Innovative Care Transitions

Addressing the complex needs of older patients and their caregivers is the focus of the Bridge Model. Developed by Rush University of Medical Center's Health and Aging Department and several community partners in Chicago, this model of transitional care emphasizes care continuity and interdisciplinary teamwork, using master's-prepared social workers in a care coordinator role. Before a patient is discharged, a Bridge Care Coordinator (BCC) collaborates with discharge planners, participates in interdisciplinary rounds, reviews the medical record and conducts a bedside visit with the patient and family. After discharge, the BCC conducts a comprehensive biopsychosocial assessment and intervenes until all identified gaps in care have been stabilized. BCCs connect with post-discharge providers and advocate on behalf of their patients, working directly with many family caregivers. This model has been replicated by 60 hospitals and community-based organizations nationwide. Results include lower readmission rates, decreased mortality and patient/caregiver burden and stress, and improved physician follow-up.

For more information, contact Walter Rosenberg, manager of transitional care, Walter_Rosenberg@rush.edu or visit www.transitionalcare.org. Read the complete case study and find more resources on improving care transitions and care coordination.