The Bridge ModelAn Innovative Social Work Model of Transitional Care

Aging in America ConferenceWashington, D.C. – March 29th, 2012

AgendaI. Welcome and IntroductionsII. Bridge Model Overview and ProcessIII. Research and EvaluationIV. Unique Components of the Bridge ModelV. Rural ImplementationVI. Policy and Health Systems Implications

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

Bridge Model Overview & Process

Walter Rosenberg, Rush University Medical Center – Health & Aging

Basic Definitions What is care

coordination? What is transitional

care? What is social work?

Core competencies Engagement and

assessment Resource linkage Self-management

support and education

Counseling Team interaction Care coordination

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

Root Cause Analysis Hospital-level

Chart reviews Interdisciplinary focus groups Individual interviews

Community-level Identify community providers Interdisciplinary focus groups Individual interviews

Bird’s eye viewPre-Discharge

• Referral• Assessme

nt• Informatio

n gathering

• Community resources

Post-Discharge

• Assessment

• Connection to providers

• Psychosocial support

30-day follow-up

• Confirm long-term support structure

• Collect data

• Decreased readmissions• Decreased mortality• Increased physician follow-up• Increased understanding of medications and discharge plan of care• Decreased patient and caregiver stress

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

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

Assessment domains Common Problem

Areas Transition/Discharge

Plan Home Health Follow-up Medical Care Medication

Management Self-Management Psychosocial

Pre-discharge

Hospital Admissio

n

Referral(Target

Population)

Pre-Discharg

e Assessment and

Intervention

The participant enters the hospital with more than an

illness.

•Caregiver•Family•SES•Race•Gender•Ethnicity•Religion•Mental Health•Personal Values and Beliefs

Referrals can originate from an electronic medical record, a discharge planner, the patient or a family member.

•Risk screen built in to the EMR•If non-hospital staff, requires access to the EMR•Balance between consistency and flexibility

Preparation for discharge must

include as broad a picture of the

patient/consumer as possible

•Discharge plan of care•Community resources•Systemic challenges•Community physicians•Interdisciplinary team•Essential information

Post-discharge

Back Home

Post-Discharg

e Assessment and

Intervention

30-day Follow-up

Walking through the house doors,

one walks back into their real life

•Caregiver•Family•SES•Race•Gender•Ethnicity•Religion•Mental Health•Personal Values and Beliefs

The map is not the territory. What

changed? How can we help?

•Understanding of discharge plan of care•Understanding of medications•Follow-up on community resources•Ensure physician follow-up•Caregiver support•Emotional support

Longer term involvement to

ensure the patient/consumer

remains connected

•Still connected to necessary resources?•Quality assurance•Emotional support (30% re-contacts post-intervention)

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

Mrs. Harrison’s two children can’t agree how to best manage

their mother’s medical needs.

Mrs. Harrison at HomeCommunity PCP

doesn’t know Mrs. Harrison was

admitted to the hospital.

Mrs. Harrison’s primary caregiver is

overwhelmed and has to return to work.The Home Health

Care Agency doesn’t arrive on time.

Mrs. Harrison has no transportation to her

follow-up medical appointments.

Mrs. Harrison doesn’t know which

medications to resume and which to stop taking at home.

Mrs. Harrison’s Community Services

are delayed

Mrs. Harrison has questions about her

medical bill and doesn’t know what her insurance will

cover.

Mrs. Harrison can’t afford her

medications anyway.

Mrs. Harrison is having difficulty coping with her

mobility changes.

Mrs. Harrison is feeling depressed

because she can’t get around anymore like

she used to.

Mrs. Harrison is feeling isolated now

that she’s homebound.

Mrs. Harrison is afraid she will fall again and have to return to the

hospital.

Is this the worst case scenario,

or is it a typical

transition?

Mrs. Harrison’s two children can’t agree how to best manage

their mother’s medical needs.

Community PCP doesn’t know Mrs.

Harrison was admitted to the

hospital.

Mrs. Harrison’s primary caregiver is

overwhelmed and has to return to work.The Home Health

Care Agency doesn’t arrive on time.

Mrs. Harrison has no transportation to her

follow-up medical appointments.

Mrs. Harrison doesn’t know which

medications to resume and which to stop taking at home.

Community Services were delayed

Mrs. Harrison has questions about her

medical bill and doesn’t know what her insurance will

cover.

Mrs. Harrison can’t afford her

medications anyway.

Mrs. Harrison is having difficulty coping with her

mobility changes.

Mrs. Harrison is feeling depressed

because she can’t get around anymore like

she used to.

