Overview

Transitions in care after a hospitalization are often complex, stressful, and difficult for patients and their caregivers to navigate. The consequences of poor transitions are serious and costly: high re-hospitalization/readmission rates, unnecessary nursing home admissions, and deteriorating health – as well as increased burden and costs on individuals, insurers, public funding sources, and safety-net healthcare providers. Further complicating this problem, national research shows that readmissions affect minorities at disproportionately high rates and are often caused by lack of or inadequate care coordination across medical and social services following a hospitalization.

To address these issues, Health & Medicine joined with other partners in 2008 to collectively develop and disseminate the Bridge Model of transitional care, an interdisciplinary and social work-led intervention that helps individuals safely transition from the hospital to their homes and communities. The Bridge Model improves transitions of care by utilizing master’s-prepared social workers in a case management role, who conduct comprehensive biopsychosocial assessments, help coordinate medical and social services after discharge, and utilize psychotherapeutic techniques to target patient engagement. Bridge programs emphasize care continuity across settings, interdisciplinary teamwork, and the importance of caregiver supports. Bridge helps reduce hospital readmission rates, decrease patient/caregiver burden and stress, and improve physician follow-up.

A 2016 analysis of a program published in the Journal of the American Geriatrics Society found that Bridge demonstrated a 20% all cause 30-day readmissions reduction among Medicare FFS beneficiaries. As of 2015, more than 60 hospitals and community-based organizations around the country have been trained in the Bridge Model, and Health & Medicine continues to play a strategic leadership role in the Bridge Model National Office.

For More Information: Bridge Model National Office