NOTE:

The care pathways and on-call decision tool have been recommended to facilitate home-based chronic disease management in high risk conditions.Care pathways/decision tools do not replace and cannot be substituted for the care (treatment) plan by a physician. They are merely tools to inform and optimize care of patients at their homes, and may aid in requesting changes to the home health care plan based on signs/symptoms/risk factors observed.The pathways/decision tools may assist with decision-making to help prevent avoidable hospitalizations and emergency room visits through timely detection of warning signs/ risk factors and application of appropriate interventions. Patient education is an integral part of providing care. Clinicians must use the company’s patient teaching sheets and other approved patient education handouts provided in this manual to facilitate patient/caregiver compliance to the care plan and patient self-care. Patient education must include lifestyle management for all chronic/repetitive conditions.Clinicians must note that pathways/tools provide guidance but do not replace clinical reasoning and judgement.Patients must be referred to a hospital to address all emergencies.