{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T23:29:28Z","timestamp":1777678168418,"version":"3.51.4"},"reference-count":32,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,2,12]],"date-time":"2026-02-12T00:00:00Z","timestamp":1770854400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Health Promotion Practice"],"abstract":"<jats:p>Consistent evidence demonstrates that care transition programs can significantly improve mental health outcomes, treatment engagement, satisfaction, and overall quality of life. However, the extent and fidelity of implementation across behavioral health systems remain underexamined. This article applies the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate the Pathway Home model, a community-based care transition program in New York that supports individuals returning to the community after psychiatric hospitalization or other institutional settings. Pathway Home integrates the evidence-based principles of Critical Time Intervention to provide person-centered, time-limited, multidisciplinary support during critical transition periods. Drawing on multiple reporting streams, prior evaluations, and program data, we examine how the model performs across each RE-AIM dimension, highlighting operational successes, implementation barriers, and areas requiring continued attention. Findings indicate that Pathway Home effectively reaches high-need populations, strengthens continuity of care, and reduces the risk of re-institutionalization through enhanced linkage to behavioral health, primary care, and social support. Its flexible, cross-system design has enabled replication and scale across diverse community settings. Despite its growth and demonstrated impact, challenges persist. Particularly related to long-term financial sustainability, workforce retention, and integration within fragmented health systems. The Pathway Home experience underscores the importance of adaptable implementation models and cross-sector partnerships in sustaining person-centered care transitions. Ongoing evaluation is critical to inform policy, funding, and practice strategies that ensure such models remain viable components of the behavioral health continuum.<\/jats:p>","DOI":"10.1177\/15248399261419105","type":"journal-article","created":{"date-parts":[[2026,2,13]],"date-time":"2026-02-13T00:04:39Z","timestamp":1770941079000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Using the RE-AIM Framework to Understand Pathway Home\u2019s Impact, Reach, and Long-Term Sustainability Within the Healthcare System"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4471-5716","authenticated-orcid":false,"given":"Barry","family":"Granek","sequence":"first","affiliation":[{"name":"New York Psychotherapy &amp; Counseling Center, Jamaica, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pamela","family":"Mattel","sequence":"additional","affiliation":[{"name":"Coordinated Behavioral Care, New York, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Angelo","family":"Barberio","sequence":"additional","affiliation":[{"name":"Coordinated Behavioral Care, New York, NY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2026,2,12]]},"reference":[{"issue":"1","key":"e_1_3_2_2_1","article-title":"Programs for care system transitions in mental health: A systematic review","volume":"10","author":"Apaydin E.","year":"2022","unstructured":"Apaydin E., Delavale V., Fu N., Larkin J., Chough I., Motala A., Hempel S. (2022). Programs for care system transitions in mental health: A systematic review. Rand Health Quarterly, 10(1), Article 8.","journal-title":"Rand Health Quarterly"},{"key":"e_1_3_2_3_1","doi-asserted-by":"crossref","unstructured":"Bowen D. J. Heald A. LePoire E. Jones A. Gadbois D. Russo J. Carruthers J. (2021). Population-based implementation of behavioral health detection and treatment into primary care: Early data from New York state. BMC Health Services Research 21 Article 922. https:\/\/doi.org\/10.1186\/s12913-021-06892-5","DOI":"10.1186\/s12913-021-06892-5"},{"issue":"2","key":"e_1_3_2_4_1","first-page":"106","article-title":"Effectiveness of discharge interventions from hospital to home on hospital readmissions: A systematic review","volume":"14","author":"Braet A.","year":"2016","unstructured":"Braet A., Weltens C., Sermeus W. (2016). Effectiveness of discharge interventions from hospital to home on hospital readmissions: A systematic review. JBI Evidence Synthesis, 14(2), 106\u2013173.","journal-title":"JBI Evidence Synthesis"},{"key":"e_1_3_2_5_1","doi-asserted-by":"publisher","DOI":"10.5243\/jsswr.2012.4"},{"key":"e_1_3_2_6_1","doi-asserted-by":"publisher","DOI":"10.1176\/ps.2009.60.4.451"},{"key":"e_1_3_2_7_1","doi-asserted-by":"publisher","DOI":"10.1176\/ps.2007.58.12.1577"},{"key":"e_1_3_2_8_1","doi-asserted-by":"crossref","unstructured":"Engstr\u00f6m I. Hansson L. Ali L. Berg J. Ekstedt M. Engstr\u00f6m S. Fredriksson M. K. Liliemark J. Lytsy P. (2023). Relational continuity may give better clinical outcomes in patients with serious mental illness\u2014A systematic review. BMC Psychiatry 23(1) Article 