Patient Path Hub — Connecting Patients. Empowering Lives.
20 Clinical Care Pathways

Patient Journeys

Stage-by-stage care pathways for 20 clinical conditions — matched to131 verified California providers. Guidance for families, checklists for professionals, and smart provider matching at every stage.

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Stroke Recovery

Neurological

From emergency response through acute care, inpatient rehabilitation, home health, and long-term recovery — the complete post-stroke care pathway.

4 stagesEmergency room or hospital admission after a stroke event.
Insurance Considerations
  • •Medicare covers up to 100 days of skilled nursing per benefit period with a qualifying hospital stay.
  • •Inpatient rehab is covered differently than skilled nursing — confirm the distinction with your plan.
  • •Home health and outpatient therapy (PT/OT/ST) are covered under Medicare Part B.
  • •Medi-Cal covers long-term custodial care for eligible Californians.
  • •Private insurance plans vary widely on rehab-day limits — verify before placement.

Joint Replacement

Orthopedic

From pre-surgical preparation through surgery, inpatient rehab, home health, and full return to activity — the complete hip or knee replacement pathway.

4 stagesOrthopedic surgeon's office after shared decision to proceed with total hip or k...
Insurance Considerations
  • •Medicare covers joint replacement and post-acute rehab with qualifying criteria.
  • •Many private plans require pre-authorization for rehab placement.
  • •The shift to outpatient joint replacement means shorter hospital stays — confirm your plan's coverage for home PT.
  • •DME (walker, raised toilet seat, shower chair) may be covered — ask before surgery.

Heart Failure

Cardiac

Managing heart failure across acute exacerbations, hospital discharge, home health, cardiac rehab, and long-term disease management — reducing readmissions and improving quality of life.

4 stagesHospitalization for acute decompensated heart failure, or cardiologist referral ...
Insurance Considerations
  • •Medicare covers cardiac rehab for stable heart failure with reduced ejection fraction.
  • •Home health is covered for homebound patients needing skilled nursing.
  • •Remote patient monitoring may be covered by some Medicare Advantage plans.
  • •Medication costs for guideline-directed medical therapy can be significant — check formulary coverage.

COPD

Respiratory

Managing COPD exacerbations, hospital-to-home transitions, pulmonary rehabilitation, oxygen therapy, and long-term respiratory care — helping patients breathe easier at every stage.

3 stagesHospitalization for acute COPD exacerbation, or pulmonologist referral for worse...
Insurance Considerations
  • •Medicare covers pulmonary rehab for moderate-to-very-severe COPD (GOLD stages 2–4).
  • •Home oxygen is covered by Medicare if qualifying blood gas levels are documented.
  • •Non-invasive ventilation (BiPAP) may be covered for eligible patients.
  • •Tobacco cessation counseling is covered as preventive care.

Cancer Recovery

Oncology

Navigating care after cancer treatment — from post-surgical recovery and chemotherapy side-effect management through rehabilitation, home health, and survivorship planning.

3 stagesCompletion of active cancer treatment (surgery, chemotherapy, radiation), or dur...
Insurance Considerations
  • •Medicare covers home health and skilled nursing for cancer patients meeting homebound criteria.
  • •Palliative care is covered alongside curative treatment — it is NOT the same as hospice.
  • •Hospice is covered by Medicare when life expectancy is ≤6 months if the disease follows its normal course.
  • •Many cancer centers have financial navigators — ask for a consultation.
  • •Clinical trial participation may affect insurance coverage — verify before enrolling.

Traumatic Brain Injury

Neurological

From trauma ICU through acute rehab, post-acute neurorehabilitation, behavioral health support, and long-term community reintegration — the complete TBI care pathway.

3 stagesEmergency department after a traumatic event (fall, motor vehicle accident, assa...
Insurance Considerations
  • •Trauma care and acute rehab are typically covered by most insurance.
  • •Post-acute neurorehabilitation may require prior authorization and is sometimes denied — be prepared to appeal.
  • •California's TBI Medicaid Waiver provides home and community-based services for eligible Medi-Cal recipients.
  • •Auto insurance (MedPay) and workers' compensation may be primary payers depending on injury circumstances.

Spinal Cord Injury

Neurological

From acute spinal stabilization through specialized SCI rehabilitation, home modifications, DME, attendant care, and lifetime health management — the complete SCI pathway.

