The Bridge Program (ITCC)
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The Bridge Program (ITCC)



The Illinois Transitional Care Consortium (ITCC) presentation at the 2011 American Society on Aging Conference: the Bridge Model of transitional care.

The Illinois Transitional Care Consortium (ITCC) presentation at the 2011 American Society on Aging Conference: the Bridge Model of transitional care.



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  • ITCC is a result of collective experience in the field of aging, and visionary leadership
  • Kristen – I’ve mentioning this a lot on presentations – when you get to the 40-50% make it clear that it does not imply that social workers can only prevent 40-50% of readmissions because social workers can intervene on numerous medical issues by connecting the right silos of care together. Things like medication regimen or discharge instruction confusion, etc.
  • ilana
  • Pre-discharge: referrals in one of a few ways (emr, walk-ins, d/c planners), assessment in one of a few ways (emr, interdisciplinary team, d/c-planner, family/patient)
  • Post-discharge: 48 hr. assessment and intervention (in-depth piece, follow up on important non-resource issues like pcp f/u, regimen understanding, caregiver burden, unmet needs, home health, etc. )
  • Key word: advocacy
  • Bring up own experience when possible (tell them a little story)“good patient” is a big reason why the situation changes post discharge. We’re all taught to respect doctors and we nod and say yes, but do we really understand? So even with good coaching, however (coleman, naylor), things will go wrong at d/c
  • Note that not all participants live in area…this is just a snapshot from one CCU
  • Building on what we have learned
  • Not a discharge planning issue but UNANTICIPATED SURPRISES!
  • Integrating intervention and data collection to minimize burden for pts and staff
  • Data on a much smaller sample --- designing data measures, irb approvals, hospital approvals, coordination
  • (point out on slide the name of the variable ---and then how the question was asked)
  • Marketing!
  • Walter and ilanaTell them that more details on BCCs and data is still coming

The Bridge Program (ITCC) The Bridge Program (ITCC) Presentation Transcript

  • Bridging Hospital to Home
    The Bridge ModelAn Innovative Social Work Approach to Transitional Care
    American Society On Aging
    Thursday April 28th, 2011
    San Francisco, CA
  • Kristen Pavle, Health & Medicine Policy Research Group
    Good Morning!
  • Agenda
    ITCC, Transitional Care
    The Bridge Model
    Building Relationships: Hospital
    & Community Based Organizations
    Aging Resource Centers
    Business agreements/contracts
    Cultural Competency
    Research, Evaluation, and Data
    Q & A
  • Who we are… the Illinois Transitional Care Consortium
    ITCC was formed to more effectively address needs of older adults transitioning from the hospital to the community by linking hospital based services with the aging network through intensive care coordination.
  • ITCC members
    Community-based organizations
    Aging Care Connections
    Shawnee Alliance for Seniors
    Solutions for Care
    Rush University Medical Center
    MacNeal Hospital
    Adventist LaGrange Memorial Hospital
    Herrin Hospital
    Memorial Hospital of Carbonda;e
    Research, Evaluation & Policy
    University of Illinois at Chicago, School of Public Health
    Health & Medicine Policy Research Group
  • So, why transitional care?
    • 19.6% of Medicare beneficiaries are readmitted in 30 days
    • 19% of patients experience an adverse event within 3 weeks of hospital discharge
    • 76% of 30 day readmissions are “highly preventable”
  • Older Adults and Care Transitions
    Older adults are particularly vulnerable to poor transition outcomes
    Multiple medical conditions, medications, and care providers
    Physical and cognitive limitations
    Health literacy
    Burdened caregivers
    Photo courtesy of “auntjojo” on
  • The United States Health Care System
    Medicare Advantage Plans
    Private Insurance
    In-Network Providers
    Skilled Nursing Facilities
    In-Patient Hospital Stays
    Community-based Organizations
    Primary Care Physicians
    Specialist doctors
    Social Workers
    Preventive Care
    Long-term care
    Family Caregivers
    Home care physicians
    Medical homes
    Accountable care organizations
    Direct-care workers: home health, home care
  • Perfect Storm
    Increasingly aged population
    Greater functionality with chronic conditions
    Living longer, yet sicker
    Bottom Line: people need better care and we need to
    offer high quality care
    while containing costs
    Photo courtesy of “striking_photography” on
  • Transitional Care
    Coordinating care from one care setting to another
    Hospital to home
    Hospital to nursing home
    Nursing home to home
    Home to nursing home
    Within hospital or nursing home
    Insurance transitions
    PCP transition
    Caregiver moving in or out
  • Advisory Board
    Jean Bohnhoff - Executive Director, Effingham County Committee on Aging
    Thomas Cornwell - Medical Director, HomeCare Physicians
    Bob Clapp - Senior Vice President, Hospital Affairs, Rush University Medical Center
    Jim Durkan - President/CEO, Community Memorial Foundation
    Karen Freda - Executive Director, Illinois Council of Case Coordination Units
    Michael Gelder - Senior Health Policy Advisory to Illinois Governor Pat Quinn
    Michael Koronkowski – Pharmacist and Geriatrics Professor, University of Illinois at Chicago
    Patricia Merryweather - Vice President, Illinois Hospital Association
    Jonathan Lavin - Executive Director, Age Options, Suburban Cook County Area Agency on Aging
    Marta Pereyra - Coalition of Limited English-Speaking Elderly
    Cheryl Schraeder - Director of Policy & Practice Initiatives, Institute for Healthcare Innovation, University of Illinois at Chicago College of Nursing
    Patricia Volland - Senior Vice President, Strategy & Business Development, The New York Academy of Medicine
    Rebecca Zuber - President, Rebecca Zuber, Inc.
