Patient outcomes cannot be improved by the medical system alone.  Patients and their families must become engaged in their own health and learn how to more effectively utilize primary care and community-based supports.  The Bridge Model is relationship-based, patient-centered approach to intervening with discharged patients.  In addition to the intervention itself, model training also focuses on operational workflow redesign, performance dashboarding, and effective administration tools to ensure longevity and sustainability.

Bridge is driven by master’s-prepared social workers who meaningfully engage the patient by getting to know their strengths and preferences.  These care coordinators then leverage this relationship as they play quarterback in the patient’s care – identifying unresolved needs and connecting relevant post-acute providers to resolve gaps in care.  Throughout the intervention, Bridge care coordinators integrate psychotherapeutic techniques in order to engage patients and families and improve their self-efficacy.

Though the Bridge model is largely implemented by social workers, many other disciplines have also been trained since 2005, including nurses, community health workers, case managers, and administrators.


4 categories of tools help ensure quality and fidelity:


Daily intervention and fidelity


Key information at a glance


Focus on continuous improvement


Effective model management

Bridge serves adults 18 and over with complex chronic health and social needs, as well as their caregivers. Subpopulations served with Bridge with past or ongoing evaluations, include:

  • Older adults and caregivers
  • Medicaid beneficiaries
  • Super-utilizers
  • Patients with cognition decline, dementia, Alzheimer’s
  • Patients discharged from SNFs
  • Uninsured
  • Patients discharged with home health
  • Hospice patients

Over 100 sites have been trained in the bridge intervention including:

  • Hospitals and hospital systems
  • Community based organizations
  • Community health centers
  • Home health agencies
  • Skilled nursing facilities
  • FQHCs

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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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