Care Pathway Heart Care Program Adjustments

Role: Manager Of Transitional Care Services

The Care Pathway Heart Care program was designed to support patients recovering from cardiopulmonary conditions through a blend of home health and remote monitoring. When I stepped in, the challenge wasn’t about starting the program—it was about refining it so it could truly deliver on its promise of coordinated, continuous care.

I began by developing a dynamic tagging protocol within the care transition tool that automatically identified eligible patients and translated their information into discharge planning tools. This eliminated manual data entry and reduced the risk of missed referrals. To increase program participation, I created alerts that flagged eligible patients earlier in their hospital stay, giving the team more time to educate and enroll them proactively.

Recognizing capacity constraints within our owned home health agency, I established a partnership with an overflow provider to maintain consistency and avoid care delays. I also built a Skilled Nursing Facility (SNF) network dedicated to cardiopulmonary rehab patients, complete with standardized protocols that mirrored home health workflows.

Impact: This reimagined process led to higher enrollment rates, improved care continuity, and stronger patient satisfaction. The dynamic EMR tagging and proactive referral alerts streamlined operations, while the new SNF and home health partnerships ensured no patient fell through the cracks. Ultimately, the program became a model for how coordinated post-acute care can drive both clinical and operational success.