Presentation from the Illinois Transitional

1. The Bridge Model
An Innovative Social Work Model of Transitional Care
Aging in America Conference
Washington, D.C. – March 29th, 2012

2. Agenda
I. Welcome and Introductions
II. Bridge Model Overview and Process
III. Research and Evaluation
IV. Unique Components of the Bridge Model
V. Rural Implementation
VI. Policy and Health Systems Implications

3. The Illinois Transitional Care Consortium
 Community-based organizations
 Aging Care Connections
 Shawnee Alliance for Seniors
 Solutions for Care
 Hospitals
 Rush University Medical Center
 MacNeal Hospital
 Adventist LaGrange Memorial Hospital
 Herrin Hospital
 Memorial Hospital of Carbondale
 Research, Evaluation & Policy
 University of Illinois at Chicago, School of Public Health
 Health & Medicine Policy Research Group

4. Bridge Model Overview & Process
Walter Rosenberg, Rush University Medical Center – Health &
Aging

5. Basic Definitions
 What is care
coordination?
 What is transitional
care?
 What is social work?

6. Core competencies
 Engagement and
assessment
 Resource linkage
 Self-management
support and education
 Counseling
 Team interaction
 Care coordination

7. Why Social Work?
 Why do readmissions take place?
 Root cause analysis
 Medical
 Psychosocial
 Existing resources or redundant resources?
 Geriatric Interdisciplinary Team Training (GITT)
 Rush post-graduate course
 “The Glue”
 Reintroduction to healthcare
 Putting social work back on the map

8. Root Cause Analysis
 Hospital-level
 Chart reviews
 Interdisciplinary focus groups
 Individual interviews
 Community-level
 Identify community providers
 Interdisciplinary focus groups
 Individual interviews

9. Bird’s eye view
Pre-Discharge Post-Discharge 30-day follow-up
• Referral • Assessment • Confirm long-
• Assessment • Connection to term support
• Information providers structure
gathering • Psychosocial • Collect data
• Community support
resources
• Decreased readmissions
• Decreased mortality
• Increased physician follow-up
• Increased understanding of medications
and discharge plan
of care
• Decreased patient and caregiver stress

11. Quick information
 Telephonic
 5-6 calls over a period of 5-6 days
 Calls made to:
 Client/caregiver
 Primary care
 Hospital of origin
 Pharmacy
 Community-based organizations

12. Target Population
 Must have all of the below
 60+
 Chronic condition
 Previous hospitalization within
6 months
 Must have at least one of the
below
 Discharged with home health
 Living alone
 Discharged to a skilled nursing
facility
 Current practice
 Expanded demand and
realistic pressures

13. Assessment domains
 Common Problem Areas
 Transition/Discharge Plan
 Home Health
 Follow-up Medical Care
 Medication Management
 Self-Management
 Psychosocial

14. Pre-discharge
The participant enters Referrals can originate Preparation for
the hospital with more from an electronic discharge must include
than an illness. medical record, a as broad a picture of
discharge planner, the Pre-
the patient/consumer as
•Caregiver patient or a family possible
•Family Referral
member.
Discharge
•SESHospital Assessme
•Discharge plan of care
•Race
Admission (Target
•Risk screen built in to •Community resources
nt and
•Gender Population)
the EMR •Systemic challenges
Interventio
•Ethnicity •If non-hospital staff, •Community physicians
•Religion requires access to the n
•Interdisciplinary team
•Mental Health EMR •Essential information
•Personal Values and •Balance between
Beliefs consistency and
flexibility

15. Post-discharge
Walking through the The map is not the Longer term
house doors, one walks territory. What involvement to ensure
back into their real life changed? How can we the patient/consumer
help?
Post- remains connected
•Caregiver
•Family Discharge
•Understanding of •Still connected to
•SES Back Assessme
discharge plan of care 30-day
necessary resources?
•Race •Understanding of •Quality assurance
Home
•Gender
nt and
medications
Follow-up
•Emotional support
•Ethnicity Interventio
•Follow-up on (30% re-contacts post-
•Religion n
community resources intervention)
•Mental Health •Ensure physician
•Personal Values and follow-up
Beliefs •Caregiver support
•Emotional support

