A Partner in Patient Education and Re-hospitalization Prevention


A Closer Look

We strongly believe that an educated patient is a healthier patient. Our Clinical Pathway Program is made with a common goal between physician and agency. It gives a relevant resource and helps patients have a better understanding of their medical conditions. In addition, our program shows we care about partnering with our physician clients. Consequently, it helps to give the best patient care possible.

Lower Hospitalizations

Superior Home Health sees the signs that could lead to rehospitalization. Thus, it’s perfectly in place to avoid costly admissions. Also, sometimes even do some of the same tasks that can be done in a hospital. All while keeping the patient at home.


Some of the most usual reasons for hospital re-admissions are: heart attacks, heart failure, Pneumonia, and others.

Our Clinical Pathway Program addresses these and other contributing factors we have identified.


How the Value of Patient Education Can be Summarized:

 – Better knowing of medical condition, diagnosis, disease, or disability

 – Improved understanding of ways to manage many aspects of their medical condition

 – Better self-advocacy in deciding to act both apart from medical providers and together with them

 – More Compliance-With effective communication and patient education, there’s more patient motivation to comply.

 – Patient Outcomes-Fewer complications, since patients are more likely to respond well to their treatment plan.

 – Informed Consent-Patients feel you’ve given the information they need.

 – Fewer unnecessary phone calls and visits, due to more effective use of medical services.

 – Satisfaction and Referrals-Patients are more likely to stay with your practice and refer other patients.

 – Risk Management-Lower risk of malpractice when patients have realistic expectations.

 – Patient more likely to avoid hospitalization!



Primary Parts of our Clinical Pathway Program include:

  • Clinical Pathway Booklets: Bilingual educational booklets. The patient gets these at the physician’s office. They have health, medication and appointment logs. They also have zone tools and disease education.
  • Educational Videos: Bilingual 10 to 15 minute educational videos shown by our nurses when admitted. They are also shown in subsequent visits. These are specific to the patient’s diagnosis.
  • Teaching Guides: Educational guides taught often at the patient’s point of care. The patient’s knowledge is re-assessed before starting new teachings at every visit.



Ongoing Education, Monitoring, & Reporting

  • Step 1

    Identify Patient and First Education: Physician identifies the need for home health services. Then, shows the Clinical Pathway Booklet to the patient. This is their initial education.

  • Step 2

    Referral, Intake and Scheduling: Physician’s office starts the home health referral. Once received, our office will process the referral and identifies the patient as a participant of the program. Consequently, admission is scheduled within 48 hours.

  • Step 3

    Admission, Initial Assessment and Introduction to our Program: One of our Registered Nurses visits the patient at his or her residence to do a broad head-to-toe assessment. Then, completes the home health admission. They will start the program by evaluating the patient’s knowledge. The booklet handed to the patient at the physician’s office will be gone over first. Then, the nurse will show a 10 to 15 minute bilingual educational video, incorporated in their tablet. The patient’s plan of care incorporates teaching guides. After that, the nurse starts an ongoing teaching plan. The nurses follow this plan on every visit. The Registered Nurse who oversees the case will monitor the teaching plan regularly. This ensures the patient is progressing and understanding their condition. 

  • Step 4

    Visits and Continued Education: The patient is re-assessed throughout the plan. We then continue the patient’s education. The managing Registered Nurse supervises this. Each patient’s case is talked about during our weekly conference. We give regular, proactive report to the physician’s office to keep good plan of care. Our team also ensures the patient is aware of follow-up appointments. We remind them at every visit. They enter these in their booklet tracking log. In this period there is a higher risk of hospitalization.

  • Step 5

    Measure Success and Outcomes: Good outcomes measure our success. Also, exceeding the patient/physician’s expectations. The patient is more compliant and aware of his or her condition. And, takes an active role in managing their care. Ultimately, we should avoid a hospitalization. Also, the patient should feel confident and educated about their condition. Then, we’ll consider that a SUCCESS!



For more information and to schedule a Clinical Pathway Program presentation, please Contact Us.