About The Bridge Model

The Bridge Model National Office (BMNO), originally known as the Illinois Transitional Care Consortium (ITCC), was founded by six partners working with older adults across sites in urban, suburban, and rural communities in Illinois. BMNO member organizations include hospitals, community-based organizations in the Aging Network, a large urban medical center and medical school, and a health policy research think-tank. The geographic, socioeconomic, and cultural diversity of its member organizations has enabled a variety of best practices to inform the development of a social work-based model of transitional care: the Bridge Model. In addition to BMNO’s commitment to national Bridge Model implementation, BMNO members also regularly participate in national discussions around transitional care needs that translate into ongoing model quality improvements.


Bridge was created in 2005 in collaboration between an academic medical center (Rush University Medical Center) and a community-based organization (Aging Care Connections). Both sites saw that patients discharged from the hospital were encumbered by much more than their diagnoses. They saw that patients and families were struggling with understanding their plan of care and navigating the complex health care system, they were becoming disengaged, often unmotivated or incapable of managing their own acute and chronic conditions, and they were unaware of the breadth of community resources available to support them.

Over the next two years, Rush and Aging Care Connections (ACC) piloted using social workers as transitional care support staff. They discovered that social work was an incredible fit for transitional care. They know how to provide care coordination, how to engage patients in their own care, how to connect siloed care providers together, and how to leverage appropriate community resources.

The successful pilot period led to a randomized controlled trial, promising results, multiple quality improvement updates, state and then national attention, and now – 13 years later – to over 100 trained sites across the country and in Canada.

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The Bridge Model integrates into any health care or community-based organization in order to improve health care outcomes for recently discharged patients. Read More

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