16. A Case Example
 Mrs. Harrison
– Widowed
– 75 years old
– Has diabetes and COPD
 Admitted through the ED after a fall
– Hospitalized for 5 days
– Discharged with home health care
– 10 medications prescribed

17. Mrs. Harrison at Home
Community PCP doesn’t
know Mrs. Harrison was
Is this the
Mrs. Harrison is afraid
she will fall again and
Mrs. Harrison’s primary
caregiver is
have to return to the overwhelmed and has to
Mrs. Harrison doesn’t
worst case
admitted to the hospital.
hospital. which medications to work.
know return
The Home Health Care
Agency doesn’t arrive on to resume and which to
time. stop taking at home.
Mrs. Harrison is feeling
Mrs. Harrison’s two
scenario,
Mrs. Harrison is having children can’t agree how
difficulty coping with her
mobility changes.
Mrs. Harrison has
to best manage their
mother’s medical needs.
depressed because she
can’t get around
anymore like she used
to.
Mrs. Harrison can’t
questions about her
or is it
medical bill and doesn’t
afford her medications
anyway.
know what her insurance Harrison is feeling
Mrs. Harrison has no Mrs.
a typical transition?
will cover.
transportation to her
follow-up medical
appointments.
isolated now that she’s
homebound.
Mrs. Harrison’s
Community Services are
delayed

18. Mrs. Harrison is afraid Mrs. Harrison’s primary
Community PCP doesn’t
Contact Community PCP Facilitate home Support caregiver and
caregiver is
she will fall again and
know Mrs. Harrison was
to inform of Mrs. evaluation by Home listen to concerns. Link
have to return to the overwhelmed and has to
Mrs. Harrison doesn’t
admitted tohospital stay.
Harrison’s the hospital. Health Care Agency. communication resources.
Facilitate to community
Call
The Home Health Care know which medications to work.
hospital. with pharmacy, return
Agency doesn’t arrive on
Agency to troubleshoot to resume and which to
prescribing physician,
Mrs. Harrison
Work with Home Health
Care Agency and
difficulty coping with her
Communicate home at home.
and taking Mrs. Harrison is feeling
stop
scheduling issues. Mrs. Harrison’swith health nurse.
time.
How does Bridge help?
two
children to plan for
Mrs. Harrison is having children can’t agree how
immediate care needs.
to best manage their
Screen for supportive
depressed because she
mental health programs
can’t get around
physician to identify Refer to care or ongoing counseling
at Home
mobility changes. mother’s medical needs. anymore like she used
Refer Mrs. Harrison to management.
therapy needs. services.
Mrs. Harrison has to.
patient access Mrs. Harrison can’t
questions about her Connect to pharmacy
immediately and connect afford her medications
medical bill and doesn’t assistance program.
to Senior Health anyway.
know what her insurance Harrison is feeling
Mrs. Mrs. HarrisonProgramMrs. and connect to
Refer
Link Harrison has no
Insurance to Communicate with CCU
will cover.
(SHIP) Counselor isolated now that she’s case managerServices
transportation to her
medical transportation local friendly visiting Community to ensure
follow-up medical
resources and assist in homebound.
program. were delayed
prompt resumption or
appointments.
scheduling services. start of services

19. Research & Evaluation
Susan Altfeld, University of Illinois at Chicago – School of Public
Health

20. Preliminary data
 As of December 2011
 Midway through project
 DO NOT QUOTE OR CITE WITHOUT
PERMISSION OF ILLINOIS DEPARTMENT ON
AGING, ILLINOIS TRANSITIONAL CARE
CONSORTIUM AND SUSAN ALTFELD

21. The Bridge Model Evidence Base
 The Bridge Model is an adaptation of the Enhanced
Discharge Planning Program (EDPP)
 EDPP is an evidence-based model developed and
evaluated with a randomized-controlled trial at Rush
University Medical Center (ITCC partner)
 Bridge implements the evidence based components
of EDPP and best practices developed by ITCC
partner sites
 Bridge is a hospital and community partnership
 Illinois Department on Aging and AgeOptions partnership
for Community Based Care Transitions through
Administration on Aging

22. Evaluation of the Bridge Model
 Important variables from our previous work and other
evidence based care transitions interventions
 Patient characteristics
 Health status
 Patient stress
 Caregiver stress
 Understanding of responsibilities for managing health
 Medical follow up
 Hospital readmissions
 Mortality
 Satisfaction

