Successful transitions from inpatient care to the community often demand navigating a complex, fragmented health care system. Extended hospital stays lead to additional challenges; patients often have not been effectively connected to ambulatory care and are frequently ill prepared for community living. Traditional case management services often do not adequately meet the needs of individuals with severe mental illnesses who are transitioning from inpatient to outpatient care; many remain disconnected from services and have high readmission rates.
In 2014, Coordinated Behavioral Care (CBC) implemented an innovative care transitions program called Pathway Home (PH), which has, through a multidisciplinary approach and use of critical time intervention, significantly improved community outcomes after long-term inpatient
hospital stays.