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 plan authorized 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.