A care transitions model that bridges the gap for patients with social-environmental barriers to better health management has expanded to more than 50 sites across the country.

  • The Bridge model’s success includes dramatic decreases in 30-day readmissions among Medicare beneficiaries.
  • The Bridge model also reduced 60-day and 90-day readmission rates and resulted in a decline in the number of high utilizers at Rush University Medical Center in Chicago.
  • The program has social workers conduct a comprehensive, bio-psychosocial assessment, and goals include care coordination, case management, and patient engagement.

A care transitions program that relies on social work principles has resulted in a huge drop in 30-day readmissions: from more than 100 among a high-utilizer cohort to a handful. It also significantly reduced the number of Medicare high-utilizers at an academic medical center.

Building on a strong community mission, Rush University Medical Center in Chicago created Bridge, a model that brings social work core competencies to the transitional care environment. The program, started a decade ago, targets at-risk Medicare beneficiaries, including the high-utilizer population that accounts for nearly half of hospital readmissions, says Walter Rosenberg, LCSW, manager of transitional care, health, and aging at Rush University Medical Center.

“We have 1,000 Medicare discharges every month,” he says. “We wanted to support patients who came home from the community.”

A recent six-month analysis looked at 456 high utilizers at Rush and found that pre-Bridge, the 30-day readmissions were 29.1%, while the 30-day readmissions after Bridge was implemented were 11.3%. Emergency department visits and post-discharge no-shows also declined, Rosenberg says.

A separate analysis of Medicare patients in a two-year demonstration project found the following, according to Rosenberg:

  • The Bridge program’s results from 2012 to 2014 showed 31% fewer 30-day readmissions.
  • Results also showed a 60-day readmission rate that was 9.4% fewer than the weighted hospital average, and a 90-day readmission rate that was 13.9% fewer.
  • The number of Medicare high utilizers at Rush declined from a peak of 282 in September 2014, to 249 in February 2015, a nearly 12% decrease.

In 2006, the health and aging department began to pilot making telephone calls to recently discharged patients, contacting over 2,500 over the next two years.

“People were confused, anxious, depressed, you name it, and we were a department of social workers. So we asked, ‘How do we support these patients better?’” Rosenberg says.

Rush researchers completed a randomized, controlled trial about the program at the same time the Affordable Care Act (ACA) became a reality, a stroke of good luck in timing, he notes.

“We were able to call ourselves ‘evidence-based,’ and the next thing we know, we had a lot of people reaching out to us, asking for training,” Rosenberg says. “Now we have 55-66 sites across the country, implementing the model.”

The Bridge model consists of the following three basic parts:

Pre-discharge phase: Social workers conduct a medical review at each referral. An electronic database generates a daily list of patients who could benefit from Bridge based on their risk factors, Rosenberg says.

“Then we connect with the interdisciplinary team and collaborate with discharge planners and conduct a care continuity call,” he explains. “The purpose is to connect a clinician from the inpatient side — either a hospitalist or resident — with an outpatient provider like a primary care provider or specialist.”

A case manager makes the care continuity call with Bridge care coordinators, leading the informal, 10-minute call with the goal of identifying all of the patient’s needs.

Then, social workers visit the patient at bedside, spending as much as 30 to 40 minutes. Their goal is to connect with each patient and strip away barriers to the patient’s health self-management, Rosenberg says.

“The big picture is we want to connect with the patient on a human level, so we have a conversation about the patient’s goals, ambitions, interests, hobbies, and family situation,” he explains. “We want to know what the nonmedical picture is of this person and who the person is in terms of motivation and the kinds of things they look forward to.”

The nonmedical information is used after discharge as a way to put the patient’s medical problems into a social context. This type of information can be crucial to helping to change a person’s behavior and activities to enhance health, he says.

“There’s this notion that if we write prescriptions and tell patients what to do with them, they’ll do it because it’s important to them,” Rosenberg says. “But they go home and real life takes over, and the next thing you know, they’re not taking medications.”

There are more compelling motivators than improving one’s health, he notes.

“We find out that people can be motivated by TV shows, board games, grandkids, and gardening,” he explains. “So we will say, ‘Mrs. Johnson, you should take your medication so you can get back to gardening.’”

Post-discharge phase: A first visit post-discharge could be via phone or in person. While in-person visits are more costly, they’re also likely to result in richer data, Rosenberg says.

Organizations that replicate Bridge might choose phone visits because they are easier to implement, and they can obtain additional data from other providers, such as home health and community-based care providers, who visit patients’ homes, he says.

“In 50% of cases, we work primarily with caregivers and have another set of eyes and ears on the ground,” Rosenberg says.

At first post-discharge contact with patients, the intent is to conduct a comprehensive, bio-psychosocial assessment. “We want to find out what needs to be stabilized immediately on the medical side,” Rosenberg says.

Goals include care coordination, case management, and patient engagement, including answering the following questions:

  • Does the patient have his/her appointment scheduled?
  • Does he/she have a way to get to the appointment?
  • What is the patient’s understanding of the appointment?
  • Has the patient been connected to resources?
  • Did the patient show up for the medical appointment?
  • Did the scheduled home visit occur?

When working with patients, social workers use psychotherapeutic techniques and motivational interviewing, Rosenberg says. “We use cognitive behavioral therapy and techniques from those approaches to try to impact patient engagement.”

It’s not enough to schedule appointments for patients or to hand them brochures with medical information. There has to be follow-through, Rosenberg says.

So for the first 30 days post-discharge, the care team learns more about patients, has conversations about what motivates them, and checks in with them at least weekly, he adds.

Termination phase: “This is ongoing, and it starts at the beginning,” Rosenberg says. “It’s very difficult to terminate these cases because patients really like the support: Here’s someone listening and helping, and it’s very hard to say ‘goodbye.’”

However, a transitional care program is for 30 days, he adds.

“We want to make sure there’s a connection to long-term services and support, so by the time of the last phone call, there have been several critical phone calls leading up to that one,” Rosenberg says.

The next to last calls involve making sure patients understand everything they need to do to stay healthy and how they can obtain community resources: “We want to hammer home the importance of primary care,” he says.

“We essentially want to make sure patients understand all the components before we let them go and disengage ourselves from them,” Rosenberg says.