After-hospital & ED follow-up
Patient outreach, review of follow-up needs, appointment coordination, and communication with the treating team.
VIRTUAL • NURSE-LED • MASSACHUSETTS
After discharge.
Between appointments.
Helping care stay connected.
Virtual, nurse-led medical and behavioral health care coordination for practices, health plans, and families in Western and Central Massachusetts, with statewide partnership inquiries welcome.
Nice Nabitaka, FNP-BC, PMHNP-BC
Founder & CEO · Family & Psychiatric-Mental Health Nurse Practitioner
Based in Western Massachusetts · Virtual partnerships considered statewide, subject to service capacity and requirements
Built for partnership
Medical practicesBehavioral health organizationsMedicare Advantage & other health plansAging services organizationsCommunity organizationsFamilies & caregiversHOW WE HELP
Support where care
needs follow-through.
Flexible coordination for patients managing complex medical needs, behavioral health needs, or the transition home.
Medication reconciliation
Support medication follow-through after discharge, including contacting pharmacies about access needs and communicating medication discrepancies to prescribers.
Ongoing care coordination
Help patients navigate their care plans, coordinate appointments and referrals, and connect with interpreter and transportation resources.
Medical & behavioral connections
Coordinate across medical and behavioral health providers so follow-up needs remain visible to the care team.
Re-engagement & care gaps
Reach patients who need additional follow-up and help coordinate outstanding appointments or recommended services.
Resource connections
Help connect patients with relevant community supports and keep partner teams informed of unresolved access needs.
A PRACTICAL PARTNERSHIP
Care coordination for
Medicare referral partners.
We welcome referral partnership discussions with Medicare Advantage plans, practices serving Original Medicare patients, and accountable care organizations seeking additional medical or behavioral health coordination support across Massachusetts. Our proposed services work alongside your existing programs and staff. Together, we define the member group, referral criteria, services, communication process, and reporting needs.
Discuss a referral partnershipPILOT FRAMEWORK
Start with a small care-coordination pilot.
- Referral group
- A small, mutually agreed cohort
- Scope
- Defined services, capacity, and service hours
- Reporting
- Outreach, completed follow-up, and open barriers
- Payment
- A paid service agreement with your organization
- Review
- A shared review of progress and next steps
Scope, duration, and pricing are agreed before services begin.
FOR AGING SERVICES & COMMUNITY PARTNERS
Clinical follow-up that
complements your team.
For aging services agencies, community care managers, and organizations supporting older adults with complex medical and behavioral health needs.
Your existing nurses, care managers, and emergency response partners remain central to the client's care. Our proposed virtual coordination service can provide scheduled follow-up for eligible clients who need help navigating appointments, medications, referrals, and multiple providers after an initial service request or discharge.
After the initial response
Coordinate non-emergency next steps after a hospital discharge or an identified care concern, with referrals and responsibilities agreed in advance.
Medical + behavioral health
Review reported medication changes, communicate concerns to treating providers, and help close gaps in recommended follow-up.
Clear handoffs
Provide agreed updates to authorized care managers and caregivers, with documented follow-up tasks and unresolved barriers.
Explore a small partnership pilot
We can discuss a defined group of 5–10 eligible clients, service hours, secure referral pathways, reporting, and a mutually agreed payment arrangement before launch.
Virtual coordination does not replace emergency response, 24/7 monitoring, primary care, or in-person nursing. Services depend on eligibility, appropriate authorization, capacity, and a completed agreement.
FOR REFERRAL & CONTRACTING TEAMS
A clear path to explore
a care coordination partnership.
For hospital discharge and transitions-of-care teams, medical practices, insurers, ACOs, and aging services agencies. First, discuss the service model and fit—do not send patient records through our public form.
Request a conversation
Use the general inquiry form to identify your organization, role, and the type of partnership you're exploring. Do not include any patient-identifying information.
Agree on the scope
Discuss eligible populations, referral criteria, service hours, responsibilities, reporting, payment approach, and whether a small 5–10-client pilot makes sense.
