Hospital-to-Home Visits

Contact the Hospital-to-Home Program


Lisa Scherber
Jimmy Fund Clinic, Dana-Farber


Pediatric patients and their families are faced with many challenges throughout treatment. One of the greatest challenges for families is caring for a child at home.

The transition of a patient’s care from hospital to home increases the demand on families and home care agencies. Even though health care systems can help make this a smooth shift, families benefit from improved community-based services like the Hospital-to-Home program.

The Hospital-to-Home program helps to ensure a safe and seamless transition for the patient back into the home and community.

What is the Hospital-to-Home program?

The program provides an on-site visit from a Community Outreach nurse from Boston Children's Hospital to eligible pediatric oncology patients.

What is the purpose of the home visit?

The visit reinforces patient and family education, identifies opportunities to improve care, develops a plan of care, and conducts a face-to-face hand-off by the home care agency nurse. In particular, the agency nurse can help families provide for needs specific to the patient’s diagnosis, treatment, side effects, and other requirements.

Who is eligible?

All newly diagnosed oncology and post-discharge stem cell transplant patients who live in Massachusetts and within 90 miles of Boston are eligible. We are currently expanding our program to include neuro-oncology and end-of-life patients as well.

What is the role of the Community Outreach nurse?

After transitioning out of the hospital, patients are linked with community home care providers when they are transferred home. However, these providers often have no experience working with pediatric cancer patients and their families, and are almost never pediatric oncology certified.

The Community Outreach nurse coordinates the home visit with the home care agency to provide specific information the agency nurse needs to increase his/her knowledge base as well as boost his/her ability to better serve pediatric oncology patients. In addition, the Community Outreach nurse offers formal education to agencies throughout New England. The nurse conducts focused education in the form of informational in-services and formal and informal presentations.

Home visits help improve patient safety and ensure that patients and families have an accurate and complete understanding of the essential elements of pediatric oncology care.

Because of the complexity of information needed to care for a pediatric oncology patient at home, families benefit directly from increased collaboration with home care providers. In turn, the home visits inform hospitals and home care agencies of ways to improve safety, care, and support when a patient is discharged.