Coordinated transitions home, with one care manager for the first 30 days
The weeks following discharge often involve changes in medications, care routines and support needs. Unicity Care Management helps coordinate services and follow-up as the person transitions home.
Discharges that benefit from care coordination
- The person lives alone or with a caregiver who can't manage the new needs
- Medications changed significantly during the stay
- Cognition is impaired or fluctuating
- Family lives out of state or disagrees about the plan
- Home may not be safe without changes
- There have been repeated admissions in recent months
We coordinate home care before discharge, confirm follow-up appointments, review medications against the discharge instructions and send updates back to the physician. You keep clinical authority, and we coordinate the logistics and communication with the family.
A 30-day plan for the transition home
Unicity Care Management's Pathway Home program supports people leaving the hospital or a subacute rehab center during the first 30 days at home.
Home care coordination
Home care arranged before discharge, with a schedule matched to the person's recovery.
Home safety assessment
A review of the home for fall risks, with recommended changes.
Discharge-day support
Transportation coordination, oversight of the discharge and help settling in at home.
Medication help
Organizing medications and reviewing discharge instructions so the schedule is understood.
Follow-up appointments
Scheduling and coordinating follow-up visits with physicians.
Ongoing care management
Care planning, monitoring and communication with the care team after the first 30 days, if needed.
How we support your orders
Medical decisions and treatment stay with you and any home health nursing you order. Unicity Care Management arranges the services you ordered, helps the family understand the instructions and follows up at home. If something isn't working, we let you know promptly. We do not prescribe or change medications.
What you can count on
Response within 24 hours
We contact the client or responsible party within 24 hours of your referral.
Assessment scheduled by urgency
A Registered Nurse or Licensed Social Worker completes a full evaluation, scheduled based on how urgent and complex the situation is.
Written care plan
After the assessment, you receive a written care plan. We send updates on the schedule you prefer, within the permissions in place.
Prompt escalation
We contact you promptly about significant medical events, observable changes in cognition, safety concerns or an unstable living situation.
Why the first 30 days matter
The first 30 days at home are when falls, medication mistakes and return trips to the hospital are most likely. Pathway Home is built around that window.
- We can coordinate home care before discharge day, so help is in place when the person gets home.
- During the first 30 days, we often recommend at least six hours of home care a day.
- We coordinate transportation home, oversee the discharge and help the person settle in.
- We help organize medications and review the discharge instructions with the person and family.
Discharge planners, case managers and social workers can share the Pathway Home program overview with patients and families.
Questions discharge teams ask
Do you provide skilled nursing or therapy at home?
No. Medical care, skilled nursing and therapy stay with you and the home health agency you order. We coordinate the services, help the family follow the discharge instructions and let you know promptly if something isn't working.
Can you start before the patient leaves the hospital?
Yes. We can coordinate home care before discharge, arrange transportation home and be there on discharge day to help the person settle in.
Who can make a referral?
Physicians, hospital discharge planners, case managers, social workers and subacute rehab teams can all refer. Families can also call us directly.
What happens after the first 30 days?
Some people need only the 30-day transition. Others continue with ongoing care management, including care planning, monitoring and communication with their doctors, billed at an hourly rate.
Will you update the physician?
Yes. With the patient's permission, we send updates to the physician and contact your office promptly if we see a problem with medications, safety or follow-up.
How a referral works
- You contact us by phone at 888.609.8008 or with this form.
- We reach out within 24 hours to the client or the person responsible for their decisions.
- We schedule a clinical assessment based on how urgent the situation is.
- You stay informed. With the right permissions, we send updates on the schedule you set, and we contact you promptly about significant medical events, safety concerns or changes in cognition.
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