  • Walter Rosenberg, Rush University Medical Center
    The Bridge Model
  • A Case Example
    Mrs. Harrison
    • Widowed
    • 75 years old
    • Has diabetes and COPD
    Admitted through the ED after a fall
    • Hospitalized for 5 days
    • Discharged with home health care
    • 10 medications prescribed
  • Is this the
    worst case scenario,
    or is it
    a typical transition?
    Mrs. Harrison at Home
    Community PCP doesn’t know Mrs. Harrison was admitted to the hospital.
    Mrs. Harrison’s primary caregiver is overwhelmed and has to return to work.
    Mrs. Harrison is afraid she will fall again and have to return to the hospital.
    Mrs. Harrison doesn’t know which medications to resume and which to stop taking at home.
    The Home Health Care Agency doesn’t arrive on time.
    Mrs. Harrison’s two children can’t agree how to best manage their mother’s medical needs.
    Mrs. Harrison is feeling depressed because she can’t get around anymore like she used to.
    Mrs. Harrison is having difficulty coping with her mobility changes.
    Mrs. Harrison has questions about her medical bill and doesn’t know what her insurance will cover.
    Mrs. Harrison can’t afford her medications anyway.
    Mrs. Harrison has no transportation to her follow-up medical appointments.
    Mrs. Harrison is feeling isolated now that she’s homebound.
    Mrs. Harrison’s Community Services are delayed
    The Bridge Model
  • The Bridge Model
    Overview of Components
    Social-worker Based: Bridge Care Coordinator
    Interdisciplinary Teams
    Hospital  Home
    Patient Focused, Community-Specific
    The Aging Resource Center
    Urban, Suburban, and Rural applicability
  • The Bridge Model
    The participant enters the hospital with more than an illness.
    • Caregiver
    • Family
    • SES
    • Race
    • Gender
    • Ethnicity
    • Religion
    • Mental Health
    • Personal Values and
    Referrals can originate from an electronic medical record, a discharge planner, the patient or a family member.
    • Risk screen built in to the EMR
    • If non-hospital staff, requires access to the EMR
    Review of the electronic medical record, meeting with an interdisciplinary pre-discharge and fast tracking community services.
  • The Bridge Model Process
    The Bridge Care Coordinator builds relationships with the community service providers.
    • Services get fast-tracked to
    aid in a seamless transition
    upon discharge
    The Bridge Care Coordinator conducts a comprehensive assessment and intervention to identify needs unrealized prior to discharge.
    • Medication compliance
    • Transportation to doctor’s
    • Community resources
    • Scheduled doctor’s
    • Safety at home
    At 30 days, the participant/caregiver gets contacted and the transitional process gets assessed.
    • Warm handoff made to
    appropriate agencies
    • Doctor’s visit completed
    • Medication regimen
    • Safety at home
    • Any additional unmet
  • Building off of Aging Network
    Conducting Choices for Care Assessments and CCC Assessments
    Setting up CCP Interim Services and Interim Home Delivered Meals
    Providing and referring families for Caregiver Support Services and Respite
    Conducting Benefits Check-Ups
    Providing Information & Assistance to Patients and their families on site (i.e. Medicaid, Food Stamps, Circuit Breaker, Tax Freezes, Medicare Part D, Home Modification, FSS)
  • Bridge Care Coordinators
  • Bridge Care Coordinators
    Why Social Workers?