23. Evaluation data collection - ITCC Bridge
 Intake assessment
 2 day post discharge assessment
 30 day follow up assessment
 Satisfaction survey
 Both “patient” and “caregiver” versions of the
assessment surveys
 Telephone
 Email /telephone satisfaction surveys
 Readmissions and mortality data from Medicare
through the Quality Improvement Organization in
Illinois

24. Evaluation of the Bridge Model
 Who are our participants?
 3090 participants at 5 sites across Illinois
 May 2010-December 2011

25. Bridge client demographics
 Preliminary data May 2010-December 2011
 Research sample (N=519)
Male 29.7%
75+ 63.5%
Living alone 44.7%
Non-English speaking 12.3%
Minority/”non-White” 29.1%

26. 2-day post-discharge assessment
 Older adult client’s health
 At this time, how is your health?/ how is (Mr./Ms. patient
last name)'s health?)
Excellent
2.2%
Very good 18.3%
Good 46.8%
Fair 26.2%
Poor 6.4%

27. 2-day post-discharge assessment
 Older adult (patient) stress
“Since I left the hospital, managing my needs has
been stressful for me”
34.4%

28. 2-day post-discharge assessment
 Caregiver stress
“Since (older adult patient) left the hospital, has
managing his/her needs been stressful for you?”
52.2%

29. 2-day post discharge assessment
 Understand medications
 “I understand the purpose of each of my
medications and how to take each of them”
95.5%

30. 2-day post discharge assessment
 Understand symptoms/”red flags”
 “I understand what symptoms I need to watch
out for”
95.5%

31. 2-day post discharge assessment
 Cue to action
“I understand who to call if these symptoms
occur”
98.0%

32. 2-day post discharge assessment
 Problems/“Surprises”
 “Are things more difficult than you expected
since leaving the hospital, less difficult or about
what you expected?”
More difficult 23.5%
Less difficult 12.1%
As expected 64.4%

33. 30-day outcomes patient follow
up/adherence
Physician visit within 30 days of discharge
84.7%

34. 30-day outcomes adverse events
Mortality
1.7%

35. 30-day outcomes adverse events
Readmissions
Awaiting report

36. 30-day outcomes adverse events
Nursing home placement
3.0%

37. Satisfaction survey
 Decision making
“The assistance or information you received from the
Bridge Program helped you (or your loved one) make
decisions about your care.”
84.7%

38. Satisfaction survey
 Links to community services
“The assistance or information you received from the
Bridge Program helped you (or your loved one) connect to
services and resources.”
77.9%

39. Satisfaction survey
 Patient stress
 “The Bridge Program helped to make the hospital
discharge experience less stressful for you/ (the patient).”
90.9%

40. Satisfaction survey
 Caregiver stress
 “The Bridge program helped to make the hospital
discharge experience less stressful for family or other loved
ones.”
97.8%

41. Satisfaction survey
 Satisfaction
 “I would recommend this program to others.”
89.5%

42. Satisfaction Survey - Quotes
Satisfaction
Unmet needs/anything you would change/what did you like about the
Bridge Program?
“I like everything about the Bridge Program.”
“You are providing a great service.”
“I would like it to be much more advertised for everyone
wherever they live.”
“It would be nice for everyone to receive the services like
my father.”
“I cannot think what else the social worker could have done
additionally since she was very helpful throughout ….”

43. Unique Components
of the Bridge Model
Ilana Shure, Aging Care Connections – Aging Resource
Center

44. Unique Components of the Bridge Model
 Social work model
 Builds off of the aging network
 Bridge requires a true partnership between the
community-based organization and the hospital
 The community-based organization is in the leadership
role

45. Bridge Care Coordinator Qualifications
 Master’s in social work
 Expertise in geriatric field
 Strong clinical and advocacy skills
 Experience in both community and hospital settings
 Knowledge of state, federal and community
resources

46. Aging Network
• Administration on Aging & Older
AoA Americans Act
• State Unit on Aging
SUA
• Area Agency on Aging
AAA
• Care Coordination Unit (Unique to Illinois)
CCU

