“Hope is the thing with feathers that perches in the soul – and sings the tunes without the words – and never stops at all.“—Emily Dickinson 

Hope is a powerful thing. It can lighten our spirits, give us purpose and empower our dreams. Yet, hope needs to be coupled with concrete goals and steps in order for true results to occur. I am often reminded about the story of two individuals that wanted to travel down to Florida. One dreamed about how nice it would be to stay in the sunshine state and swim in the ocean. The other dreamed these same fantasies too but also researched how to get down there. He found out how much he would need to rent a car, stay in a hotel and cover his food expenses. He then worked extra hard to save up the money so he could actually make it happen. Eventually, he took time off from work, mapped out his route and embarked on a once-in-a-lifetime experience.

The other man was found still sitting in his chair dreaming about what it would be like.

If you are struggling with a certain disease or illness realize that having a plan or a “pathway” can make all the difference in the world. You may be in a hospital with congestive heart failure or COPD and desiring to be back at home.

What is the pathway you need to take?

Your medical team will be your best asset to help you determine your individual pathway but below we have outlined some common, generalized pathways for an assortment of disease processes. Don’t use this information as a replacement for the medical direction you are receiving. Use it for informative purposes only.

Please also realize that whatever plan you are on you must follow it in order to achieveresults.

Pathways to Home Program: The Necessary Steps To Help You Get Back In Your Home

Below are specific disease processes and their correlating “pathway to home”. You can find a full description of each one as you scroll down the page:

• Congestive Heart Failure
• Joint Replacement Program
• Stroke/CVA
• Pneumonia
• Diabetes Program
• Parkinson’s Disease Program  
• Pain Management Program
• Dementia Program
• Chronic Obstructive Pulmonary Disease Program
• Wound Care Program
• Palliative Program
• Pediatric Services for Medically Fragile Children
• Fall Prevention
• Respite Program
• Cancer Care and Treatment
• Traumatic Brain Injury (TBI)
• Medication Management
• Infection Control and IV Therapy
• Falls Intervention Training (FIT)
• Bariatric Program
• Coronary Artery Disease
• Spinal Cord Injury Program

 

Congestive Heart Failure

Goal:  Regain strength; optimize a better quality of life

• Exceptional continuity of care between your physician(s)
• Heparin or Coumadin management
• Monitoring vital sign(s)
• Complying with exercise regimen
• Education on causes Congestive Heart Failure
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding your diet and fluid restrictions
• Symptom Management
• Tobacco cessation
• Stress Management
• Conservation of energy management
• (Oxygen, Exercise, Breathing, Daily Living Activities)
• Signs and Symptom of CHF
• Physical and Occupational / Cardiac rehabilitation
• Resource and Support for the patient/family
• Prevention of rehospitalization

Joint Replacement Program

Goal:  Enhancement of joint mobility, ambulation and active lifestyle

• Exceptional continuity of care between your physician(s)
• Management of surgical incision
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding restrictions
• Transfer/Gait  Training
• Fitting and use of assistive devices
• Lab Draws / Anticoagulation therapy, in conjunction with symptom management
• Symptom and Pain Management
• Safety management
• Physical and Occupational therapy
• Resource and support for the Patient/Family
• Prevention of re-hospitalization

Stroke/CVA

Goal:  Stabilization of condition and regain everyday functional skills

• Exceptional continuity of care between your physician(s)
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding restrictions
• Transfer/Gait Training
• Fitting and use of assistive devices
• Lab Draws/Anticoagulation therapy, in conjunction with symptom management
• Physical/Occupational/Speech/Social Work therapy’s
• Understanding of diet restrictions/modifications
• Promote and understanding the disease process
• Maintain optimal skin integrity
• Monitoring of vital sign(s)
• Safety assessment in home
• Assessment and symptom management
• Resource and support for the Patient/Family
• Prevention of rehospitalization

Pneumonia

Goal:  To promote ease of breathing and prevention of relapse

• Exceptional continuity of care between your physician(s)
• Increase knowledge/risk factors of disease process
• Discuss your treatment Plan/Goals
• Lab draws, in conjunction with symptom management
• Monitoring Oxygen saturation
• Understanding of medication compliance
• Understanding your diet and fluid intake
• Symptom Management
• Physical, Occupational therapy
• Oxygen therapy / breathing treatments
• Signs and Symptoms of Pneumonia
• Resource and Support for the patient/Family
• Preventions of rehospitalization

Diabetes Program              

Goal:  To educate on prevention of diabetic complications

• Exceptional continuity of care between your physician(s)
• Discuss your treatment Plan/Goals
• Education and management of blood sugar with diet and medications
• Wound Care Management
• Education of insulin administration
• Blood glucose teaching and monitoring
• Understanding your diet
• Skin and Foot care
• Lab Draws, in conjunction with symptom management
• Assessment and Symptom Management
• Physical and Occupational directed by physician
• Resource and Support for the Patient/Family
• Preventions of hospitalization

Parkinson’s Disease Program       

Goal: Understanding the disease processes and modifies a lifestyle to fit limitations