Mrs. Harrison is feeling isolated now

that she’s homebound.

Mrs. Harrison is afraid she will fall again and have to return to the

hospital.

Contact Community PCP to inform of Mrs. Harrison’s hospital

stay.

Support caregiver and listen to concerns. Link to community

resources.

Communicate with children to plan for

immediate care needs. Refer to care

management.

Call Home Health Care Agency to

troubleshoot scheduling issues.

Facilitate communication with

pharmacy, prescribing physician, and home

health nurse.

Facilitate home evaluation by Home Health Care Agency.

Communicate with CCU case manager to

ensure prompt resumption or start of

services

Connect to pharmacy assistance program.

Screen for supportive mental health

programs or ongoing counseling services.

Link Mrs. Harrison to medical

transportation resources and assist

in scheduling services.

Refer Mrs. Harrison to patient access

immediately and connect to Senior Health Insurance Program (SHIP)

Counselor

Work with Home Health Care Agency

and physician to identify therapy

needs.

Refer and connect to local friendly visiting

program.

How does Bridge help?Mrs. Harrisonat Home

Research & Evaluation

Susan Altfeld, University of Illinois at Chicago – School of Public Health

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

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

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

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

Evaluation of the Bridge Model Who are our participants?

3090 participants at 5 sites across Illinois May 2010-December 2011

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%

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%

2-day post-discharge assessment Older adult (patient) stress

“Since I left the hospital, managing my needs has been stressful for me”

34.4%

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%

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%

2-day post discharge assessment Understand symptoms/”red flags”

“I understand what symptoms I need to watch out for”

95.5%

2-day post discharge assessment Cue to action

“I understand who to call if these symptoms occur”

98.0%

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%

30-day outcomes patient follow up/adherence

Physician visit within 30 days of discharge

84.7%

30-day outcomes adverse events

Mortality

1.7%

30-day outcomes adverse events

Readmissions

Awaiting report

30-day outcomes adverse events

Nursing home placement

3.0%

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%

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%

Satisfaction survey Patient stress

“The Bridge Program helped to make the hospital discharge experience less stressful for you/ (the patient).”

90.9%

Satisfaction survey Caregiver stress

“The Bridge program helped to make the hospital discharge experience less stressful for family or other loved ones.”

97.8%

Satisfaction survey Satisfaction

“I would recommend this program to others.”

89.5%

Satisfaction Survey - QuotesSatisfactionUnmet 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 ….”

Unique Components of the Bridge Model

Ilana Shure, Aging Care Connections – Aging Resource Center

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

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

Aging NetworkAoA •Administration on Aging & Older Americans Act

SUA •State Unit on Aging

AAA •Area Agency on Aging

CCU •Care Coordination Unit (Unique to Illinois)

AAAs are Your Community Service Experts

Medicaid Waiver

Program

•Adult Day Care•Case Management•Emergency Home Response•In-home Services

Older Americans Act

Services

•Home Delivered Meals•Caregiver Support Services•Transportation•Information and AssistancePrivate

and /or Volunteer Services

•Counseling•Ethnic Resources•Community-specific and local

Area Agencies on Aging

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

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

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

Who are Your Transitional Care Partners?

AAA

Hospital

Primary Care

Physician

Home Health

Community Based Agencies

Caregivers

Skilled Nursing Facility

Pharmacy

Non-traditional Resources

Hospital – Aging Network

collaboration

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

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

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.

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

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.

Rural Implementation of the Bridge Model

Amanda Groaning, Shawnee Alliance for Seniors

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

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

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

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

Geographic and Social Isolation Pros

Community support Extended family Better communication

and relationships between agencies who are sharing clients

Cons Isolation from resources,

family, and friends Dependence on non-

family supports that are not always reliable

Higher risk for burn-out and caregiver stress

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

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

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

30-day follow-up Transportation Possible financial exploitation

Policy and Health Systems Implications

Kristen Pavle, Health & Medicine Policy Research Group – Center LTC Reform

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

http://magicofteams.wordpress.com/2010/12/02/silos-firm-they-stand/

A Systemic Look at a Transitional Care

Event

Hospital

How do I

bill for this?

Community

Can we connect to the EMR?

Health Insurer

What is the

code for

pyschosocial?

How do we coordinate this

care transition?!

Care Coord

-inator

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)

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 accepted

http://hrfishbowl.com/2010/12/your-carrot-needs-more-stick/

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?

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

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-trainingBridge Model

http://edutechnow.sharepoint.com/Pages/Training.aspx

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

Thank You to Our Funders & Partners

Contact InformationSusan 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