    Systems Theory
    determinants of
  • The Post-Discharge Environment
  • Psychosocial Issues
    Social isolation
    Difficulty coping with change
    Financial stressors
    Language barriers
    Health literacy barriers
    Older generations taught to be “good patients”
    40-50% of readmissions linked to psychosocial issues and lack of community resources
  • Calculating the Cost
    What is the REAL cost?
    Staff allocation
    Case load efficiency
  • Sustainability
    Can’t do good without doing well
    Who’s money are you saving?
    Who is your audience?
    Business case options
    Higher yield patients
    Patient Satisfaction
    The “3026 RFP”
  • Building Relationships
    Ilana Shure, Aging Care Connections
    Esther Izaguirre, Solutions for Care
  • Aging Resource Center
  • The Role of the ARC
    Symbol of hospital-community collaboration
    Greater ability to interface with the community
    Promotes the notion of “systems” approach to discharge planning.
    Maximizes the opportunity for a servable moment.
  • Community-Hospital Partnerships
    Aging Care Connections (CCU - Suburban Chicago)
    Adventist LaGrange Memorial Hospital
    Shawnee Alliance for Seniors (CCU – Rural, downstate Illinois)
    Memorial Hospital of Carbondale
    Herrin Hospital
    Solutions for Care (CCU – Suburban Chicago)
    Mac Neal Hospital
    Central West (CMU – Chicago)
    Rush University Medical Center
  • Aging Network: National  State
  • Illinois Aging Services Network
  • Establishing a Connection to the Aging Network
    Many older adults seen at the hospital by Bridge Care Coordinators have yet to get connected to resources available through their community
    54% of ARC clients had no previous interaction with their local Care Coordination Unit (N=399)
    Bridge Care Coordinators connect older adults to the aging network
    49% of ARC clients utilized services offered through their local Care Coordination Unit for the first time after their encounter with a Bridge Care Coordinator (N=399)
  • Establishing an ARC
    Time frames for developing the ARC
    Outreach to hospital
    Through existing programs or contracts already established
    Begin contacting individuals at the hospital who are supportive of the model.
  • Establishing a Partnership
    Evaluate Potential Partners
    Make the “ASK”
    Identify what you are asking the partner to contribute
    Establish the basic structure of the partnership prior to launching the project
    Keep parameters loose enough to allow for growth development
    An MoU at a minimum should be in place prior to the start date of the project
  • Establishing a Partnership Cont.
    Legal agreements should be created broadly defining the service provision, the recipient of the service and duties of each partner in the relationship including:
    Purpose of the program
    Responsibilities of both parties
    Individual responsibilities of the partners
    Financial liabilities
    Confidentiality and data sharing
    Annually review agreement!
  • Lessons Learned
    Integrate at all levels of the hospital system
    • Front desk reception to Regional Director
    Be patient and persistent
    • Guest versus Team Member
    Troubleshoot challenges before they become barriers
    Learn both cultures and languages
    • Network, network, network
  • Cultural Competency
    SFC services a Diverse Population
    40% Hispanic
    37% Limited English Speaking or only speak Spanish
    Bilingual and Bicultural Bridge Care Coordinators
  • Cultural Competency Continued
    Assess clients and caregivers in their language and coordinate and link them to services
    BCC are able to participate in the important aspects of culture, value and belief systems
    All printed material are in Spanish including Consent forms
  • Cultural Competency Continued
    Support Groups for Spanish Speaking Caregivers
    Chronic Disease Self Management Classes taught in Spanish
    -Take Charge of your Health
    Outreach Program to target cultural linguistically isolated individuals in the communities
  • Susan Altfeld, University of Illinois at Chicago – School of Public Health
    Research & Evaluation
  • The Bridge Model Evidence Base
    The Bridge Model is an adaptation of the Enhanced Discharge Planning Program (EDPP)
    EDPP is an evidence-based model developed and evaluated with a randomized-controlled trial at Rush University Medical Center (ITCC partner)
    Bridge implements the evidence based components of EDPP and best practices developed by ITCC partner sites
    Bridge is a hospital and community partnership
  • Rush University Medical Center Study
    Randomized controlled trial of 720 patients
    All patients older than 65 with multiple medical conditions
    Half received follow-up intervention, half were in the “usual care” group
    Qualitative study
    Interviews with intervention social workers
  • What did we learn from the Rush study?