952. https:\/\/doi.org\/10.1186\/s12888-023-05440-1","DOI":"10.1186\/s12888-023-05440-1"},{"key":"e_1_3_2_9_1","doi-asserted-by":"publisher","DOI":"10.1097\/NCM.0000000000000550"},{"key":"e_1_3_2_10_1","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.bp.114.149997"},{"key":"e_1_3_2_11_1","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.2013.301299"},{"key":"e_1_3_2_12_1","first-page":"487","article-title":"Evaluation of theory-based interventions","volume":"4","author":"Glasgow R. E.","year":"2008","unstructured":"Glasgow R. E., Linnan L. A. (2008). Evaluation of theory-based interventions. Health Behavior and Health Education: Theory, Research, and Practice, 4, 487\u2013508.","journal-title":"Health Behavior and Health Education: Theory, Research, and Practice"},{"key":"e_1_3_2_13_1","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.89.9.1322"},{"key":"e_1_3_2_14_1","first-page":"10","article-title":"From Institution to Community: Implementing the Pathway Home Approach for High-Risk Members With Behavioral Health Needs Transitioning From an Adult Home","author":"Granek B.","year":"2024","unstructured":"Granek B., Barberio A., Mattel P. (2024a). From Institution to Community: Implementing the Pathway Home Approach for High-Risk Members With Behavioral Health Needs Transitioning From an Adult Home. Professional Case Management, 10\u20131097.","journal-title":"Professional Case Management"},{"key":"e_1_3_2_15_1","doi-asserted-by":"publisher","DOI":"10.1097\/NCM.0000000000000493"},{"key":"e_1_3_2_16_1","first-page":"10","article-title":"Case management practice improvement award recipient: Pathway Home program","volume":"5","author":"Granek B.","year":"2019","unstructured":"Granek B., Frisco J. (2019). Case management practice improvement award recipient: Pathway Home program. CMSA Today, 5, 10\u201312.","journal-title":"CMSA Today"},{"key":"e_1_3_2_17_1","unstructured":"Granek B. Mattel P. Ramos G. (2024b). The pathway home program revisited: Update on the recipient of the 2019 CMSA foundation award for case management practice improvement. CMSA Today. https:\/\/cmsatoday.com\/2024\/11\/25\/the-pathway-home-program-revisited-update-on-the-recipient-of-the-2019-cmsa-foundation-award-for-case-management-practice-improvement\/"},{"key":"e_1_3_2_18_1","unstructured":"Granek B. Ramos G. Queliz M. (2024c). Safe at last: Safe options support (SOS) offers options to support the homeless. Behavioral Health News. https:\/\/behavioralhealthnews.org\/safe-at-last-sos-offers-options-to-support-the-homeless\/"},{"key":"e_1_3_2_19_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10935-007-0099-3"},{"key":"e_1_3_2_20_1","doi-asserted-by":"publisher","DOI":"10.1097\/00005053-200003000-00002"},{"key":"e_1_3_2_21_1","doi-asserted-by":"publisher","DOI":"10.1176\/ps.62.7.pss6207_0713"},{"key":"e_1_3_2_22_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ps.54.6.884"},{"key":"e_1_3_2_23_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10488-022-01224-z"},{"key":"e_1_3_2_24_1","doi-asserted-by":"publisher","DOI":"10.1111\/eip.12782"},{"key":"e_1_3_2_25_1","unstructured":"National Committee for Quality Assurance. (2023). Follow-up after hospitalization for mental illness: HEDIS measures and technical resources. https:\/\/www.ncqa.org\/hedis\/measures\/follow-up-after-hospitalization-for-mental-illness\/"},{"key":"e_1_3_2_26_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10597-021-00902-w"},{"key":"e_1_3_2_27_1","doi-asserted-by":"publisher","DOI":"10.1176\/appi.ps.69803"},{"key":"e_1_3_2_28_1","doi-asserted-by":"publisher","DOI":"10.1177\/1062860615615426"},{"key":"e_1_3_2_29_1","doi-asserted-by":"publisher","DOI":"10.1037\/1053-0479.18.2.167"},{"key":"e_1_3_2_30_1","volume-title":"Radical collaboration: Five essential skills to overcome defensiveness and build successful relationships","author":"Tamm J. W.","year":"2004","unstructured":"Tamm J. W., Luyet R. J. (2004). Radical collaboration: Five essential skills to overcome defensiveness and build successful relationships. HarperCollins."},{"key":"e_1_3_2_31_1","doi-asserted-by":"publisher","DOI":"10.1542\/hpeds.2020-002246"},{"key":"e_1_3_2_32_1","doi-asserted-by":"crossref","unstructured":"Vigod S. N. Kurdyak P. A. Dennis C.-L. Leszcz T. Taylor V. H. Blumberger D. M. Seitz D. P. (2013). Transitional interventions to reduce early psychiatric readmissions in adults: Systematic review. British Journal of Psychiatry 202(3) 187\u2013194. https:\/\/doi.org\/10.1192\/bjp.bp.112.115030","DOI":"10.1192\/bjp.bp.112.115030"},{"key":"e_1_3_2_33_1","doi-asserted-by":"publisher","DOI":"10.1097\/ACM.0000000000001328"}],"container-title":["Health Promotion Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/15248399261419105","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/15248399261419105","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/15248399261419105","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,29]],"date-time":"2026-04-29T08:26:28Z","timestamp":1777451188000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/15248399261419105"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,12]]},"references-count":32,"alternative-id":["10.1177\/15248399261419105"],"URL":"https:\/\/doi.org\/10.1177\/15248399261419105","relation":{},"ISSN":["1524-8399","1552-6372"],"issn-type":[{"value":"1524-8399","type":"print"},{"value":"1552-6372","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,12]]},"article-number":"15248399261419105"}}