Pathways to Home Program

Lower Your 30 Day Readmission Rates Through the “Pathways to Home” program

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 Companion – to follow their discharge plan or manage their care following hospitalization. For some patients, discharge plans become confusing – even those they are able to successfully “teach back” in the hospital – when confronted with their home environment and factors such as the additional medications they may have at home. Oftentimes, they don’t have the means or transportation to make sure prescriptions are picked up, groceries are in the home, and a follow-up visit is scheduled and made with their primary care physician. Or, they have not made the simple adjustments to their home that will promote their own safety and reduce their risk of falling.

The “Pathways to Home” program provides an affordable solution for patients at risk for 30 day readmission

“Pathways to Home” provides a “frontloaded” approach to care with an initial supportive care visit that can occur immediately upon discharge. The patient can be met in the hospital by their PTH Companion and accompanied home, or can be met at home.

The goals of the PTH Companion include:

  • Assisting with tele-health solutions (tele-health products are an additional fee).
  • Assisting the patient in “comfort measures”, dressing, etc.
  • Making “safety adjustments” in home, removing clutter in pathways, placing heavily used items such as phones and remotes within easy reach.
  • Making sure new prescriptions have been picked up.
  • 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.

A second visit occurs approximately 3 -10 days of 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.
  • The PTH Companion will also assist the patient in preparing for talking to their Primary Care Physician, by encouraging patient to bring discharge plans and their Pathway to Home Personal Guide.
  • The PTH Companion can provide transportation to the Primary Care Physician and back home, if necessary.
  • Patients who do not require assistance with transportation will have additional “comfort care” provided in their home.

The “Pathways to 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 to Home visits can take up to four hours each visit to complete the necessary tasks.

Other Value-Adds of the Program

  • PATHWAYS TO 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. Information is gathered through a telephone interview conducted by a third party vendor.