Hospital at Home

Innovative Programs

A program designed for hospitals that require urgent in-home medical assessments of patients who have had an exacerbation of an existing disease or injury. The Post intensive care team is driven by Physicians and Nurse Practitioners who provide home visits until the patient has been stabilized. Seeing patients in their home environment is not only more cost effective, but also allows for an in-depth view into a patient’s environment, allowing for a better understanding of potential reasons for an exacerbation or injury.

Our innovative model is perfect for home health patients because it adds the unique feature of a physician organization. We are a Medicare certified organization, accredited by ACHC.

Cardiac

This program is designed for patients who are recovering from cardiac conditions as a result of a heart attack, congestive heart failure, valve replacement, among others. Our interdisciplinary team provides a customized care plan for each patient

Pulmonary

This program is designed for high risk patients with any respiratory diagnosis who would benefit from a medically driven pulmonary rehabilitation program. The program includes home medical assessments and intensive therapy to increase the patient’s daily activity. The “high risk” patient demographic pertains to those most at risk for returning to a hospital setting. This factor demands health coaching for self-management techniques. High risk patients require a physician–directed highly skilled team which will provide a detailed evaluation, ongoing assessment, and individualized treatment plan that is more intensive than what traditional homecare agencies can offer. The program’s treatment provided by physical and occupational therapists, combined with skilled nursing care, teaches the patient energy conservation techniques and compensatory strategies allowing them to improve their ability to perform daily activities, thus improving their quality of life. The program offers patients the choice to receive rehabilitation care in the safety and privacy of their own home and avoid the risk of institutional infections.

Assisted Living Continuity of Care

This program is designed to offer residents of assisted living facilities continuous medical services in the comfort and safety of their own homes. Pathways will provide primary care services, as well as nursing, physical therapy, occupational therapy, and behavioral services. As a covered facility, the assisted living residents are enrolled in our On-call Program, giving them access to a physician or nurse practitioner 24 hours a day, 7 days a week. The Pathways medical staff will work in conjunction with the resident’s PCP and/or Specialist in regard to their ongoing care. In addition to individual care. In the case that a resident is hospitalized, a Pathways nurse liaison will follow the patient through their hospital stay, providing updates to caregivers and facility personnel regarding their return to the assisted living facility.

MD & NP Bridge/House Call Program

This program is designed for patients who require urgent medical assessment in the home. Pathways staff assesses if the condition may be successfully treated in the home, or if an ER admission is necessary for patients that had or is a experiencing an exacerbation of a disease process. The highly skilled team members provide an individualized treatment plan, with the approval of the PCP, for monitoring and stabilizing the disease process to avoid hospitalizations.

Wound Management

With Oversight from our Physicians and Nurse Practitioners this program is managed by clinicians who are trained and experienced in wound management to promote the healing process Wound Ostomy Continence Nurse (WOCN). Our nurses have access to the latest standards of practice and products for wound care. This includes a comprehensive clinical training program that has been designed to improve patient comfort, decrease time spent on dressing changes, improve healing time, prevent complications, improve patient outcomes.

Memory Impairment

Our Memory Impairment Program tailors personalized care plans for patients whether they are experiencing moderate dementia or severe symptoms, to maximize each patient’s comfort and quality of life. We meet the needs of the whole person – physical, cognitive, and emotional – while supporting, relieving and preparing caregivers.

Who Pays for Home Health Care

Certified home health care services are ordered by a physician, require skilled care, and is typically paid for by Medicare or other health insurances plans.