Create clinical pathways for patients with commonly seen conditions to build efficiency among visits, improve outcomes and help keep patients out of the hospital.
 
Pathways ensure that the key points are being covered by clinical staff, notes Sherri Parson, CEO of Infusion Health in Ypsilanti, Mich.
 
“Checklists have traditionally always promoted accuracy, streamlined care and ensured completeness,” she adds. “I always say I don’t want to get on a plane where my pilot hasn’t gone through a checklist.”
 
Because pathways ensure that tasks are being completed accurately and engage the patient in the process, agencies tend to see better outcomes, Parson says.
 
For example, zone tools with guidance on monitoring and responding to symptoms promote health literacy and self-management due to their simplicity, she explains.
 
“Patients know before anyone how things are going,” Parson says. “And when patients understand when they need to reach out, they stay out of the hospital, even after the agency has discharged them.”
 
Consider cardiac conditions
 
Creating a template for home health patients with cardiac conditions is a great place to start.
 
In fact, data provided by Strategic Healthcare Programs (SHP) shows that cardiac conditions — as well as a code for aftercare following surgery on the circulatory system — appeared four times in the list of the top 10 primary diagnoses for Medicare payment periods between January and June 2025.
 
These codes include:
  • I13.0 (Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease)
  • I11.0 (Hypertensive heart disease with heart failure)
  • I10 (Essential (primary) hypertension)
  • Z48.812 (Encounter for surgical aftercare following surgery on the circulatory system)
“There are so many risk factors that feed into this trend, some amenable and some not,” notes Apryl Swafford, QA specialist with SimiTree based in Hamden, Conn. “Factors such as diet choices, sedentary lifestyle, smoking and stress levels are just a few of the things we can alter, while family history and genetics are seldom changeable.”
 
And sometimes, people are not even aware that heart disease is a problem.
 
Hypertension is a great example, Swafford says.
 
“The majority of patients diagnosed with hypertension have no symptoms which means until they become symptomatic, such as when complications show up such as heart or renal failure, they have no idea they ever had a problem with their blood pressure.”
 
By using a pathway, agencies can provide consistent interventions to patients with specific cardiac diagnoses.
 
“Standardizing the delivery of treatment measures can assure that all patients receive certain necessary interventions as a baseline in addition to those interventions that may be more specific to the patient’s unique condition,” notes Ohio-based home health and coding expert Brandi Whitemyer. “This also gives clinicians clarity in the delivery of those interventions to all patients with such conditions.”
 
Consistency in the delivery of interventions for the patient care plan across specific conditions also allows agencies to better collect data for evaluation of outcomes and other areas, such as rehospitalization rates, she says.
 
“If you know that everyone that is admitted with hypertension should be receiving education on a cardiac diet, you can then trend that information and see where improvements need to be made and which clinicians are more, or less, successful at the intervention, etc.,” Swafford adds.
 
Create a pathway template
 
Pathways are usually specific to a diagnosis, Swafford notes.
 
She offers hypertension as an example.
 
“Pathways that I’ve used and helped develop would show the most common areas to address with patients that have that diagnosis,” she adds. “So with hypertension, you would address medications, diet, normal and abnormal readings, how to check blood pressure, etc.”
 
Keep in mind that these variables would be specific to your patient, such as:
  • What type of cardiac diet?
  • What would be normal parameters for your patient (this can vary depending on patient specific factors)?
  • What type of blood pressure cuff do they have?
While a pathway template can be used for all patients with this diagnosis, it can also be customized for each patient and should establish the baseline of interventions to be included within a care plan for patients with the diagnosis.
 
Each patient should have individual consideration given for additional interventions to be included in the care plan that are more specific to the diagnosis based on their condition, Whitemyer says.
 
“Patients have many of the same treatments, but everyone has different care plans,” Parson notes. “The care pathway serves only as a template to help guide the clinician.”
 
Consider these tips for creating a pathway:
  • Do your homework. Clinician pathways are — or should be — evidence-based meaning that research has shown that what you plan for the patient has been revealed to lead to improvements, Swafford says. “There is lots of research out there on clinician pathways in all aspects of health care as a means to guide improvement.”
  • Don’t forget documentation. A pathway can also help with documentation across the episode, Swafford says. “If interventions and goals are clearly stated, then the clinician only needs to document toward those to show progress, or lack thereof, on the goals,” she adds. Some examples of what to include in your documentation are: Can the patient and caregiver verbalize how the condition affects circulatory function, verbalize signs and symptoms of exacerbation, explain side effects and actions of medications and demonstrate use of the weight log or warning signs of zone tool.
  • Make changes as needed. Goals can be amended or updated as needed since you can clearly see what the goals are, Swafford says.