Pathway Home CTI for People Leaving Institutional

Care

Mark Graham, LCSW Todd Barnes, RN

Michael Greene, Peer Joseph Drucker, LMSW

The Revolving Door Patient

About 11.8% of the 40,504 adult Medicaid beneficiaries under the age of 65 who were discharged from an inpatient psychiatric facility in 2007 were readmitted within 30 days.

Males made up 63% of readmitted patients

67% aged between 25 - 54

Number of past hospitalizations increases risk of 30 day readmission

Factors Predicting Readmission Housing Stability

Family Supports

Community Supports

Substance Abuse

Medical Conditions

Daily Living Skills

Social Stigma

Outpatient Attendance

The Need for Change

Financial Cost

Emotional Cost

Impact on systems – housing, care management, hospital

Lowers expectations and motivation

A Pathway Home… Engagement and

Intensive Support

Clinician-led Interventions

Identify Support Network

Advocacy

• 0-3 Months

Reassessment of need

Consumer Led Interventions ‘Shadowing’

Empowerment/ Self Advocacy

• 3-6 Months

Step Down Support • 6-9 Months

A Department of Health Grant Funded

Transitional Support Program

Adapted Critical Time Intervention Model

Of Care

Pathway Home: Program Model

Two Multi-Disciplinary Teams Covering Bronx, Manhattan and Brooklyn

Immediate Response to New Referrals

Consumer screened within 72 hours of referral received

Ideally a Minimum of Two Encounters at Hospital | Actively Partake in Discharge Planning

Immediate Needs Assessment (Enhancement Funds)

Pathway Home: Program Model

Escort Home and to Initial BH and

PCP Appointments

Ongoing Home/ Community

Visits – Intensity Determined by

Clinician’s Assessment

Medication and Benefit

Reconciliation

Identification and Engagement with Appropriate

Community Supports

Support to Housing Care

Managers and/ or Family Members

Integrating Physical & Behavioral Health

Chronic Medical Disease

Management

• Obesity, Cardiovascular Disease, Lung Cancer & Diabetes

Barriers to Care

• Obtaining Health History

• Outpatient Siloes • Non-traditional

Medical roles

Critical Success Factors

• Education • Coordination • Client-centered

Approach

The Community Behavioral Health Nursing Role

Intake Screening

Biopsychosocial Nursing

Educator

Medication Management and IM administration

Safety Assessment

Medical Case Management & Medical Case Management

Eligibility Requirements

• Medicaid recipient;

• Hospital admission 15 days + ;

• Difficulty obtaining and/ or maintaining housing in the community;

• Open to receiving additional support in the community.

Referral Sources

Primary Diagnosis

Pathway Home: Program Goals Reduce ER Visits and Readmissions

Shorten Hospital Length of Stay

Increase attendance/engagement with outpatient providers

Overcome Barriers to Obtaining and/ or Retaining Housing

Appropriate Community Support Network

Pathway Home: Outcomes 92% of enrolled participants attended an BH Outpatient appointment within 30 days of returning to the community

75% of enrolled participants attended a PCP appointment within 30 days of returning to the community

8.2% 30-Day Readmission Rate

90% Housing Retention Rate

A Peer Perspective

“I am them”

Motivation

Empower

Building Trust

Empathy

A Pathway Home Story • 35 year old client with Schizophrenia from State Hospital

• Substance Abuse and parole status affecting stability and housing opportunities

• Assistance finding the right services, and coordination between services

• Ongoing outreach, support and advocacy

• Establishing community and family support

Housing Perspective: Client History Ms. Smith

70 year old white female, 10 years in current residence, recurring issues with hoarding

Extremely intelligent, good sense of humor, kind and caring for others

Isolated, presents as very frail, unsafe behaviors, difficulty passing funder’s room inspections

No insight into mental health issues, diagnosis of Schizophrenia, Paranoid Type

Poor ADLs, limited engagement with medical providers, history of cellulitis

Sees onsite psychiatrist, medication monitoring

Frequent hospitalizations, physical complaints especially around allergens

Housing Court

APS Deep Cleaning

Court Stipulation for monthly inspections by landlord

Housing Cont’d: How to Declutter? Situation leading to Pathway Home’s involvement

APS Deep Cleaning not available, clutter growing

Lice infestation, clutter still growing

Limited involvement from Home Health Aide

Frequent falls leading to hospitalization

Involuntary admission to psychiatric unit

Private Estate Clearance Service paid by Pathway Home

Cost prohibitive for client

Person Centered

Effective