One of the biggest challenges hospitals face in lowering 30 day readmission rates is providing viable and affordable solutions for patients who are not able, either through their own efforts or those of their family caregivers, to follow their discharge plan or manage their care following hospitalization.

Discharge plans can be confusing. Medications, Follow-ups, Exercise Programs, Proper Nutrition, Post surgical or post admission visits… when does it end?

Time to adjust. Maybe it’s what we all need. Sometimes it’s just overwhelming.

Our “Pathways Home” program can help with some of the “adjustments” and follow up that comes with getting back home. Having a program in place to return home, monitor the in-home care and communicate with your medical professionals can take a lot of pressure off of you or your loved on and help him or her focus on getting better, and remaining home.

When patients move from the hospital to the next site of care, they benefit from having a clear treatment plan they can understand and follow. We can be there to offer support and services and help the return home be a successful one.

Pathways Home provides a frontloaded approach to care with an initial supportive care visit that can occur prior to or immediately upon discharge. The patient can be met in the hospital by our Director of Patient Services and be accompanied home having services already in place. Our Pathways Home service can help in many ways, including but not limited to:

• Making sure that all medical equipment is already in the home.
• Work with medical care providers to make sure that prescriptions are called in and picked up so they are home before, or at the same time of your arrival home.
• Providing safe and adequate transportation to your home upon discharge.
• Making “safety adjustments” in home, removing clutter in pathways, placing heavily used items such as phones and remotes within easy reach.
• Making sure items in refrigerator are fresh, groceries have been picked up, and preparing a light meal if requested.
• Assisting patient in calling their primary care physician to schedule follow-up visit if this has not been scheduled.

Often, a second visit occurs approximately 3 -10 days after the patient’s return home. This visit is scheduled to coincide with the patient’s scheduled appointment with their primary care physician. The goals of this visit are:

• To assist the patient in dressing and getting ready for their physician appointment.
• Assist the patient in preparing for talking to their Primary Care, including providing care notes and concerns.
• Provide transportation to the Primary Care Physician and back home, if necessary.

The Pathways Home program does not eliminate the need for skilled home health services, but simply supplements this care with the critically needed support services that Medicare and private insurances do not pay for. The Pathways Home visits can take up to four hours to complete the necessary tasks.

Other Value-Adds of the program:

• PATHWAYS HOME PERSONAL GUIDE: Provided to patients in the hospital before discharge, this guide is designed to facilitate a successful transition to their home environment. The guide also provides the patient with an opportunity to “journal” care plan instructions and organize important care plan information.
• READMISSION RATE REPORT CARD (OPTIONAL): Provided to hospital on a monthly basis, and after the 30 day period following discharge has elapsed.

Pathways Home is designed to be an affordable solution for lowering the risk of readmission for both Hospitals and/or consumers.