All posts by Kelly Federle

Patient Journey at PathWell Health for Patients Who Need Post-Acute Care

At PathWell Health, as a home healthcare provider, we strive to ensure that patients receive the care they need in the comfort of their own homes. We receive referrals through various means including electronic referrals via hospital portals, eFax, phone calls and we initiate the intake process. Once a patient is referred to us, eligibility and authorization are confirmed, and the patient is entered into our electronic medical records system.

Next, the patient’s primary care physician (PCP) is contacted to confirm their willingness to sign home care orders. The patient is then assigned to a start-of-care clinician, and a welcome call is made to the patient to ensure that the correct address is on file, the patient is available for a home visit, and they are willing to receive care. During the welcome call, emergency contacts and PCP information are confirmed.

Within 48 hours of referral or discharge from an inpatient facility, a nurse or physical therapist evaluates the patient to develop a holistic plan of care and recommends any additional service needs. A medication reconciliation is performed, and a home safety evaluation is conducted. The presence of any health-related social needs that could impact care is also assessed.

Patient-centric goals are created, and the PCP is notified of the plan of care and any concerns. Further evaluation is conducted through additional disciplines such as physical therapy, occupational therapy, speech therapy, and medical social work.

Once the plan of care is in place, the home care team carries out visits based on the initial evaluations. A “Tuck-in” call is made on the first weekend a patient is on service to ensure they have all of their medications and no new medical concerns since the start of care.

During care delivery in the home, patients receive medication teaching and monitoring, wound care, cardiopulmonary assessment, fall prevention, deconditioning, diabetic teaching and monitoring, ostomy management and teaching, pain management, activities of daily living, and community resources. We also have a readmission reduction program in place to ensure patients are able to maintain their health and avoid hospital readmissions.

At the time of discharge, anticipated outcomes include increased functional status, increased compliance with medications, knowledge related to signs and symptoms of exacerbation of illness, knowledge pertaining to remaining safe at home, increase independence with activities of daily living and instrumental activities of daily living, stabilization of acute illness, improvement or healing of wounds, decreased pain, and appropriate resources in place to address health-related social needs.

At discharge, the physician is notified of the discharge and the status of goals met.

At our home healthcare agency, we strive to provide personalized care to help our patients regain their independence and improve their quality of life.