47. AAAs are Your Community Service Experts
• Adult Day Care
Medicaid • Case Management
Waiver • Emergency Home
Program Response
• In-home Services
• Home Delivered Meals
Older • Caregiver Support
Area Agencies on Americans Services
Act • Transportation
Aging Services • Information and
Assistance
Private • Counseling
and /or • Ethnic Resources
Volunteer • Community-specific and
Services local

48. Connecting to Community-based Services
Assessment of need
Set-up services based on assessment (eligibility
and application); including caregiver support
Benefits Check-Ups (receiving all eligible
benefits)
Provide information & assistance for older
people and their families

49. Aging Network – a critical tool in the Bridge
toolkit
 Identifying older adults in the hospital who are at-risk
for potential adverse events post-discharge
 Connecting the hospital and the older adult to the
existing Aging Network (home and community-based
resources)
 Reduce the risk of adverse events  reduce re-
hospitalizations

50. Complementing the Aging Network
 The Aging Network provides an important safety net.
Here are other areas critical to successful transitions
addressed by Bridge:
 Transition/Discharge Plan complications
 Home Health – systemic and client-level issues
 Follow-up Medical Care
 Medication Management
 Self-Management
 Psychosocial complications

51. Who are Your Transitional Care Partners?
Hospital
Hospital – Aging
Network collaboration
Non- Primary
traditional Care
Resources Physician
Pharmacy AAA Home
Health
Skilled Community
Nursing Based
Facility Agencies
Caregivers

52. Working Together
 Recognize the differences between cultures
 We come from different perspectives and have
different languages
 What does MI mean to you?
 Working together you encounter a lot of “Why a Duck?”
situations…
 Address concerns early and troubleshoot problems
together
 Share both successes and challenges

53. Culture Change is a Challenge
 Integrate at all levels of
the hospital system
 Front desk reception to
Regional Director
 Be patient and persistent
 Guest versus Team
Member
 Troubleshoot challenges
before they become
barriers
 Learn both cultures and
languages
 Network, network, network

54. The Aging Resource Center (ARC) On-Site at the
Hospital
 Physical office space for the Bridge Care
Coordinators (BCCs) to receive referrals and access
hospital and community records
 A library of resources for Bridge clients and
caregivers
 Space for the BCCs to collaborate with the
interdisciplinary team
 A location for the BCC to meet with Bridge clients
and their families to discuss community-based
resources available
The ARC is an on-site hospital location for the Bridge
Program. The establishment of an ARC symbolizes
the commitment of both partners to sustaining
Bridge.

55. The Role of the ARC
 Symbol of hospital-community collaboration
 Greater ability to interface with the community
 Promotes the notion of “systems” approach to discharge
planning
 Maximizes the opportunity for a servable moment

56. Benefits of the ARC
 Time and expertise to focus on participant and the
transitional process
 Community expertise
 The transition happens fast and the BCC has to
know how to put all of the pieces together in an
expedited manner to ensure a safe transition home.
Not only does the BCC need to know the unique language,
values, and perspectives of the client and family but also
what services and resources are available to the
individual.

57. Rural Implementation
of the Bridge Model
Amanda Groaning, Shawnee Alliance for Seniors

58. Shawnee Alliance for Seniors
 Shawnee Alliance for Seniors, an Illinois Care
Coordination Unit, serves the southernmost counties
of Illinois
 An entirely rural area roughly 4,557 square miles
 The largest community, Carbondale, has 20,000 residents
 20.5 % of population in the lower 13 counties is over the age of 60

59. Shawnee Alliance for Seniors (con’t)
 Shawnee utilizes BCCs with experience working in
the rural area and have a sensitivity to and
awareness of issues specific to rural elders,
including:
 Limited access to care
 Literacy and Language Barriers
 Geographic and Social isolation
 Extended family such as neighbors and friends often must step in when
the elder has no family members living in the immediate area

60. Problems Facing Seniors in Rural Areas
 Limited Access to Care
 Distance
 5 out of the 13 counties do not
have hospitals
 Most seniors face at least a 30
minute drive to access basic
services
 Limited public transportation
services
 Lack of Resources
 Smaller populations means less
funding for services
 Emergency and Specialty needs
referred out of the area

61. Literacy and Language Barrier
 Limited Education
 Due to need to work
 Gender bias
 Disability
 Language Barrier
 Limited access to interpreters
 Few resources and materials
 Reliance on Family as translator