3 stagesTrauma center after a traumatic spinal injury, or hospital after non-traumatic s...
Insurance Considerations
  • •SCI is catastrophically expensive — lifetime costs range from $1M–$5M depending on injury level.
  • •Medicare covers SCI rehab at approved facilities, but lifetime coverage limits apply to therapy.
  • •Medi-Cal may cover attendant care and home modifications through waiver programs.
  • •Auto insurance and workers' compensation should be primary payers when applicable.
  • •Private insurance may have lifetime maximums — verify coverage early.

Dementia & Alzheimer's Care

Neurological

From diagnosis through early-stage support, middle-stage care management, safety planning, and late-stage skilled care — a comprehensive pathway for families navigating Alzheimer's and related dementias.

3 stagesPrimary care or neurology visit for cognitive concerns, often triggered by famil...
Insurance Considerations
  • •Medicare covers diagnostic cognitive assessments but does not cover long-term custodial care.
  • •Medi-Cal covers long-term care for eligible individuals through institutional care or HCBS waivers.
  • •Long-term care insurance may cover memory care, assisted living, and home care — review your policy.
  • •VA benefits may be available for eligible veterans with dementia.

Parkinson's Disease

Neurological

From early diagnosis through medication management, LSVT BIG/LOUD therapy, deep brain stimulation evaluation, and advanced-stage care — the complete Parkinson's care pathway.

3 stagesNeurology visit after noticing tremor, stiffness, bradykinesia, or gait changes.
Insurance Considerations
  • •Medicare covers outpatient PT/OT/ST including specialized LSVT BIG and LOUD programs.
  • •Deep brain stimulation is covered by Medicare for appropriate candidates.
  • •Home health is covered for homebound patients with skilled needs.
  • •Long-term custodial care is not covered by Medicare — plan ahead.

ALS (Amyotrophic Lateral Sclerosis)

Neurological

From diagnosis through multidisciplinary ALS clinic care, respiratory support, communication technology, and compassionate end-of-life care — a comprehensive pathway for patients and families facing ALS.

3 stagesNeurology or neuromuscular specialist after progressive weakness, slurred speech...
Insurance Considerations
  • •Medicare covers ALS patients immediately — no 24-month waiting period for SSDI.
  • •ALS is a Medicare-qualifying diagnosis for hospice with specific criteria.
  • •DME, speech-generating devices, and power wheelchairs are covered with proper documentation.
  • •Non-invasive ventilation and cough assist devices are covered by Medicare.

Pediatric Complex Care

Pediatric

Supporting children with medical complexity — from NICU discharge through home nursing, therapy services, school transition, and family support — a pathway for families navigating pediatric special needs.

3 stagesNICU or PICU discharge planning, or pediatrician referral after diagnosis of a c...
Insurance Considerations
  • •California Children's Services (CCS) provides care coordination and coverage for eligible conditions.
  • •Medi-Cal waiver programs (HCBS) may cover home nursing and respite for eligible children.
  • •Early intervention (0–3) and school-based therapy (3–21) are mandated services under IDEA.
  • •Private duty nursing hours are often under-prescribed — advocate for adequate hours.

Behavioral Health

Behavioral Health

From crisis intervention through inpatient stabilization, outpatient therapy, medication management, and community-based recovery support — a comprehensive mental health care pathway.

3 stagesEmergency department, crisis line referral, or primary care visit for worsening ...
Insurance Considerations
  • •Mental health parity laws require insurance to cover behavioral health at the same level as medical/surgical care.
  • •Medi-Cal covers behavioral health through county mental health plans.
  • •Medicare covers inpatient psychiatric care (190-day lifetime limit) and outpatient services.
  • •Crisis stabilization services may be covered even when standard behavioral health benefits are limited.

Substance Use Recovery

Substance Use

From detoxification through residential or outpatient treatment, medication-assisted treatment (MAT), relapse prevention, and long-term recovery support — a complete substance use disorder care pathway.

3 stagesEmergency department, detox center, primary care screening, or self/family refer...
Insurance Considerations
  • •Mental health parity laws require coverage for SUD treatment at parity with medical care.
  • •Medi-Cal covers SUD treatment through Drug Medi-Cal Organized Delivery System.
  • •Medicare covers SUD treatment including MAT and outpatient services.
  • •Residential treatment coverage varies significantly — verify benefits before admission.

