Programs & Services

Transitions of Care

Your Partner in Navigating Life’s Transitions

At Access Care Partners, we’re here to help you or your loved ones make informed decisions and smooth transitions at every stage of life. Whether you’re exploring ways to live independently through Options Counseling, recovering at home with support from our Hospital to Home Program, or planning a return to community living with help from our Community Transition Liaison Program, our compassionate team is ready to guide you every step of the way. No matter your age, circumstances, or goals, we’ll work with you to ensure you have the resources, support, and confidence you need to live the life you want.

See our brochure
Echa un vistazo al folleto

Options Counseling

What is Options Counseling?

Options Counseling is a free service available to individuals of all income levels and ages. Our counselors can meet with you wherever you are most comfortable—your home, nursing home, rehabilitation facility, or hospital.

We’re here to help you answer important questions like:

Can I live safely and independently in the community?
Should I consider assisted living, supportive housing, or another living environment?
What services, assistive devices, or home modifications can help me stay in my home?
Does my insurance cover these services? If not, what other funding options are available?
Can I privately pay for the care and support I need?

How We Help

Our Options Counselors provide:

Personalized support: We’ll discuss your goals, abilities, support system, and financial situation to understand your needs
Exploration of all options: Together, we’ll look at available programs, funding sources, and services tailored to your situation
Unbiased guidance: Our team offers objective advice to help you weigh your choices
Practical resources: You’ll receive written materials and referrals to connect you with the right long-term care options.
Ongoing support: We’ll follow up to ensure your needs are met and adjust plans as needed.

Hospital to Home Program

Our Hospital to Home program, in partnership with Holyoke Medical Center helps patients transition smoothly from the hospital to home. Access Care Partners’ Hospital Liaisons work directly with the medical team during daily rounds to coordinate services, making it easier for you to recover at home instead of in a rehabilitation facility.

Benefits of Hospital to Home:

Recover in the comfort of your own home – With the right support in place, you can heal in a familiar environment instead of spending additional time in a hospital or rehabilitation facility.
Access to essential services – Our team ensures you have the home care and support services you need when you’re discharged.
Personalized care coordination – We work directly with your discharge team to create a care plan tailored to your recovery needs.
Ongoing support to help prevent hospital readmissions – With a dedicated team looking out for your well-being, you have an extra layer of support to catch potential health concerns early and avoid unnecessary trips back to the hospital.
Connections to community resources – You’ll be linked to valuable services you may not have known existed, such as home-delivered meals, transportation, personal care assistance, and more.

With Hospital to Home, you can focus on healing while we take care of the rest.

See our brochure
Echa un vistazo al folleto

Community Transition Liaison Program

Are you or a loved one currently living in a nursing facility but considering returning to the community? Our Community Transition Liaison Program (CTLP) is here to help make that goal a reality.

Our CTLP team will:

Work closely with you to understand your interest in transitioning to community living.
Assist with discharge planning to ensure a safe and supported move.
Connect you with programs and local community resources to meet your needs.
Advocate on your behalf and help resolve any concerns related to your transition.

This program is open to all nursing facility residents aged 18 and older, regardless of insurance type. If living in the community is your goal, we’re here to support you every step of the way.

Blue Cross Blue Shield
Transitions in Care Program

The Transitions in Care Program provides short-term support to individuals returning home following an emergency department visit or hospital stay. The program is designed to help participants better understand their health needs, navigate the healthcare system, and connect with community resources that support their independence and well-being.

How the Program Works

A trained care professional will work one-on-one with participants for approximately 30 days following discharge. Support may include:

Reviewing discharge instructions and follow-up recommendations
Helping participants prepare for appointments with primary care providers and specialists
Discussing medications and encouraging questions for healthcare providers
Identifying warning signs that may require medical attention
Connecting participants with community resources and support services
Encouraging self-management skills and confidence in managing health conditions

What Participants Can Expect

Participants typically receive:

One in-home visit or telephonic visit, when appropriate
Several follow-up telephone contacts
Assistance identifying unmet needs and available community resources
Support with care coordination and healthcare navigation

Benefits of Participation

The program helps individuals:

Feel more confident managing their health after returning home
Better understand their medical conditions and treatment plans
Improve communication with healthcare providers
Access community resources that support health, safety, and independence
Reduce barriers that may affect recovery and well-being

For Caregivers

Family members and caregivers often play an important role in a successful recovery. Program staff can help caregivers understand discharge instructions, identify community supports, and connect with resources that may assist them in their caregiving role

For more information please visit: Member Support & Assistance Program | Blue Cross Blue Shield of MA

Why Choose Access Care Partners?

At Access Care Partners, we believe everyone deserves the chance to live comfortably and independently in the setting of their choice. Whether you’re transitioning from the hospital or a nursing facility, our team is ready to assist.

You don’t have to navigate caregiving alone. Let Access Care Partners be your partner in this journey. Contact us today to learn more about how we can support you and your family.