Integrating Care across Settings: The Illinois Transitional Care Consortium's Bridge Model

Abstract

A forward-thinking collaborative model is sensitive to the complex factors impacting older patients in the post-discharge transition.In 2008, several organizations in the field of aging formed the Illinois Transitional Care Consortium (ITCC). The ITCC's partner agencies have decades of experience with a broad range of issues affecting older adults: Rush University Medical Center's Health and Aging Department addressed transitional needs throughout Chicago's metro area with a social worker-led, post-discharge intervention; Aging Care Connections, a community organization in suburban Chicago, staffed social workers as transitional specialists on site at a partner hospital; and the Health & Medicine Policy Research Group conducted statewide focus groups with older persons and their caregivers to identify consumers' transitional needs.These agencies formed the ITCC to develop the Bridge Model (Bridge)-a social work- based transitional program that addresses the complex needs of older adults. The ITCC subsequently added a research organization member (the University of Illinois at Chicago's School of Public Health) as well as community organizations with rural and ethnically diverse populations (Solutions for Care, which serves a primarily Latino populace, and Shawnee Alliance for Seniors, which serves several rural counties).Psychosocial and Community Factors Impact Care TransitionsThe ITCC's collective experience confirms that the phrase silos of care remains a durable metaphor for the rigid and disconnected systems elders and their caregivers must negotiate as elders return to the community after a hospital stay. In addition to the fragmented network of post-discharge providers, the complexity of older adults' psychosocial lives before they enter the hospital also impacts their approach to understanding healthcare treatment and any instructions they receive during their hospital stay.Many transition models place significant emphasis on the medical approach to transitional care, whereas a growing body of research suggests that psychosocial, environmental, and community factors greatly impact older adult transitions. For instance, studies have found that 40 to 50 percent of hospital re-admissions are linked to psychosocial problems and lack of community resources, and that more than 80 percent of recently discharged older adults have unaddressed psychosocial needs in the immediate post-discharge period (Proctor et al., 2000; Altfeld et al., 2012).Proper medications and adherence to discharge plans are critical during the vulnerable transition period, but systemic issues in the patient's home or community and with their families, resources, and providers also impact the transition's success. Focusing solely on the medical condition of a patient is frequently insufficient in targeting all issues that may lead to re-admissions (Morrow-Howell, Proctor, and Mui, 1991; Kohn, Corrigan, and Donaldson, 2000; Parry et al., 2003).Psychosocial issues, including confusion, adjustment to illness, stress, caregiver burden, family dynamics, cultural differences, language proficiency, and knowledge of available resources can also adversely impact the older adult during a transition (Graham, Ivey, and Neuhauser, 2009; Brown-Williams, 2007).The Bridge ModelThe ITCC created Bridge by integrating ITCC transitional best practices established in the community, with evidence-based transitional protocols developed in a hospital. Bridge's theoretical framework is rooted in core social work competencies- primarily motivational interviewing, the person-in-environment perspective, and Ecological Systems Theory-providing the foundation for a comprehensive social work assessment (Bronfenbrenner, 1979).Bridge consists of three phases: predischarge, two days post-discharge, and a thirty-day follow-up. A comprehensive client assessment is conducted before and after discharge, based on research showing that 61 percent of recently discharged older adults had significant needs post-discharge that were not identified during hospitalization (Altfeld et al. …