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.

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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.

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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

During this four-week program, a Transitions Coach supports patients with complex care needs by teaching them self-management skills that will ensure their needs are met during their transition from hospital to home. Patients enrolled in the program are much less likely to be readmitted to the hospital, and more likely to achieve self-identified personal goals when it comes to symptom management and recovery.

Once enrolled, your transitions coach will guide you in the following areas to avoid another ED visit:

Review and understand your ED discharge instructions
Identify questions to ask your primary care provider (PCP)
Assist you with scheduling timely follow-up care
Discuss health warning signs and when to seek immediate care or call 911
Gather a list of your conditions, medications, and questions to bring to your provider

What to Expect

It is a 30-day program
One in-home visit
Three follow-up phone calls

For Caregivers

Bringing your loved one home from the hospital can be overwhelming. There are so many things to remember and to do. Having a good plan is the first step. Our Transitions in Care Coaches will help you with all of this.

Helpful Resources

Care Transitions Intervention – Care Transitions Intervention

Download the Personal Health Record

For more information, please visit: https://medicare.bluecrossma.com/member-resources/find-care/member-support-assistance-program

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.