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. Oftentimes, they don’t have the means of transportation to make sure prescriptions are picked up, coordinate with durable medical equipment companies, make sure groceries are in the home, and schedule follow-up visits 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 or just to help readjust to getting back home.
“Pathways to Home” provides a “frontloaded” approach to care with an initial supportive care visit that can occur before discharge or 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 the patient in “comfort measures”, dressing, etc.
Coordinating with durable medical equipment companies
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 the refrigerator are fresh, groceries have been picked up, and preparing a light meal if requested.
Assisting patients in calling their primary care physician to schedule follow-up visits if this has not been scheduled.
A second visit occurs within 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 the 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, as well as take notes during the appointment if requested.
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.
ALZHEIMER'S DISEASE OR DEMENTIA
Alzheimer’s disease or dementia is the diagnosis that can strike dread in the hearts of most family caregivers. If you’re living it now, you know all too well. If you’ve just received the prognosis for your senior, you’re likely scared and confused.
You Are Not Alone
There is support for you and your loved one. We have partnered with Relias training, we have Certified Dementia Care Practioners on staff (including our Dementia Specialist, Corey Tague) to provide training to our caregivers so they may in turn provide the highest quality of Alzheimer’s care, changing the way people live with Alzheimer’s or other dementia. These courses have been specifically designed to prepare individuals for work as a caregiver in an in-home setting, assisted living facility, or residential care community.
Our caregivers have a passion and desire to work with Alzheimer’s or dementia clients and receive ongoing classroom and on-line training. They bring the following skills and support to families of those with Alzheimer’s disease or dementia:
Remembering Life’s Journey – Gathering past stories and experiences helps the caregiver give comfort and customized care; all the while honoring who the senior was earlier in life.
Techniques to Manage Behavior – Caregivers use techniques such as giving simple choices and redirecting, allowing the senior to remain calm and safe.
Encouraging Interaction – Engaging seniors throughout the day builds self-esteem, enhances physical strength, and reduces behaviors that need to be managed.
Supporting the Family – Our caregivers understand the struggles and challenges that accompany caring for a loved one with Alzheimer’s or dementia. They are trained to work closely with the family and have open communication, which results in quality care.
We are constantly attending classes on the latest innovations to assist in this process.
Who likes to be in a hospital room alone? Not us. But realistically family and friends cannot always be there around the clock.
Our companions can be there for you and with you.
Sometimes just a little help can make a HUGE difference. Maybe your loved one doesn’t like to be alone in the hospital room overnight. Sometimes that remote or walker is a little too far away to reach. Nurses are often spread across many patients. We make sure your hospital stay is as comfortable as possible with 100% attention.
If you are a caregiver – You must take care of yourself!
Almost all caregivers place themselves last… Not healthy for you! The role you’ve taken as a family caregiver is an important one. Your loved one and other family members depend on you. As the primary caregiver, not only do you deserve an occasional break, but also it’s necessary so you can recharge your physical, spiritual and emotional batteries. It’s critical that you take the time to care for yourself — a night out with friends, a massage, doctor’s appointments, counseling sessions or support group meetings — to ensure you’re not getting rundown and that you’ll be up to the challenges of this responsibility.
Our respite care services allow you to relax and enjoy your time away, knowing your family member is well cared for in your absence.