Resource Library: Care Pathways in Post-Acute Settings

Standardized care protocols can help reduce unwanted care variation and ensure high quality outcomes across an episode of care. This page provides a collection of implementation guidance and example protocols for specific conditions commonly managed in both acute and post-acute settings, including cardiovascular, neurological, orthopedic, and pulmonary.

Select a service line from the drop down menu:

For evidence-based guidelines and clinical documents to help manage a variety of cardiac conditions, see The American College of Cardiology


  1. AHA/ACC Clinical Performance and Quality Measures for AMI | This resource from AHA and ACC provides clinical and quality benchmarks to monitor care and identify improvement opportunities for AMI patients.
  2. Nursing/Case Management pathway | This resource from Atrium Health includes guidelines for nursing and case management staff to manage AMI patients throughout an acute episode, with post-discharge guidance.
  3. Post-discharge AMI navigation instructions | This resources from Atrium Health includes post-discharge instructions for AMI patients to help develop a successful care navigation and variation reduction strategy.


  1. CABG Post-Acute Care Roadmap | This roadmap from Baystate Medical Center provides day-by-day guidelines for assessments, diet, treatment, discharge planning goals, and medication delivery recommendations to better manage CABG patients in post-acute settings.
  2. Home Care Management of the Heart Surgery Patient | This checklist from New Hanover Regional Medical Center provides key instructions for home health agencies to manage post-surgical CABG patients.

Heart Failure

  1. Intermountain Health Heart Failure Pathway | This pathway includes clinical staff responsibilities and post-discharge instructions in order to help execute a successful HF pathway.
  2. Practical Guide on Home Health in Heart Failure Patients | This resource provides implementation guidelines to build an integrated home care pathway for heart failure patients.

For evidence-based guidelines and clinical documents to help manage a variety of neurological conditions, see The American Academy of Neurology


  1. Aegis Therapies’ CVA Functional Clinical Care Path | This example from Aegis includes a list of ‘red zone triggers’ and three milestones for CVA patients.
  2. Neuro Care Pathways Protocol | This document provides stroke care pathways, post-discharge care guidelines, and general tips to help acute and post-acute providers develop cross-continuum care protocols.
  3. Post-Acute Protocols for Neuro | This resource includes protocols to help acute and post-acute providers collaborate to improve post-discharge patient outcomes.

Joint Replacement

  1. TJA Care Pathway | This resource from Institute for Healthcare Improvement identifies steps to provide safe, efficient, and patient-centered care across an entire joint replacement episode.
  2. Joint Replacement and Spine Patient Navigation | This resources describes key duties patient navigators should play to direct patients throughout their acute care stay and coordinate post-discharge care.
  3. Build a Sustainable Outpatient Joint Replacement Program | Pages 11-15 identify two strategies to help home health providers play a role in building outpatient care pathways and coordinate care across the continuum.
  4. Resources for Predicting Discharge Disposition | This resource provides two tools that help predict post-acute discharge disposition for joint replacement patients.
  5. Timed Up and Go (TUG) Test | This tool provides caregivers guidance on how to administer a TUG test in order to help evaluate patients’ risk of falling and further manage patient care in the home setting.


  1. Spine Care Pathway-Tactical Guide | This pathway provides specific actions to strengthen each step of the care process as well as potential impacts from those actions.


  1. COPD Care Pathway | Page 12 of this resource offers COPD care pathways to improve home health and telemedicine support.

Next, Check Out

Telehealth in Post-Acute Care Settings

Learn More