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Bridge Model

The Enhanced Discharge Planning Program, now the Bridge Model, is designed to aid in patients’ transition from hospital to home. Transitional care is delivered by master's-prepared social workers who provide telephonic follow-up and short-term care coordination for recently discharged adults.

Our social workers conduct biopsychosocial assessments driven by a review of medical records, discharge plans and participation in pre-discharge interdisciplinary rounds. Social workers work with patients and caregivers after discharge to recognize gaps in care and intervene to resolve identified needs. This provides a resource for patients and their caregivers and an opportunity for social workers to provide early intervention for any difficulties.

A randomized control trial showed a decreased readmission rate at 30, 60, 90 and 120 days post discharge. Participants were more likely to make and keep follow-up appointments, had a better understanding of medication management, experienced reduced caregiver burden and had lower mortality rates. Transitional care social workers also encourage patients to recontact them with any future needs.

Rush Health and Aging is a founding member of the Bridge Model National Office, the first organization in the nation to bring forward a social work transitional care model – the Bridge Model. Rush University Medical Center served as the evidence base for the Administration on Aging-recognized Bridge Model. It is currently replicated at urban, suburban and rural sites in Illinois and other states.

Under the leadership of the AgeOptions Area Agency on Aging, the Bridge Model National Office was recently awarded a competitive Community-Based Care Transitions Program contract by the Centers for Medicare and Medicaid Services.