• Exceptional continuity of care between your physician(s)
• Discuss your treatment Plan/Goals
• Education and management of blood sugar with diet and medications
• Wound Care Management
• Education of insulin administration
• Blood glucose teaching and monitoring
• Understanding your diet
• Skin and Foot care
• Lab Draws, in conjunction with symptom management
• Assessment and Symptom Management
• Physical and Occupational directed by physician
• Resource and Support for the Patient/Family
• Preventions of hospitalization

Pain Management Program

Goal:  To educate on prevention and management of pain

• Exceptional continuity of care between your physician(s)
• Discuss your treatment Plan/Goals
• Education on pain management
• Controlling your pain
• Education on pain medications , including break through pain
• Management of everyday living skills
• Relaxation Therapy
• Physical and Occupational therapies directed by physician
• Resource and Support for the Patient/Family
• Preventions of hospitalization

Dementia Program             

Goal:  To reside in a safe environment

• Exceptional continuity of care between your physician(s)
• Discuss your treatment Plan/Goals
• Education of caregiver on disease progression and symptoms
• Speech Therapy for swallow difficulties, memory, cognition issues and care giver training
• Medication Management
• Understanding  diet needs
• Utilization on Community Services
• Private Duty Services
• Assessment and Symptom Management
• Physical Therapy, help maintain mobility function, maintain balance to prevent falls.
• Occupational Therapy for home safety
• Behavioral interventions with Psych and Social Work management support
• Resource and Support for the Patient/Family
• Preventions of hospitalization

Chronic Obstructive Pulmonary Disease Program

Goal: Control ease of breathing and management of pulmonary stability          

• Exceptional continuity of care between your physician(s)
• Discuss your treatment Plan/Goals
• Education and management of medications
• Breathing Exercises
• Explain and educate disease process and impact on breathing
• Education of oxygen, inhalers, nebulizer treatments/equipment
• Tobacco cessation education
• Assessment and Symptom Management
• Occupational Therapy to address, energy conservation related to breathing and everyday living skills
• Diet Education
• Physical Therapy to enhance strengthening and endurance skills
• Resource and Support for the Patient/Family
• Preventions of hospitalization

Wound Care Program

Goal:  Promote healing, growth of healthy infection free skin

• Exceptional continuity of care between your physician(s)
• Discuss your treatment Plan/Goals
• Education and management of type of wound
• Wound Care Management of complicated non healing wounds
• Education of proper food and fluids to promote healing
• Instruction and education of pain control
• Signs and symptom of infections
• Wound care treatment and dressings
• Medication management
• Activity restrictions
• General skin care
• Assessment and Symptom Management
• Physical and Occupational directed by physician
• Resource and Support for the Patient/Family
• Preventions of hospitalization

Palliative Program              

Goal:  Comfort Measures for end of life

• Exceptional continuity of care between your physician(s)
• Discuss treatment Plan/Goals
• Education of Advance Directives
• Education and management of pain medications
• Support and emotional care to patient and family
• Education and support of end of life
• Caregivers assistance
• Spiritual Support
• Personal Care
• Positioning and movement
• Bereavement Support through Community Resources
• Nutritional Support
• Assessment and Symptom Management
• Physical and Occupational support directed by physician
• Resource and Support for the Patient/Family
• Preventions of hospitalization

Pediatric Services for Medically Fragile Children

Goal:  Providing family centered approach.  Our nurses work closely with the family to build confidence and create and implement the right plan of care.  We believe our care should support family involvement and improve the quality of life and foster independence.  This care gives patients and family dignity respect and hope.

• Meet with family and coordinate with discharge planners to make a smooth transition to home
• Exceptional Nursing Care
• Discuss the child’s treatment Plan/Goals with the family
• Multidisplanary Team approach
• Highest quality patient care
• Family centered approach
• One on One care
• On call 24 hour nursing
• RN case management for assessment and supervision of patient and staff
• Exemplary Education and support for medications, new diagnoses , equipment
• Attend Dr. visits
• Attend Therapy visits
• Attend school/escorts to school
• Individualized scheduling
• Pediatric nursing competency tested before hired
• Ventilator and other hi-technology based medical equipment
• Lab draws, in conjunction with symptom management
• Therapy(s) Available – OT PT Speech SW
• Promote the child of the growth and developmental milestones
• Provide Respite
• Resource and Community support for the Patient/Family
• Preventions of hospitalization

Fall Prevention

Goal:  Regain strength; optimize a better quality of life

• Exceptional continuity of care between your physician(s)
• Heparin or Coumadin management
• Monitoring vital sign(s)
• Complying with exercise regimen
• Education on causes Congestive Heart Failure
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding your diet and fluid restrictions
• Symptom Management
• Tobacco cessation
• Stress Management
• Conservation of energy management, Oxygen, Exercise, Breathing, Daily Living Activities
• Signs and Symptom of CHF
• Physical and Occupational / Cardiac rehabilitation
• Resource and Support for the patient/family
• Prevention of rehospitalization

Respite Program

Goal:  Provide exceptional care to a loved one to extend relief for the caregiver/family

