of-liverpool-care-pathway-for-dying-patients; 2013 19 European Pathway Association [no date] http://e-p-a.org/care-pathways 20 NHS Five year forward plan https://www.england.nhs.uk/wpcontent/uploads/2014/10/5yfv-web.pdf; 2014 85 Discharge Planning, Communications With the Team Providing Care in the Ambulatory Setting and the “Medical Home” Paul Stephens Jr, Tyra Bryant-Stephens, Jena Tanem, Gil Wernovsky