PATH ALONG Patient Centered Wisconsin Model

PATH ALONG is an original Wisconsin model that connects inpatient providers to community staff who support the patient during health system transitions.  PATH ALONG staff accompany the patient through the inpatient stay. 

PATH ALONG staff take a pragmatic approach to supporting cultural tradition, personal preference, family values, chosen life style, and additional aspects of social living.  PATH ALONG fulfills a supportive role that respects medical professionalism and values a providers scientific expertise.

PATH ALONG staff facilitate active patient engagement at each identified point of transition. 

Inpatient pharmacist     (transition)           Outpatient pharmacist

Hospitalist                    (transition)           Primary MD

Skilled nurse, PT, OT  (transition)            CMS certified skilled
ST                                                                  home care agency

Nurse aide, dietary assistant (transition)    Supportive in home
housekeeper                                                   agency
                                                                    (www.homecarepath.com)

This allows the patient to discuss (meet in thought) how each separate transition will unfold prior to implementation.  This enhances the patients participation as a partner with the varied departments providing service.  PATH ALONG staff assist the patient to incorporate wants, needs, and preferences, in the ongoing inpatient stay and following outpatient recovery.  This establishes opportunities for guidance on maximizing the benefit of available options. A more transparent approach to accessing information and resources.

The PATH ALONG process leaves the inpatient practitioner, the patient, the family, and the outpatient provider with a settling feeling knowing what is going to happen as the patient walks out the hospital door.  The depth of the PATH ALONG focus goes beyond tracking follow up appointments and checking if presribed medications have been filled. 

PATH ALONG delivers a community application to a supportive practise designed to:

1. Increase patients ability to be discharged to home

2. Reduce emergency room visits

3. Reduce readmissions to the hospital

4. Enhance rapport with the primary provider and clinc staff

In this way the patient remains central to the varied disciplines delivering care for the individual, while inserting a coordination component that reduces hospital readmission rates.  The patient experiences a supportive connection throughout the continuum of understanding with the changes related to the medical condition.  This falls neatly in to the care assurance role.

PATH ALONG is an evidence based model with three defined services to help the hospitalist fulfill their continuity of care role.  Focus is on care filled transitions.  For more information check out this site with free access:
http://www.homecarepath.com/Pages/PRESSRELEASEOriginalWisconsinModelToReduceHospitalReadmissionRates.aspx