• Exceptional continuity of care between your physician(s)
• Case management and care planning for services
• Nursing Management
• Assist with bathing/grooming and other everyday living skills
• Provide companionship
• Meal preparation and planning
• Light housekeeping and laundry
• Medication management
• Wake Up and Tuck In Program
• 24 hour care/7 days per week
• Care conferences as needed
• Transportation to Doctors appointments/outings
• Excellence communication and reporting to family
• Care Givers Code of Conduct Trained
• Discuss your treatment Plan/Goals

Cancer Care and Treatment

Goal:  Provide care, treatment, support to care for body and sprit

• Exceptional continuity of care between your physician(s)
• Medication Management
• Achieve and maintain pain control
• Chemotherapy/ Radiation management and of complication of
• Palliative Care
• Monitoring vital sign(s)
• Lab draws, in conjunction with symptom management
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding your diet
• Symptom Management
• Stress Management
• Conservation of energy management
• Physical, Occupational, Speech Therapy, and Social Work
• Resource and Support for the patient/family
• Prevention of rehospitalization
• Bereavement support through community resources

Traumatic Brain Injury (TBI)

Goal:  Promote maxuim independent in the least restricted environment

• Exceptional continuity of care between your physician(s)
• Maximize mobility
• Monitoring vital sign(s)
• Participate in self-care activities
• Communicate needs appropriately
• Identify causes of and deal with stress appropriately
• Identify and select appropriate leisure time activities
• Complying with exercise regimen
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding and managing diet
• Stress Management
• Management of Life after a TBI
• Physical, Occupational, Speech, and Social Work
• Resource and Support for the patient/family
• Prevention of rehospitalization

Medication Management

Goal:  To provide safe affective medication compliance

• Exceptional continuity of care between your physician(s)
• Medication reconciliation
• Medication set up
• Education and management of medication management
• Monitoring of Medication usage
• Determine best method of dispensing of medications
• Reorder medications as needed
• Nursing oversight
• PT/INR monitoring
• IV therapy services
• Lab Draws, in conjunction with symptom management
• Prevention of rehospitalization

Infection Control and IV Therapy

Goal:  Regain strength; optimize a better quality of life

• Exceptional continuity of care between your physician(s)
• Medical Assessment
• Lab work, in conjunction with symptom management
• Monitoring vital sign(s)
• Over site of  IV therapy, Peripheral or Central Line management
• Teach education on administration through IV Therapy
• Education Infection control and prevention
• Discuss your treatment Plan/Goals
• Education and management of your medications including antibiotics Treatment
• Understanding your diet
• Conservation of energy management
• Physical and Occupational Therapy
• Resource and Support for the patient/family
• Prevention of rehospitalization

Falls Intervention Training (FIT)

Goal:  To keep patients in their home environment as long as possible, and as safely as possible, with maximum ability.

• Exceptional continuity of care between your physician(s)
• Fall risk assessment – assessment for falls every visit
• Educate resident/family about fall risk
• Target key areas balance, strength and mobility
• Teach resident/family  how to fall safely
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Vision assessment and interventions for low vision
• Home modification to reduce hazards
• Stress Management for the caregiver
• Modification of Every Living Activities
• Maintenance exercise program
• Nutrition evaluation
• Resource and Support for the patient/family
• Prevention of rehospitalization
• Physical Therapy – strengthening and balance program
• Occupational Therapy for everyday living skills
• Home Health Aide referral for assistance with bathing
• Medical Social Worker evaluation for social support
• Pain assessment

Bariatric Program

Goal:  Regain strength; support a major change in life style

• Exceptional continuity of care between your physician(s)
• Monitoring vital sign(s)
• Assessment for safety at home
• Complying with exercise regimen
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding and maintaining your diet
• Stress Management
• Physical and Occupational
• Nursing/Aide  for wound/skin integrity/treatment
• Psych and social work consult for emotional support
• Resource and Support for the patient/family
• Prevention of rehospitalization

Coronary Artery Disease

Goal:  Regain strength and strength and management of the disease process

• Exceptional continuity of care between your physician(s)
• Attain medical stability
• Monitoring vital sign(s)
• Complying with exercise regimen/cardiac rehabilitation
• Education on causes Coronary Artery Disease
• Discuss your treatment Plan/Goals
• Education and management of your medications/side effects
• Understanding your heart healthy diet/weight management
• Symptom Management
• Tobacco Cessation
• Stress Management
• Physical and Occupational / Cardiac rehabilitation
• Resource and Support for the patient/family
• Prevention of rehospitalization

Spinal Cord Injury Program

Goal:  Regain strength; optimize a better quality of life

• Exceptional continuity of care between your physician(s)
• Heparin or Coumadin management
• Monitoring vital sign(s)
• Complying with exercise regimen
• Education on causes of Congestive Heart Failure
• Discuss your treatment Plan/Goals
• Education and management of your medications
• Understanding your diet and fluid restrictions
• Symptom Management
• Tobacco Sensation
• Stress Management
• Conservation of energy management, Oxygen, Exercise, Breathing, Daily Living Activities
• Signs and Symptom of CHF
• Physical and Occupational / Cardiac rehabilitation
• Resource and Support for the patient/family
• Prevention of rehospitalization

 

 path to home,