« The Dual Agenda: August 5, 2015 Issue

Eldercare Voices

Bridging the Gap: Social Work-Driven Care Coordination as a Priority for Improving Health

Robyn Golden, MA, LCSW

Care coordination is gaining increased attention as it is one of ten National Quality Strategy principles for improving health and health care quality, building on the Institute for Healthcare Improvement’s Triple Aim framework: improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care. A fairly small segment of Medicare beneficiaries – those who have one or more chronic conditions and are dually eligible for Medicaid – account for a disproportionately high share of spending within both programs. This costly care tends to be inefficient for the system and often does not lead to improved health outcomes for these high-need individuals.

Historically, medical care and long-term services and supports (LTSS) have been fragmented due to different funding streams, separate professional training programs, and a lack of accountability across settings, leading to duplicative and inefficient care. The siloed nature of  medical care and LTSS results in poor communication between providers, often leading to social and mental health concerns falling through the cracks. Furthermore, individuals with multiple chronic conditions and LTSS needs are often left to navigate these two complex health care systems on their own. This experience can be taxing and confusing for patients and their families, and the complexity often leads to disengagement and poor adherence to the plan of care. Health care reform efforts, including the Medicare-Medicaid Financial Alignment Initiative, are testing care coordination between medical and LTSS settings as a method to improve the care experience and health outcomes and, so far, we have seen promising results.

Transitional Care Coordination

A universally identified challenge for older adults and those with multiple conditions is transitional care. Without a designated professional responsible for a care transition, the responsibilities default to individuals and their families, who are under many other stressors at the time of a hospital discharge. This burden reduces patient satisfaction and jeopardizes the health of already-compromised individuals. Lack of care coordination is linked to adverse outcomes such as higher hospital readmissions and emergency room visits. Providing transitional care services is an effective approach to help reduce hospital readmissions and improve health outcomes. 

Some of the recognized interventions to improve care transitions include:

The Bridge Model

The Bridge Model is an evidence-based care coordination model that encompasses a focus on enhanced transitional care. It is a social work-led, person-centered, interdisciplinary model of transitional care that aims to reduce hospitalization rates and emergency department visits, improve patient satisfaction, and improve quality of life for older adults, individuals with chronic conditions, and their caregivers. Developed in partnership by Rush University Medical Center, various Illinois Aging Network organizations, a health policy organization, and research stakeholders, Bridge integrates best practices from a variety of settings.

In the Bridge Model, a masters-level clinical social worker supports individuals before and after hospital discharge as they transition to the community. Bridge Care Coordinators conduct a comprehensive assessment after discharge to identify gaps that have emerged and remain involved until all identified needs are stabilized. The Bridge Care Coordinator focuses on developing rapport with individuals and on identifying what is important to them in order to best support their integration back into the community. By integrating psychotherapeutic techniques into their care coordination activities, Bridge Care Coordinators are able to increase patient engagement in their own care. In addition, they provide support to caregivers to reduce stress and burden. In order to best meet patients’ needs, the social workers develop relationships with a variety of community partners, are aware of available resources and their eligibility requirements, and provide “warm handoffs” during the transition. Bridge programs emphasize provider engagement and collaboration, engaging an interdisciplinary team that often includes the Aging Network, primary care clinics, home health, durable medical equipment team, pharmacy, and other community-based service providers.


The Bridge Model’s approach of addressing both medical and social issues leads to many positive outcomes, including significantly lower readmission rates and decreased stress for patients and family caregivers. Findings from participation in a transitional care demonstration project for Medicare beneficiaries indicate that Bridge recipients had 30% fewer 30-day readmissions than expected based on the baseline rate for the target population. Bridge has also led to increased rates of primary care follow-up visits and to fewer 60- and 90-day hospital readmissions, showing the long-term impact of supporting patients through the transition home and increasing patients’ engagement in their own care. The Bridge Model has been recognized as evidence-based by the Administration for Community Living and the Agency for Healthcare Research and Quality.

The Bridge Model has grown considerably since we began our first pilot at Rush University Medical Center in 2005. With the support of many partners and funders, we have trained over fifty community-based organizations and hospitals around the nation and one hospital in Canada. The Bridge Model National Office provides continuing support to replication sites through our Bridge Model Collaborative, in which we host regular webinars and discussions, and also offer an online community for sites to easily access Bridge tools and connect with each other. Based on input from replication sites, we continue to refine the protocol to ensure we are best situated to meet the needs of the organizations that implement Bridge, and the individuals and families they work with.

As the number of older adults grows and the need for medical care and LTSS increases commensurately, care coordination becomes increasingly important. The Bridge Model is one approach to bridging the gap that exists between medical and LTSS settings to best support older adults and people with multiple chronic conditions after a hospitalization.

For additional information on Bridge and to learn about opportunities for replication, please visit www.transitionalcare.org  or contact info@transitionalcare.org.

Robyn Golden, MA, LCSW, serves as the Director of Population Health and Aging at Rush University Medical Center in Chicago where she also holds academic appointments in the Departments of Preventive Medicine, Nursing, Psychiatry, and Health Systems Management and the College of Nursing. For over 25 years, Ms. Golden has been actively involved in service provision, program development, education, research and public policy aimed at developing innovative initiatives and systems integration to improve the health and well-being of older adults and their families. In 2003-04, she was the John Heinz Senate Fellow based in the office of Senator Hillary Rodham Clinton in Washington, D.C. Ms. Golden is also a past chair of American Society on Aging and currently co-chairs the National Coalition on Care Coordination, and is a fellow of the Gerontological Society of America. Ms. Golden holds a Master’s degree from the School of Social Service Administration at the University of Chicago and Bachelors degree from Miami University.

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