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Our Goals | Patient Profiles | Role of Bridge Coach | National Model, Local Impact

Bridge Care Transition Program CC2019-03-05T04:32:31+00:00

Overview

CRIS Healthy-Aging Center has partnered with local hospitals in Champaign and Vermilion County to assist qualified individuals in the transition from hospital to home. This program is provided at no cost to the participant.

What We Do

A Bridge Care Transition Coach will assist with developing a personal health record, making/keeping doctor’s appointments, managing medication and identifying additional community resources. Our mission is to help our area residents live a stronger, healthier life by reducing readmissions and increasing access to resources.

Our Goals

1. To improve the transition of clients from the inpatient hospital setting to other care settings.
2. To maintain or improve quality of care
3. To reduce readmissions for high-risk beneficiaries
4. To document measurable savings to the Medicare program

Patient Profiles

  • Congestive heart failure (CHF)
  • Chronic obstructive pulmonary disease (COPD)
  • Atrial fibrillation (Afib)
  • Chronic kidney disease (CKD)
  • Coronary artery disease (CAD)
  • Diabetes (DM)
  • End-stage renal disease (ESRD)
  • Pneumonia
  • Stroke (CVA/TIA)
  • Hypertension (HTN)
  • Heart attacks (MI/AMI/NSTEMI/STEMI)
  • Major joint replacements (e.g., hips, knees)

The Role of the Bridge Care Transition Coach

Coaches are stationed in the hospital and identify patients at high risk for readmission.

  • Review hospital census daily
  • Review electronic medical records, medical charts, history & physicals
  • Act on referrals from all hospital staff, including social workers and care management
  • Visit patient in the hospital and discuss benefits of 30 day program with the patient
  • Call or visit Bridge patients at least 3 times, within targets of 2, 7, and 30 days of discharge

National Model, Local Impact

Bridge is a widely-replicated, evidence-based, social work-led model for transitional care. It does not add another layer of care; rather, it connects existing silos to address barriers to independence and meet the patient’s needs after discharge. The national model demonstrates lower 30-day readmission rates, increased attendance of post-discharge appointments, and lower patient and caregiver stress.