Overview
The HARP transitional care program supports eligible patients covered by Medicare who are at moderate to high risk of being readmitted to the hospital within 60 days after they leave. By working closely with you and your caregivers, the team can help make sure you have a safe discharge and stay as healthy as possible when you leave the hospital.
The HARP team includes nurse practitioners, community wellness advocates, a pharmacy liaison, and a nurse manager. If your providers think you’d be a good fit for our program and you agree, you’ll be enrolled and start working with our team while you are still in the hospital.
We then continue to work with you for 30-60 days after you’re discharged. HARP staff can help you with many needs during this time, including ensuring you get the right care and connecting you to community resources and support services
Treatments and Services
The time after you’re a hospital inpatient can be confusing and complex. The HARP team supports you and your caregivers during this time to help you manage your health after you are discharged. This may include:
- Answering questions about care, including medications
- Doing a home visit to examine you
- Arranging transportation to appointments
- Coordinating primary and specialty care
- Connecting you to in-home support services
- Helping you use your medications safely
- Supporting your individual healing-related goals
- Helping you get medication and durable medical equipment, such as wheelchairs
- Advocating on your behalf for your medical and social needs
- Helping you apply for government assistance benefits
- Connecting you to community-based supports and services
Contact
Please contact DG-HARP@bmc.org with any questions.