Hospice

End-of-Life Care

Compassionate end-of-life care focusing on comfort, dignity, and quality of life — from hospice election through symptom management, emotional and spiritual support, and bereavement care for families.

3 stagesReferral from oncologist, primary care, hospitalist, or family when a patient ha...
Insurance Considerations
  • •Medicare Hospice Benefit covers all hospice services with no copay (medications, equipment, nursing, aide, social work, chaplain, bereavement).
  • •Medi-Cal and most private insurance cover hospice similarly.
  • •Choosing hospice means forgoing curative treatment for the terminal illness.
  • •Hospice can be revoked at any time — it's always the patient's choice.

Palliative Care

End-of-Life Care

Specialized medical care focused on relief from symptoms and stress of serious illness — available alongside curative treatment at any stage, not just end of life.

2 stagesReferral from primary care, oncologist, cardiologist, or hospitalist for a patie...
Insurance Considerations
  • •Palliative care is different from hospice — no requirement to stop curative treatment.
  • •Medicare covers palliative care as part of standard medical care (no separate benefit).
  • •Some Medicare Advantage plans and private insurers have dedicated palliative care programs.
  • •Hospital-based palliative care teams are typically covered by insurance.

Post-Surgical Recovery

Post-Surgical

From hospital discharge after major surgery through skilled nursing, home health, wound care, and full functional recovery — a pathway for patients recovering from complex surgical procedures.

2 stagesHospital discharge planning after major abdominal, thoracic, vascular, or other ...
Insurance Considerations
  • •Medicare covers SNF care for up to 100 days with a qualifying 3-day inpatient hospital stay.
  • •Home health is covered for homebound patients needing skilled nursing or therapy.
  • •Post-surgical DME is covered by Medicare with proper documentation.
  • •Wound care supplies may be covered under DME or home health benefit.

Chronic Wound Care

Chronic Care

Managing chronic wounds — pressure injuries, diabetic ulcers, venous stasis ulcers, surgical wounds — through specialized wound care, infection control, nutrition support, and prevention of recurrence.

2 stagesHospital discharge with a wound, primary care or home health nurse identifying a...
Insurance Considerations
  • •Medicare covers wound care supplies as part of home health or under DME benefit if specific criteria are met.
  • •Advanced wound therapies (negative pressure, bioengineered skin) require prior authorization.
  • •Nutritional supplements for wound healing may be covered with documentation of malnutrition.
  • •Medi-Cal covers wound care with similar documentation requirements.

Ventilator & Trach Care

Respiratory

Managing patients with tracheostomy and/or ventilator dependence — from ICU through weaning, home ventilation setup, ongoing respiratory care, and prevention of complications.

2 stagesICU after tracheostomy placement for prolonged mechanical ventilation, or hospit...
Insurance Considerations
  • •Medicare covers home ventilator and respiratory equipment including supplies.
  • •Private duty nursing may be covered for vent-dependent patients — hours are often negotiated.
  • •Backup power sources (generator, battery) are generally NOT covered by insurance — family responsibility.
  • •Medi-Cal covers home ventilation and nursing for eligible patients.

Dialysis

Chronic Care

Managing end-stage renal disease — from dialysis initiation through access management, treatment options (in-center, home hemodialysis, peritoneal), transplant evaluation, and long-term care coordination.

2 stagesNephrologist referral when GFR declines below 15–20 mL/min, or emergency departm...
Insurance Considerations
  • •Medicare covers dialysis for all ages with ESRD (End-Stage Renal Disease) regardless of age.
  • •Medicare becomes primary after 30 months of coverage (or immediately if already Medicare-eligible).
  • •Transplant medications are covered under Medicare Part B if Medicare was primary at time of transplant.
  • •Medi-Cal covers dialysis and may cover transportation to treatments.

IV Infusion

Chronic Care

Managing patients requiring intravenous medications — antibiotics, immunotherapy, chemotherapy, biologics, hydration, or parenteral nutrition — through infusion centers or home infusion services.

2 stagesHospital discharge with ongoing IV medication needs, or specialist order for inf...
Insurance Considerations
  • •Home infusion is covered by Medicare Part B for certain drugs (antibiotics, TPN, inotropes, some biologics).
  • •Many infused medications require prior authorization — plan for lead time.
  • •Infusion center vs. home infusion: coverage varies by plan and drug — verify which setting is covered.
  • •Medi-Cal covers infusion therapy with prior authorization.

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