Pathway Home: An Innovative Care Transition Program From Hospital to Home

Petit, Jorge R.; Graham, Mark; Granek, Barry

doi:10.1176/appi.ps.69803

Cited by 6 publications

(4 citation statements)

References 1 publication

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“…By addressing the many challenges faced during a care transition period, including focusing on clinical and social determinants of health at the critical time of a transition, Pathway Home has demonstrated that intensive community-based and timelimited support increases access to treatment in a cost-effective and wide-reaching manner ( Petit et al, 2018 ). Specifi cally, Pathway Home reduces preventable hospitalizations, reduces the length of any subsequent hospitalizations, improves attendance at follow-up behavioral health appointments, and incorporates appropriate medical care and health interventions ( Granek & Frisco, 2019 ;Petit et al, 2018 ;Petit et al, 2021 ).…”

Section: Initial Phase Interventions Includementioning

confidence: 99%

“…In 2017, 89% of Pathway Home participants had not been readmitted to the hospital within 30 days of hospital discharge. In the same sample, 77% of participants had attended an initial behavioral health appointment within 7 days of hospital discharge, and 88% of participants attended a medical appointment during their service course with the program ( Petit et al, 2018 ). Failure to attend outpatient behavioral or medical follow-up is known to be a strong predictor of hospital readmittance (those who do not attend are up to twice as likely to be readmitted in the same year; Nelson et al, 2000 ).…”

Section: Literaturementioning

confidence: 99%

“…Teams are also multidisciplinary (registered nurses, licensed social workers, peer specialists, and care managers), which increases the fl exibility of services and results in more comprehensive care due to the multiple theoretical viewpoints that are present. Because of a smaller participant-to-staff ratio (approximately 7-10 participants per staff member), team members are able to spend longer amounts of time with individual participants to engage and build rapport, respond appropriately to crises, and spend their time doing activities that promote health and wellness ( Petit et al, 2018 ). Traditional care coordination programs often have high caseloads, up to 30-50 participants per care manager ( Intagliata, 1982 ), which results in less time devoted to each participant.…”

Section: Literaturementioning

confidence: 99%

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The Effect of Time Spent With Participants on Program Outcomes

Ernst

Granek

2022

Professional Case Management

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Purpose of Study: Little research exists on the correlation between time spent with participants in Critical Time Intervention–modeled programs, such as Coordinated Behavioral Care's (CBC) Pathway Home, and successful completion of the programs. This study explored associations between the total amount of time spent with participants in the initial 3 months of the program and positive program outcomes. Methodology and Sample: Data on total time spent with participants in their initial phase of the program were gathered from Pathway Home participants who were enrolled in the program from 2016 to 2019 and then were compared with program outcomes. Results: The study found positive correlations between amount of time spent with participants and the attendance of a behavioral health appointment within 1 month of community entry, and positive disenrollment outcomes. This study did not find predictive significance of time spent. Implications for Case Management Practice: Time spent with participants is a significant variable to study, yet more research is needed on its relationship to positive outcomes.

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Section: Initial Phase Interventions Includementioning

confidence: 99%

Section: Literaturementioning

confidence: 99%

Section: Literaturementioning

confidence: 99%

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The Effect of Time Spent With Participants on Program Outcomes

Ernst

Granek

2022

Professional Case Management

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“…1 This model has been implemented over the years in various markets across the country and overseas, all documenting various levels of success. [1][2][3][4][5] This model of care is aimed at either an acute hospital substitution model, admitting patients from the ED, or as a reduced LOS ABSTRACT Interest is growing in hospital-at-home as a model of patient care. Given the pandemic, various entities are exploring methods to deliver hospital-level care in nontraditional settings to clinically stable patients with adequate home support.…”

mentioning

confidence: 99%

Providing advanced hospital care at home

Felix¹,

Wieringa²,

Monnig³

2022

Jaapa

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A 72-year-old man with acute kidney injury and pyelonephritis. A 68-year-old woman with saddle embolus and hyperglycemia. An 82-year-old woman with pneumonia and COPD exacerbation. A 74-year-old man with lower extremity cellulitis. A 74-yearold man with acute kidney injury, decompensated heart failure, hyponatremia, and hyperglycemia.What do all of these patients have in common? They were enrolled and successfully managed in a reduced length-of-stay (LOS) home hospital program after spending 1 to 2 days in a traditional hospital setting. Although this concept may not be new, the pandemic has shed light on the utility of alternative care pathways. Given the regulatory news released by the Centers for Medicare and Medicaid Services (CMS) in late 2020, this represents not only opportunity for innovation in healthcare delivery but also an important niche for PAs and NPs. CMS has implemented a waiver and is now allowing patients to be admitted to home from the ED or an inpatient bed before their second midnight; nearly 60 diagnostic-related groups (DRGs) are considered safe to monitor and treat at home under the direction of a physician. 1 This model has been implemented over the years in various markets across the country and overseas, all documenting various levels of success. [1][2][3][4][5] This model of care is aimed at either an acute hospital substitution model, admitting patients from the ED, or as a reduced LOS ABSTRACT Interest is growing in hospital-at-home as a model of patient care. Given the pandemic, various entities are exploring methods to deliver hospital-level care in nontraditional settings to clinically stable patients with adequate home support.

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