Service Line 01
Home Health
Medicare-certified skilled visits: daily nursing, IV antibiotic infusions, lab draws, wound care, PT/OT, aide hours. The daily clinical labor of acute care, executed in the home.
Pathways Clinical Programs
For hospitalists, ED physicians & discharge planners
Hospital-level care. Delivered home.
Acute-condition management for patients who could be admitted — or who could finish their stay at home.
For the right patient and the right diagnosis, the hospital ward is not the safest place — the home is. Hospital-at-Home is the program that makes acute-level care possible there: physician oversight, IV therapy, daily monitoring, escalation paths. 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.
Same-day admission from ED or floor
Physician oversight, daily
Escalation paths back to the hospital if needed
For some acute admissions, the ward is not the safer setting. It’s just the only available one.
Acute hospitalization is high-stakes care. It is also high-risk care. Hospital-acquired infections, delirium, deconditioning, sleep disruption, polypharmacy interactions, and the simple fact that the patient is in a building staffed for a thousand strangers — all of these are real downsides of an admission. For a meaningful subset of patients, none of it is necessary if the underlying clinical work can be done elsewhere.
Hospital-at-Home is the program that does that. For appropriately selected patients, the daily IV antibiotics, the diuresis monitoring, the labs, the imaging, the physician oversight — can all happen in the home with the right team. Either to avoid an admission, or to discharge from inpatient earlier than the hospital’s clock would normally allow.
This is not telehealth and it is not home health. It is a structured acute-care program with daily clinician visits, on-call coverage, IV access management, point-of-care diagnostics, and direct escalation back to the inpatient setting if the trajectory changes. Available because Pathways already has the three-service-line backbone the program requires.
A real Hospital-at-Home program is three programs woven together.
The three components below are the structural minimum for acute-level care in the home. Each one is a separate clinical capability with its own licensing, its own staff, and its own operations. Most agencies have one. Pathways has all three, integrated, with one chart and one team. The integration is the program.
Service Line 02
Palliative
Daily physician/NP oversight, order writing, symptom management protocols, peer-to-peer with the referring hospitalist or ED physician. The medical-director layer that makes daily adjustments possible without bouncing the patient back to the ED.
Service Line 03
Hospice
If the trajectory turns — an unexpected decline, a goals-of-care shift — we transition to hospice without changing the team, the chart, or the home setup. The same physicians, the same nurses, the same DME. No re-admission paperwork. No discharge gap.
One organization. One chart. One care team. When the patient’s acuity changes — up or down — the team flexes around it. No new organization. No new intake. No re-explaining the patient’s story.
What an episode actually looks like. What you, the referring physician, can expect.
Hospital-at-Home episodes are typically 3 to 10 days, depending on diagnosis and trajectory. Eligibility is patient-selective — this isn’t for everyone, and we’ll be honest with you about whether a given patient is a fit.
Who is eligible
Eligibility
- Acute diagnosis with a defined treatment plan executable at home (e.g., cellulitis, pneumonia, CHF exacerbation, UTI/pyelo, COPD exacerbation, mild-moderate sepsis).
- Hemodynamically stable; not requiring ICU-level monitoring or interventions.
- Safe home environment with caregiver support or solo-capable patient.
- Clear escalation criteria agreed with the referring physician.
Who shows up
The team in the home
- RN — one to two visits per day during acute phase.
- Nurse practitioner — daily visits for the first 48–72 hours, then as needed.
- Medical director — daily oversight + peer-to-peer with the referring physician.
- On-call clinician — live, 24/7. Not a triage line; a clinician who knows the patient.
When it happens
Episode flow
- Hours 0–6: intake call, eligibility confirmation, home setup, first visit.
- Days 1–3: peak intensity — daily nursing, NP, MD oversight, labs as ordered.
- Days 4–7+: step-down or discharge plan finalized; transition to home health or PCP follow-up.
- If trajectory turns: escalation back to inpatient OR transition to hospice without changing team.
What we equip
Acute care equipment
- IV access & infusion — antibiotics, hydration, electrolytes, diuresis.
- Point-of-care labs — same-day basic chemistries, INR, troponin where indicated.
- Point-of-care diagnostics — portable ultrasound, EKG, imaging coordination.
- Remote monitoring — continuous vitals when clinically indicated.
What we measure — and what we’ll publish. Honestly.
These are the four metrics that matter for a Hospital-at-Home program. We track all of them. The specific numbers will be filled in directly from our operations data — or labeled pending if our quality team hasn’t finalized them yet. We will not fabricate numbers for marketing.
Escalation rate
PENDING
% of episodes that escalated back to inpatient during care.
30-day rehospitalization
PENDING
% of completed episodes with rehospitalization within 30 days post-discharge.
Length of acute episode
PENDING
Median days of acute-phase care vs benchmark inpatient LOS for matched diagnoses.
Patient satisfaction
PENDING
Patient-reported experience scores at episode close.
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 the program is performing.
Peer to peer
This is not a backdoor discharge program. It’s a different setting for the right patient.
We know hospitalist-driven Hospital-at-Home programs have failed before for predictable reasons: insufficient patient selection, weak escalation paths, inadequate physician coverage in the home setting, no real backup when an acute decompensation happens at 2 a.m. We’ve built around those failure modes. Our medical director takes peer-to-peer calls in real time. Our escalation pathway back to inpatient is explicit and pre-agreed. If we accept a patient, we accept the responsibility for staying ahead of the trajectory.
We do not pull patients from your service that you would have admitted yourself if no program existed. We take the patients who could safely complete acute care at home, who want to, and whose home situation supports it. For the patients you should keep inpatient, keep them inpatient. We’re happy to consult on which is which.
If you’d like to spec out which diagnoses we can absorb from your service, set up an escalation protocol, or do a trial of a handful of patients to see how it runs — call our medical director directly. We’ll structure it however your hospital wants it structured.
How to refer · one number · direct medical-director line
One call. Same-day admission from ED or floor.
800.939.1855Call the line. Ask for Hospital at Home intake. Our medical director or NP triages the call in real time, reviews the proposed patient against our acceptance criteria, and coordinates with your discharge planner. For appropriate patients, the first home visit is within hours of the referral.
Where we work from
Twelve offices. One organization.
12
offices across six states
Massachusetts · Rhode Island · New Hampshire · Maine · Pennsylvania · Virginia
See the coverage map →
Notice of Privacy Practices
Available at our Westwood office or by request via the 24/7 line
© Pathways Healthcare
Reimagining Care at Home · since 2012