Home has provided services since 2014 throughout New York, serving over 1,600 individuals.

According to data provided by the New York State Office of Mental Health, 35 percent of NYC Health + Hospitals Medicaid behavioral health admissions are defined as high utilizers of acute care services. Pathway Home will be offered to patients at four acute care facilities, which document 39 percent of their Medicaid behavioral health admissions as high utilizers.

The Pathway Home multidisciplinary intervention model is being piloted at NYC Health + Hospitals/Bellevue since February 2019. During this pilot, 82 percent of patients who were a part of the program kept their mental health appointments within 30 days of discharge. The average for the public health system was 57.5 percent for the first three months of 2019.

About NYC Health + Hospitals

NYC Health + Hospitals is the largest public health care system in the nation serving more than a million New Yorkers annually in more than 70 patient care locations across the city’s five boroughs. A robust network of outpatient, neighborhood-based primary and specialty care centers anchors care coordination with the system’s trauma centers, nursing homes, post-acute care centers, home care agency, and MetroPlus health plan—all supported by 11 essential hospitals. Its diverse workforce of more than 42,000 employees is uniquely focused on empowering New Yorkers, without exception, to live the healthiest life possible. For more information, visit and stay connected on Facebook at or Twitter at @NYCHealthSystem.

About OneCity Health

OneCity Health is the NYC Health + Hospitals-sponsored Performing Provider System (PPS), formed under the auspices of the New York State Delivery System Reform Incentive Payment (DSRIP) program. Comprising hundreds of healthcare providers, community-based organizations, and health systems, OneCity Health is the largest PPS in New York State.

About Coordinated Behavioral Care

CBC is a results-driven healthcare organization dedicated to improving the quality of care for Medicaid beneficiaries with serious mental illness, chronic health conditions and/or substance use disorders. CBC was launched in 2011 by innovative NYC not-for-profit behavioral health organizations in order to meaningfully participate in NYS’s Medicaid redesign and Value Based Purchasing initiatives. In the following years CBC developed a citywide Health Home, which is currently one of the largest of its type in NYC. CBC became an Independent Practice Association (IPA) in 2014 and has launched effective gap-filling service programs for low-income New Yorkers that build on the expertise of its community-based service network. CBC knits together affiliated programs to holistically address individuals’ treatment and recovery needs, while assessing community deficiencies and connecting individuals to needed support.