Model Description

The hospital experience is taxing and confusing for patients and their families, particularly those with limited economic and social resources. This complexity often leads to disengagement, poor adherence to the plan of care, and high readmission rates. The Bridge Model is a person- centered social work-based, interdisciplinary transitional care intervention that addresses these challenges as it helps adults safely transition from the hospital back to their homes and communities.

The Bridge Model combines 4 key components—patient engagement and self-efficacy, primary care integration, appropriate use of community resources, and coordinated care that is weaved throughout effective clinical case management.

Result snapshots: We have demonstrated 30.7% readmission rate reductions.


Since 2005 we have refined four categories of tools to ensure proper model delivery, implementation, and administration:

  • Core Tools – Used daily in the intervention: Checklist, Intake, Assessment, Care Plan
  • Reference Tools – Used to guide the BCC along with psychotherapeutic techniques and evidence based protocols: Scripting, Diagnosis-specific questions, Psychotherapy cheat sheets, and Evidence-based screens
  • Clinical & Quality Tools – Used to support the BCC in complex clinical interventions and to ensure model fidelity: Readmission review, Case conceptualization, Care continuity form, and Fidelity check
  • Administrative Tools – Suggested templates used by supervisors to collect and report data Running list template, Dashboard template, Access database and Relationship tracking form

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 is designed to integrate into any health care system in order to address the taxing and confusing health care experience that often leads to disengagement and poor adherence to the plan of care. Read More

Contact Us
(312) 563-0260