Community-based care management services are vital in helping New York City’s most vulnerable members navigate an evolving healthcare landscape. CBC’s Pathway Home™ (PH) program is an evidence based multidisciplinary care transition intervention, tailored to walk side by side members from institutional setting back to their communities, providing emotional and practical support every step of the way. Pathway Home™ specializes in care transitions from a variety of institutional settings such as State Psychiatric Centers, Adult Homes, Hospital Inpatient Units, and transitional living residences. Pathway Home’s™ unique approach builds trust and rapport to mutually design a transition plan while inpatient, segueing into intensive supportive community-based visits. Through modelling and active linking from the PH multidisciplinary team, members strengthen skills for independence and take active ownership over their healthcare needs. The multidisciplinary team is comprised of Licensed Mental Health Clinicians, Case Managers, Registered Nurse, and Peer Specialists. Pathway Home™ utilizes several evidence-based practices such as Critical Time Intervention (CTI), Harm Reduction, Motivational Interviewing, and Peer Support. Peers are those with shared lived experience of mental illness, substance use, or homelessness who utilize disclosure to engage, develop, and strengthen rapport with the members.