Engaging Patients and Lowering Readmissions by Focusing on Transitional Care

TheBridgeModelBy Walter Rosenberg, MSW, LCSW; Manager of Transitional Care, Rush University Medical Center – Health and Aging; and
Jessica Grabowski, AM, LCSW; Program Manager, Transitional Care, Aging Care Connections

Hospital readmission rates in the United States are among the highest in the world. In 2011, there were 3.3 million 30-day readmissions to the hospital, which contributed more than $41 billion in hospital costs. Medicare patients accounted for $26 billion of these costs, and $17 billion of these Medicare readmission costs were deemed avoidable by the Center for Health Information and Analysis (CHIA). With all of the money that readmissions are costing the hospital system, it’s important to look at a vital, yet often undervalued, factor in reducing readmissions: transitional care.

Transitional care focuses on the coordination and continuity of care as a patient moves from one care setting to another. When it is available, transitional care is most often provided in the immediate post-hospital discharge timeframe. A number of breakdowns and challenges are common during this period. Interdisciplinary collaboration is frequently thwarted by poor health information exchange and few financial incentives or venues for provider-to-provider communication. Community-based providers and services are typically left out of the conversation entirely, and there is rarely a single “owner” of the transition process – no professional whose established responsibility is to monitor the patient and coordinate the care. In order to improve longer-term outcomes, the health care system must identify strategies to connect relevant providers and, importantly, to engage the patient and/or their caregiver in their own care.

The Bridge Model of Transitional Care prioritizes regular post-discharge engagement with patients to help them “land safely” in the community. Bridge Care Coordinators (BCCs) take a comprehensive approach to each patient’s care plan, in order to effectively advocate for the patient, facilitate communication with all medical- and non-medical providers, and incorporate psychotherapeutic techniques to encourage patient activation. There are three phases to the model:

  • Pre-discharge – Upon receiving a referral, BCCs review the electronic medical record and conduct a bedside visit, which focuses on developing rapport with the patient. During this phase, BCCs will also attend interdisciplinary rounds or participate in multi-provider Care Coordination Calls.
  • Post-discharge – One to two days after discharge, BCCs conduct a comprehensive biopsychosocial assessment to identify gaps in care. They remain actively involved for the next 30 days, as they work to stabilized all the identified needs. A number of standardized social work-based and quality improvement tools are utilized during this phase of the intervention.
  • Termination – Once identified needs have been stabilized, the patient is gently transitioned to longer-term supports, including their primary care physician and community-based case managers.

Over 50 sites currently replicate the model nationally. For six hospitals that implemented Bridge as part of a single Medicare Community-based Care Transitions Program (CCTP), readmissions decreased substantially. 30-day readmission rates dropped by more than 30 percent – and in 90 days, readmissions were down nearly 14 percent. It’s clear that providing patients with personalized care outside the hospital walls is vital to keeping a clear and strong path of communication between patients and their medical- and non-medical providers. By integrating transitional care models into the regular operations, hospitals may be able to not only improve patient outcomes, but reduce costs and readmission rates.

This article was originally published on The Connected Clinician and is republished here with permission.