Pathway Home Transition Teams

The Pathway Home Transition Teams are innovative care transition programs funded by the New York State Office of Mental Health (OMH). Catholic Charities currently operates the Queens Transition Team, serving residents of Queens, and the Kingsborough Transition Team, embedded at Kingsborough State Psychiatric Center, serving clients preparing for discharge from the inpatient units.

The Transition Teams implement an evidenced-based Critical Time Intervention (CTI) model, providing intense services beginning shortly before hospital discharge which continues with the individual in the community for six to nine months after hospital discharge. These transition teams are multi-disciplinary teams offering community-based time-limited services for adults with serious mental illness who have experienced long-stays in psychiatric inpatient care. Staff address a host of issues—housing, food, economic security, medication adherence, linkage with outpatient providers, family conflict, and social isolation faced by individuals transitioning to the community. The goal of the program is to enhance the system of care for those transitioning to the community from the hospital and facilitate community integration and engagement with community support and providers to meet the various service needs that exist during the critical period following a hospital discharge. To ensure continuity of care, clients who graduate from Pathway Home Transition Teams are then stepped down for additional home and community follow-up support offered by the Catholic Charities Care Coordination program.