Transition Care Programs

Transitions to Home

Homebound patients that are learning to manage their care at home can benefit from the support and education of Home Health care services from Pathways. Our care teams are specially trained to support patients during that vulnerable period between an acute episode and independence. With our coaching and medication management, patients transition from being cared for to caring for themselves.

Pathways Home Health patients may be eligible for the following coaching and teach-back programs:

• Chronic disease management including our specialized program for heart failure
• Home Health Telemonitoring Program: It consists of easy-to-use equipment that measures weight and vital signs. Home Health nurses don’t visit daily, so telemonitoring gives Pathways a way to assess the patient 7 days a week, from our office. If you are a patient, click here. If you are a referral source, click here for more info.
• Housecall re-Admissions Reduction Program (HARP): nursing and physician housecalls in collaboration with El Camino Hospital and Dr. David Jones.
• Pharmacist Assisted Transition Home (PATH): pharmacist guided medication management program to reduce rehospitalizatons in collaboration with Sequoia Hospital

These programs address the unique needs of older adults suffering from chronic illness. Without focused intervention, these patients are at a higher risk of medical emergencies leading to re-hospitalization. Pathways has implemented these evidence-based programs to help this high risk group of patients.

Arranging Home Health Care

If you are hospitalized, talk with your doctor, nurse or hospital social worker about home health care and ask for Pathways as your home health provider. We will work closely with them to provide a smooth transition from hospital to your home.

If you are not in the hospital you can talk with your doctor or with our admissions staff. We will work with your doctor to develop a plan for your home health care. Our insurance coordinator will verify benefits for you.

Pathways Informational Downloads

• Heart Failure Program
• Telemonitoring Program (for patients and families)
• Telemonitoring Program (for physicians)
• Housecall Admission Reduction Program (HARP)
• Pharmacist Assisted Transition Home (PATH) (for patients and families)
• Pharmacist Assisted Transition Home (PATH) (for physicians)

Contact our Admissions Department if you have any questions or for more information about starting home health care services by calling 1.888.755.7855 or 408.730.5900.