Hospital to Home

A bridge and support for youth and their caregivers during times of transition.

Northern Rivers’ Hospital to Home (H2H) program provides a structured, supportive transition for youth ages 11 to 17 with acute mental health needs who are discharging from psychiatric hospitalization or emergency room stays. Through a multi-phase care model, the program aims to reduce unnecessary readmissions and long-term placements by offering comprehensive and community-based supports. Using the Critical Time Intervention (CTI) approach, we partner with hospitals and families to ensure a seamless discharge and sustainable reintegration into home and community life.

Who We Are

Our H2H treatment team includes case managers, clinicians, peer advocates, educational and vocational specialists, recreational therapists, and behavior intervention specialists. We work in close coordination with hospital discharge planners and treatment teams to create individualized service plans. Our approach focuses on assessing immediate needs, building a community support network, and promoting long-term emotional and behavioral health stability and avoidance of emergency services.

What We Do

H2H is a 9–12-month transitional case management program that begins with hospital-based engagement and extends into the community. It includes:

• Critical Time Intervention (CTI): Intensive, phased case management involving family engagement, skill-building, resource linkage, and advocacy.
  
  
• Transitional Residential Setting (TRS): (Launching Fall 2025) Up to 120 days of short-term residential care as needed at our Park Place facility in Schenectady in a dedicated 8-bed unit, supported by H2H service.

Getting Started

Referrals to H2H are made directly by hospitals. We serve youth ages 11 to 17 (Youth who turn 18 while enrolled may continue to be served through age 19) who:

• Are medically and psychiatrically cleared for discharge.
  
  
• Have been (or are expected to remain) boarding in Inpatient or Emergent Care Units for more than
  72 hours.
  
  
• Would benefit from structured transition services and wraparound care.
  
  

Questions? Contact This email address is being protected from spambots. You need JavaScript enabled to view it.. 

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Every Child Deserves a Seat at the Table 

At the Johnston dinner table, foster mom Monique has a tradition: before the food makes its way around, each child shares something about their day. It’s a small ritual—born from a family therapy session—that has transformed their home into a place of healing. 

• Jazmine, 9, proudly shares that she bought a new book with points she earned for meeting her behavioral goals. 

• Jae, 16, is one step closer to independence after polishing up a first-ever resume with help from an employment coach. 

• Carter, 14, quietly works on homework assigned by his clinician, pausing to apologize for a fight with his sister earlier in the week. 

• Renee, 11, recently adopted, beams as she explains why she chose a new name. “Renee means reborn,” she tells her mom. 

Four kids. Four stories of resilience, growth, and new beginnings. Just a glimpse of the more than 19,000 lives transformed each year through the work of Northern Rivers Family of Services and our affiliates, Parsons and Northeast. 

You Make Stories Like This Possible 

Your generosity fuels programs that provide: 

• Mental health services 
• Foster care and adoption support 
• Residential treatment 
• Special education 
• Community-based care 

When you give to Northern Rivers, you don’t just make a donation—you become part of the story. You help children heal, families grow stronger, and young people discover hope for their future. 

Join Us 

Every child deserves a chance at a new beginning. With your gift, you help make that possible—one story, one family, one life at a time. 

The Current - Spring 2025

During the month of February, we are seeking donations of personal hygiene items, socks and underwear for the children and youth we serve in the community.  

To make the giving process even easier, we’ve put together an Amazon wish list. Items can be shipped directly or dropped off at our Albany campus.

In Morning of Kindness tradition, we will have a special donation drop off event on National Random Acts of Kindness Day!  

Monday, February 17th
9:00 a.m. and 12:00 p.m.
SATRI building at 60 Academy Rd, Albany, NY 12208

View our Amazon Registry

This holiday season, we want to share a story that shows what your generosity makes possible.

For the first time, Nico, 5, and his sister Jewel, 7, will experience the warmth of a family holiday around Tammi’s table. After facing neglect, fear, and instability, they were welcomed into Tammi’s foster home this summer. Through the patience of their foster family, the dedication of their Northern Rivers team, and the support of compassionate people like you, Nico and Jewel are finally discovering what it means to be home.

This holiday season, your gift will have double the impact, thanks to a $20,000 matching gift from the Rose & Kiernan Charitable Foundation. Together, we can bring twice the joy, comfort, and security to those who need it most.

Right now, so much feels uncertain. The world is changing rapidly, and many are searching for a way to create real, lasting impact. But even in these uncertain times, we still have hope—hope that, together, we can provide children with the stability and care they deserve.

For kids like Nate, that uncertainty isn’t new. Nate’s parents couldn’t keep him safe, and when they signed away their parental rights, his world was turned upside down. Then, when a family who promised him forever decided his needs were too much, he was left to wonder if he would ever belong anywhere.

That’s when Northern Rivers opened our doors—and our hearts—to him. Here, Nate found safety, structure, and people who refused to give up on him. Over the past year, he’s learned to manage his emotions, to trust, to dream. And last month, for the first time, he had an answer when we asked what he wants to be when he grows up. He wants to be a doctor.

Kids like Nate need to know that even when the world feels unpredictable, there are people who will always stand by them. And that’s why we need you.

Right now, every dollar you give will go twice as far, thanks to a $5,000 challenge matching gift. Your gift will provide the care, support, and stability that children like Nate need to heal and thrive.

Since 1829, we’ve answered the call whenever our community has needed us. We’ve never done it alone. Your support makes everything we do possible.

Proceeds to benefit Northern Rivers Family of Services. A copy of Northern Rivers’ latest financial report may be obtained, or requested, by contacting Northern Rivers Family of Services, 60 Academy Rd, Albany, NY 12208, or the from the NYS Attorney General’s Charity Bureau, 120 Broadway, 3rd Floor, New York, NY 10271.

When you're out on your next shopping trip, pick up a few items from our wish list!

If you're shopping online, check out our Amazon Wish List, and items will be shipped directly to us!

Make a monetary donation here to sponsor a wish list item: