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safe at home program


What is Safe at Home?

Safe at Home is a demonstration project designed to transition high risk older patients from MMC to home more effectively by providing enhanced discharge and transitional medical house calls from the Safe at Home team’s nurse, social worker and Nurse Practitioners (NPs).


What is the Project Design?

Hospitalized frail older patients and their caregivers will meet the Safe at Home team prior to hospital discharge. The team, in conjunction with case management, will instruct the patients and their families on safe discharge and review with them the plans for home, including medications and follow-up care. The team will ensure the coordination, education and continuity of healthcare, as patients transition from the hospital setting to their homes. The patients and their families will meet a nurse practitioner, who will come to their homes for a period of 30 days and/or up to 3 months.


What are the Project’s Goals?

This project has three main goals:

  1. To determine whether an enhanced hospital discharge and NP home visits, prevent readmissions to the hospital, reduce emergency room visits, and prevent nursing home placements.
  2. To prepare for legislative mandates for coordination of care across settings and among providers (such as Medical Homes and Accountable Care Organizations). 
  3. To improve patient, family and physician satisfaction with hospital discharge process.


What is Your Role?

During your patient’s hospitalization, your encouragement of your patients to take advantage of this enhanced discharge and transitional home care opportunity is very important.  After discharge, you will be working collaboratively with a home-visiting NP on the patient’s management for up to 3 months, a determination that will be made in consultation with you.  Finally, the NPs will communicate with you predominately by MMC’s secure email.


What are the Benefits of Participating?

We expect improved satisfaction for your patients and their families not only with their transition from hospital to home, but also with their enhanced capacity to live at home with greater safety and confidence. In addition, you will be in the vanguard of physicians who are involved in the design of best practices for coordinated and transitional care. You will be using electronic information and communication technology, all of which will be part of new health care mandates and financial incentives for physician involvement in transitional care programs.



If you would like to learn more about the Safe at Home Program, please contact the Division of Geriatric Medicine:

Dr. Barbara Paris at (718) 283-7084
Dr. Melvyn Hecht at (718) 283-5917