    83% of the patients in the intervention group had problems identified by the social worker during the assessment at 2 days post-discharge
    For ¾ of these individuals, problems did not emerge until after discharge –
  • Needs Identified at 2 day post discharge contact* - Rush study
    *select variables
  • Randomized Controlled Trial Outcomes at 30 day follow up – patient follow up/adherence
  • Adverse Outcomes –30 days post discharge
  • Post-Intervention Contact- Rush RCT
    Almost 1/3 of patients (29.3%) contacted the Bridge social worker for additional services or information
    after the case was closed
  • Evaluation of the Bridge Model
    Important variables from our previous work and other evidence based care transitions interventions
    Patient characteristics
    Health status
    Patient stress
    Caregiver stress
    Understanding of responsibilities for managing health
    Medical follow up
    Hospital readmissions
  • Evaluation data collection- ITCC Bridge
    Intake assessment
    2 day post discharge assessment
    30 day follow up assessment
    Satisfaction survey
    Both “patient” and “caregiver” versions of the assessment surveys
    Email /telephone satisfaction surveys
  • Evaluation of the Bridge Model
    Who are our participants?
    1766 participants at 5 sites across Illinois from May 2010-March 2011
  • Bridge client demographics preliminary data 5/10-3/11
    Male 39.7%
    75+ 52.2%
    Frail 64.8%
    Living alone 41.5%
    Social need 87.2%
    Non-English speaking 8.4%
    Minority/”non-White” 35.7%
    At risk for nursing home placement 37.6%
  • 2-day post-discharge assessment
    Older adult client’s health
    At this time, how is your health?/ how is (Mr./Ms. patient last name)'s health? (N=117)
    Excellent 4.3%
    Very good 15.4%
    Good 47.0%
    Fair 19.7%
    Poor 11.1%
  • 2 day post discharge assessment
    Older adult (patient) stress
    Since I left the hospital, managing my needs has been stressful for me/ Since he/she left the hospital, managing his/her needs has been stressful for him/her (N=109)
    Yes 50.5%
    No 49.5%
  • 2 day post discharge assessment
    Caregiver stress
    Since I left the hospital managing my needs has been stressful for my family or other caregivers/ Since he/she left the hospital managing his/her needs has been stressful for you. (N= 102)
    Yes 57.8%
    No 42.2%
  • 2 day post discharge assessment
    Understand medications
    I understand the purpose of each of my medications and how to take each of them (N= 118)
    Yes 98.3%
    No 2.7%
  • 2 day post discharge assessment
    Understand symptoms/”red flags”
    I understand what symptoms I need to watch out for and who to call if they occur(N= 118)
    Yes 94.9%
    No 5.1%
  • 2 day post discharge assessment
    Are things more difficult than you expected since leaving the hospital, less difficult or about what you expected? (N=110)
    More difficult 30.0%
    Less difficult 10.9%
    As expected 59.1%
  • 30 day outcomes patient follow up/adherence
    Physician communication- 95.1%
    Physician visit -95.3%
  • 30 day outcomes adverse events
    Rehospitalized within 30 days of d/c- 8.9%
    Mortality - 2.0%
  • Satisfaction survey
    Decision making
    The assistance or information you received from the Bridge Program helped you (or your loved one) make decisions about your care
    Strongly agree 40.1%
    Agree 59.1%
    Disagree 0%
    Strongly Disagree 0%
  • Satisfaction survey
    Links to community services
    The assistance or information you received from the Bridge Program helped you (or your loved one) connect to services and resources.
    Strongly agree 42.1%
    Agree 57.9%
    Disagree 0%
    Strongly Disagree 0%
  • Satisfaction survey
    Patient stress
    Bridge Program helped to make the hospital discharge experience less stressful for you (the patient).
    Strongly agree 39.1%
    Agree 52.2%
    Disagree 4.3%
    Strongly Disagree 4.3%
  • Satisfaction survey
    Caregiver stress
    The Bridge program helped to make the hospital discharge experience less stressful for family or other loved ones
    Strongly agree 31.8%
    Agree 59.1%
    Disagree 4.5%
    Strongly Disagree 4.5%
  • Satisfaction survey
    Bridge Care Coordinator - knowledge
    The Bridge social workers were knowledgeable.
    Strongly agree 47.8%
    Agree 47.8%
    Disagree 4.3%
    Strongly Disagree 0%
  • Satisfaction survey
    I would recommend this program to others
    Strongly agree 41.0%
    Agree 59.0%
    Disagree 0%
    Strongly Disagree 0%
  • Satisfaction Survey - Quotes
    Unmet needs/anything you would change/what did you like about the Bridge Program?
    “I like everything about the Bridge Program.”
    “You are providing a great service.”
    “I would like it to be much more advertised for everyone wherever they live.”
    “It would be nice for everyone to receive the services like my father.”
    “I cannot think what else the social worker could have done additionally since she was very helpful throughout ….”
  • Contact Information
    Susan Altfeld (
    Esther Izaguirre (
    Kristen Pavle (
    Walter Rosenberg (
    Ilana Shure (