Transitional Services

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To help people transition to life in the community following periods of homelessness or institutional care, specialty teams provide case management and care coordination services.

Programs use the evidence-based Critical Time Intervention (CTI) model for community integration and continuity of care to ensure that an individual has support systems and viable ties to the community during the critical period following discharge. These programs typically provide support for nine to 12 months, depending on individual needs.

To make a referral, contact the program directly.

The Bridger Team Program in East New York provides support services to people moving from homelessness to stable independent housing.

Residential Transitional Support (RTS) Provides support to residents of congregate residences, state psychiatric hospitals, inpatient hospitals, nursing homes, or shelters transitioning to more independent, community-based settings.

Pathway Home is for those transitioning to the community from the hospital.



Bridger Team Program

2581 Atlantic Avenue
Brooklyn, NY 11233
Phone: (718) 272‐6025


Pathway Home

2384 Atlantic Ave
Brooklyn, NY 11233
Phone: (646) 245‐1116


Residential Transitional Support (RTS)

221-10 Jamaica Avenue
Queens Village, NY 11428
Phone: (718) 468-4700

Other supportive links for Coordinated Care

Institute for Community Living, Inc.

125 Broad Street
New York, NY 10004

(844) ICL-HOPE 
(844) 425-4673

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Use code 10325


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