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.
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