Next Steps: Critical Time Transition Program

About this Program

Hillside’s Next Steps: Critical Time Transition Program (CTTP) provides pre- and post-hospital discharge services to youth who have been boarding or on social stay for at least 72 consecutive hours within a hospital’s emergency psychiatric or inpatient psychiatric/medical setting. This program is ideal for youth who have experienced high utilization of hospital acute care settings and have not been able to access other community programs. Next Steps: CTTP is intended to serve youth with complex needs, including mental health conditions, co-occurring substance abuse and/or intellectual or developmental disabilities, who have otherwise been unable to achieve psychosocial and clinical stabilization.

Once accepted to Next Steps CTTP, youth are discharged from the hospital to their home, directly into a Transitional Residential Services (TRS) bed, if available and appropriate, or to another eligible community location. Youth can remain in the Next Steps program for up to nine months, receiving care management services, with the option to occupy a TRS bed for up to 120 days at any time during enrollment in the program, pending TRS bed availability and assessment. In some situations, CTTP services may be available for youth while they await an opening in another service. This would be determined on a case-by-case basis.

While in the program, youth will have access to care-management services and transitional beds (if available) including:

Referrals to Next Steps: CTTP are only accepted directly from a hospital. The following criteria are necessary for a referral to the program:

• Youth must be 11-17 years of age, with a diagnosed mental health condition(s), including those with co-occurring substance use, or intellectual or developmental disability (I/DD).
• Youth would benefit from an intervention during a critical transition in care, primarily focusing on youth boarding in ED/CPEP, pediatric unit or inpatient psychiatric unit who are medically and psychiatrically cleared for discharge.
• Youth has been in the ED or CPEP for at least 72 consecutive hours at the time of admission to CTTP (the referral can be made to CTTP prior to the 72 consecutive hour mark, eligibility for admission to CTTP includes the youth spending at least 72 consecutive hours in the hospital setting).
• There has been an exploration of referrals to community-based services and/or previous engagement in similar service types like HBCI and Youth ACT.
• The youth has an identified long-term discharge residence, such as returning home or a stable alternative placement (e.g., Kinship care, foster home, or Residential Treatment Center) to work towards, as CTTP is not a residential program.
• The youth and their family must be willing to regularly and actively engage with the Next Steps: CTTP team, as well as all identified community-based service providers.
• Co-enrollment in CTTP and HBCI, Youth ACT, CCR, RTF or Health Home Care Management is not allowed.
• The youth must not require a higher level of care than a community-based setting
• The youth must not have been ordered to detention or for court-ordered clinical assessment or placement by Family or Criminal Court, or require medical withdrawal management/medical detox or inpatient medical or psychiatric care.

To utilize a TRS bed during enrollment in CTTP, the youth must:

• be able to self-administer all of their medication with minimal supervision and support.
• be independent with ADLs and not require 1:1 supervision to complete ADLs.
• be verbal and not reliant on assistive technology in order to communicate.
• not be assessed to be actively at risk for suicidal or significant self-harming behaviors, at high risk for violence or aggression, fire-setting or elopement, or require a locked facility and must be able to be safely served in a restraint-free, community setting.
• not require 24/7 nursing care or monitoring due to a medical or psychiatric condition.

Locations

Monroe Campus

1183 Monroe Avenue
Rochester, NY 14620

Contact Information

For details about this or any Hillside program, contact us 24 hours a day at 585-256-7500 or info@hillside.com

This Program is Supported by the Office of Mental Health