Establish a secure workflow
Before accepting an individual referral, agree on a secure information-sharing method, necessary authorizations, and applicable privacy and contracting requirements.
Serving Massachusetts partners: Based in Western Massachusetts. Inquiries from organizations elsewhere in the state are welcome; service arrangements depend on capacity, eligibility, and applicable requirements. No statewide contract or coverage is implied.
Request a partnership conversationFOR FAMILIES & CAREGIVERS
Help managing the pieces
of a loved one’s care.
When appointments, medications, and multiple providers become difficult to keep track of, we offer virtual coordination to help your family organize next steps.
Keep care organized
Help coordinate appointments, referrals, and follow-up after a hospital stay or emergency department visit, including connecting patients with interpreter and transportation resources.
Connect the care team
Review reported medication lists, identify questions for prescribers, and help communicate concerns across medical and behavioral health providers.
Navigate the next steps
Help families organize care plans, navigate community resources, and coordinate communication with existing healthcare providers, with the patient’s permission or appropriate authorization.
PRIVATE-PAY FAMILY SUPPORT
Choose support that fits your family.
Contact us for a personalized quote. We agree on services, included hours, response times, and fees before starting.
We start with a conversation about your family’s needs. Services, availability, and fees are agreed before care coordination begins. All coordination is virtual; treatment and prescribing remain with the treating providers.
Ask about family supportNN
FNP-BC, PMHNP-BC
FOUNDER & CEO
Nice Nabitaka
Family & Psychiatric-Mental Health Nurse PractitionerFNP-BC, PMHNP-BC
MEDICAL + BEHAVIORAL PERSPECTIVE
Care coordination with
a broader view.
Led by founder and CEO Nice Nabitaka, a board-certified family and psychiatric-mental health nurse practitioner, Western Mass Individualized Home Care LLC brings a medical and behavioral health perspective to virtual care coordination.
Our focus is helping families and partner organizations connect the pieces of care: patient outreach, provider communication, follow-up, and access to support.
Our service model
This program provides fully virtual care coordination. Clinical treatment decisions and prescribing remain with the patient’s treating providers.
PARTNER QUESTIONS
A few useful details.
Can families contact you directly?
Yes. Families and caregivers can inquire about virtual care coordination for a loved one. We discuss the support needed, patient permission or appropriate authorization, availability, and fees before starting.
Can my family pay privately?
Yes. Ask about an after-discharge support package or monthly family care coordination. We discuss your needs and provide a quote, with services, coordination hours, response times, and payment terms agreed before starting.
Who can partner with us?
Medical practices, behavioral health organizations, health plans, aging services agencies, and community organizations seeking virtual coordination support. We discuss geographic fit and eligibility before accepting referrals.
How are services delivered?
Services are delivered remotely, with patient outreach and partner communication defined in the service agreement. This program does not provide in-person patient visits.
How does payment work?
We discuss a paid pilot or service agreement directly with your organization. Pricing depends on the patient group, workload, scope, and reporting requirements. For Medicare-related services, eligibility, coverage, billing responsibilities, and any patient costs require review before services begin.
What can a pilot measure?
Measures can include patients reached, follow-up appointments completed, medication discrepancies identified, unresolved barriers, and coordination time. We agree on measures before starting.
LET’S TALK
Contact form
Request a 15-minute introductory call or ask about our services.
Tell us which type of support or partnership you are exploring, without naming patients or sharing medical information. Hospital discharge teams, health plans, and aging services agencies can request a conversation about a defined pilot. Families can ask about general service availability.
For general inquiries only
Please do not include diagnoses, medication lists, insurance IDs, medical records, or other sensitive patient information. Call 413-450-1500 to ask how to submit a patient referral securely.
Email and this public form are for general inquiries only. We arrange a separate approved secure referral method before any patient information is exchanged. Read our Privacy & Inquiries Notice.
145 Old Amherst Road
Belchertown, MA 01007
Virtual services onlyBased in Western Massachusetts · Statewide partnership inquiries welcomePlease use ordinary email for general inquiries only. Call to discuss the appropriate process for patient referrals.