Post-acute recovery with the clinical depth of a SNF, in the place patients actually want to be.
A coordinated, physician-led, in-home program for patients who would otherwise discharge to a skilled nursing facility. This only works because Pathways runs all three service lines under one chart — Home Health, Palliative, and Hospice — so one team carries the patient across when their needs change.
For the post-surgical patient who can’t yet manage stairs. The CHF exacerbation that needs daily diuresis monitoring. The wound that needs a nurse three times a week. The COPD patient whose new inhaler regimen needs supervision. Home health alone — intermittent skilled visits, no physician on staff — isn’t enough. So they go to the SNF.
What happens there is well-studied. About one in five Medicare SNF patients is rehospitalized within thirty days. Hospital-acquired infections move into post-acute settings. Deconditioning compounds quickly: the average patient loses meaningful function inside a week of bed-bound care. Delirium worsens in unfamiliar surroundings. Families drive an hour twice a day, then stop coming.
Pathways SNF at Home is the home-based alternative. Not home health — home health plus a hospice-experienced physician group, advanced symptom management, 24/7 on-call, and the rest of our three-service-line capability tied together as one program.
SNF at Home is not a Medicare benefit you bill against. It’s an operational design — what a skilled nursing facility does, decomposed and rebuilt around a patient’s home. The components require three different clinical capabilities. Any program missing one of them quietly fails. We have all three.
Medicare-certified, intermittent skilled visits: nursing, PT, OT, ST, wound care, IV antibiotics, infusion support, aide hours. The bones of any home-based recovery program. Most agencies can do this part — just not the rest.
Physician oversight, daily symptom management, advance care planning, pain protocols, goals-of-care conversations. The medical-director cap that makes daily clinical adjustment possible without bouncing to an ED. The piece a home-health-only agency does not have.
If trajectory turns — and in post-acute care it sometimes does — we transition the patient into hospice without changing the team, the chart, or the in-home equipment. No new admission. No discharge gap. No call to a different organization. That is what we mean by one team, the whole way through.
The exact composition flexes by diagnosis and acuity. Below is the typical envelope for the first two weeks of a SNF-at-Home episode. We work with your facility’s case management to set the right starting cadence and adjust from there.
This page is being built honestly. The four metrics below are the metrics we track. The specific numbers will be filled in directly from our operations data rather than fabricated for marketing — if our team can substantiate them today, we’ll publish them; if we’re still building the report, we’ll say so.
Our program vs benchmark for matched post-acute population.
Avoidable ED visits during the episode — tracked against home-health-only.
Median days the patient spent at home during episode vs SNF benchmark.
ADL recovery at 30 / 60 / 90 days post-admission.
Outcomes data is currently being assembled by our quality team. Until our published version is ready, we share working data with referring providers on request. Call our medical director for a current view of how our program is performing in your patient population.
Some patients who would otherwise go to your SNF — or who are in your SNF — want to recover at home. They’ve told us. They’ve told you. For those patients, we exist. For everyone else, your SNF is the right place: complex rehab, unstable post-op, patients without a safe home environment, family-system reasons. We refer those patients to SNFs. We’re not in the business of pulling patients who belong in your beds out of your beds.
Where Pathways SNF at Home tends to win the patient’s preference: post-surgical recovery where the home environment is solid, CHF exacerbations with reliable caregivers, palliative-shifted oncology cases, patients whose families can’t manage the SNF drive but can manage the home setup. We’d rather coordinate with you on which patients are right for which setting than compete for the same beds.
If you’re a SNF medical director and you’d like to compare notes on which of your patients we’d be a good fit for — or vice versa — call our medical director directly. No sales people. No pitch decks. Doctor to doctor.
Call the line. Ask for SNF at Home intake. Our medical director or NP triages the call in real time, our intake nurse coordinates with your discharge planner, and we have the patient admitted and the first home visit done within 24 hours of the referral. No fax-and-pray. No two-week intake delay.
