BRIDGE Model of Transitional Care (Title III-D Program)

The Bridge Model (Bridge) is a social work based transitional care model designed for older adults discharged home from an inpatient hospital stay. Bridge helps older adults to safely transition back to the community through intensive care coordination that starts in the hospital and continues after discharge to the community. Bridge emphasizes collaboration among hospitals, community-based providers, and the Aging Network in order to ensure a seamless continuum of health and community care across settings. It does not add another layer or silo of care, but rather connects existing silos to assist older adults and their caregivers who are transitioning across the continuum of care. Bridge is the only widely-replicated model of transitional care that is explicitly social worker led.

Bridge employs master’s prepared social workers, called Bridge Care Coordinators (BCCs) to coordinate post-discharge older adult care and integrates Aging Resource Centers (ARC) inside hospitals. The ARCs provide a dedicated space for older adults and their caregivers to explore community resources, health information and caregiving materials, and to develop community care plans prior to discharge.

The model emphasizes six principles, including social determinants of health, community-specific focus, and hospital-community collaboration. Bridge Care Coordinators apply a thorough social work assessment to address the many biopsychosocial factors that may challenge clients and their caregivers in their transition home and back into their communities.

  • Program Goals:
    • -Bridge emphasizes collaboration among hospitals, community-based providers, and the Aging Network in order to ensure a seamless continuum of health and community care across settings.

 

  • Target Audience:
    • -Older adults and their caregivers who are transitioning across the continuum of care

 

  • Program Description:
    • -Bridge is designed to be adapted to fit each site’s unique client population and workflow.
    • -The one-day, in-person replication training is geared toward all levels of staff who will be involved with program implementation, from directors to managers to clinicians.

 

  • Program Delivery:
    • -Social Worker Led

 

Contact information

Texas Programs

Reference Material