62. Geographic and Social Isolation
 Pros  Cons
 Community support  Isolation from resources,
 Extended family family, and friends
 Better communication and  Dependence on non-family
relationships between supports that are not always
agencies who are sharing reliable
clients  Higher risk for burn-out and
caregiver stress

63. Role of the Bridge Care Coordinator
 What does a BCC bring to the table?
 Integration of community resources in the
hospital
 On site materials and direct access to the
Bridge Care Coordinator
 Expanded access to care for clients and
caregivers
 Education to hospital staff
 Breadth of post-discharge support

64. Initial Bridge Assessment
 Medical record review
 Patient set up with in home services to assist with care
 Home delivered meals were arranged for 5 days a week
 Health education for his diabetes
 Medication management
 Transportation

65. 2-day follow-up
 Medications management
 Health Education for diabetes
 Concerns over bathing, possible need for DME
 New financial concerns over electrical bill

66. 30-day follow-up
 Transportation
 Possible financial exploitation

67. Policy and Health Systems
Implications
Kristen Pavle, Health & Medicine Policy Research Group – Center LTC
Reform

68. Transitional Care: Integrating Medical and Social
Models of Care
 Medical models of care
do not sufficiently cover
an individual’s
comprehensive needs,
but health care is
typically categorized and
reimbursed as a medical
commodity
 Culture Change
 Systems Change
 Bridging silos of care
http://amandabauer.blogspot.com/2010/03/romantic-circles-by-kandinsky.html

69. How do we A Systemic Look at a
coordinate this care Transitional Care Event
transition?!
Care
Coord
-inator Hospital Community Health Insurer
http://magicofteams.wordpress.com/2010/12/02/silos-firm-they-stand/

70. Transitional Care, Health Reform, and
Community Involvement
 Affordable Care Act
 Aging & Disability Resource Center Care Transitions
Grant
 Providing Aging & Disability Resource Centers (community-
based organizations) an opportunity to participate in a nation-
wide care transitions network
 Sharing best-practices
 Highlighting community (ADRC) and hospital partnerships
 Provisions 3025 & 3026 (next slide)

71. Affordable Care Act Provisions 3025 and
3026
 Section 3025 - The
“Stick”
 Withholding total Medicare
reimbursement rates up to
3% for high readmission
rates.
 Section 3026
Community-based Care
Transitions Program –
The “Carrot”
 Contracting with CMS to
provide fee-for-service
care transition services
through Medicare
 $500 Million, several
contracts/projects already
http://hrfishbowl.com/2010/12/your-carrot-needs-more-stick/
accepted

72. 3026 Impact on Integrating Medical & Social
 Over the next 5 years, Mathematica and the Lewin
Group will be evaluating the Community-based Care
Transitions Program through a contract with CMS
 Will this opportunity contribute to a change in the
health care system as we know it?
 Bridging silos? Bridging hospital and community? Holding
different entities across the care continuum accountable
for quality outcomes in care?

73. Bridge Model and 3026
 The Bridge Model has been used in two Community-
based Care Transitions Program proposals that have
been accepted
 Illinois: “Bridge Transitional Care Partnership”
 Illinois Transitional Care Consortium partnership with
AgeOptions (suburban Cook County AAA/ADRC)
 Pennsylvania: “Philadelphia Bridge Care Transition
Program, North Philadelphia Safety Net Partnership”.
 Philadelphia Corporation for Aging, Einstein Medical Center
Philadelphia, Temple University Hospital

74. Opportunities for Bridge Model Training
 The Illinois Transitional Care Consortium offers a
training package to agencies/hospitals interested in
replicating the Bridge Model
 Full-day, in-person training
 Follow-up consultation via conference calls over 3-months
post-training
Bridge
Model
http://edutechnow.sharepoint.com/Pages/Training.aspx

75. http://www.eci.com/blog/archives/2011-10.html

76. Thank You to Our Funders & Partners

77. Contact Information
 Susan Altfeld (saltfeld@uic.edu)
 Amanda Groaning (agroaning@shsdc.org)
 Kristen Pavle (kpavle@hmprg.org)
 Walter Rosenberg
(walter_rosenberg@rush.edu)
 Ilana Shure
(ishure@agingcareconnections.org)
www.transitionalcare.org