Whether you are a patient or caring for someone who is, returning home after a hospital stay can be a stressful and challenging time. New diagnoses, changes in medications, appointments, and new resources... The Bridge Model was created to help you stay on top of your needs by helping you to organize and access follow-up care, teach you how to manage it effectively, and provide support for all the frustration you may be experiencing.

If your hospital does not offer Bridge, encourage your physicians or discharge planners to visit this site so future patients may benefit. In the meantime, here are some helpful recommendations and national resources:

  • Understand the discharge plan *before* you leave the hospital. Don’t be afraid to ask your discharge planner to explain it to you as many times as you need.
  • Schedule all of your post-discharge appointments as soon as possible (most may even be scheduled before leaving the hospital) and keep in mind how you plan to travel to and from these important follow-up appointments.
  • Make sure that you understand and have access to your medications. Pay special attention to any medication changes and what your insurance is able to cover.
  • Think of your home and your normal daily routine. Now that you are coming home, will you be able to do things the same way as before? If not, what kind of supports will you have in place? In most areas of the country, there are many community agencies that can help (see the “Eldercare Locator” link below).
  • Don’t lose sight of your mental health! Whether you are a patient or caregiver, it is very normal to experience frustration, anxiety or depression related to your health or to being a caregiver. Please take care of yourself and don’t be afraid to ask for help. Many caregiver support resources are listed below.

Helpful links:
Discharge Planning Checklist
Next Step in Care
Discharge Planning How-To
Eldercare Locator
Free CARE Act Wallet Card

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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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Telephone:
(312) 563-0260
E-mail:
info@transitionalcare.org