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 care 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 care 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 care needs.
These agencies formed the ITCC to develop the Bridge Model (Bridge)—a social work–based transitional care 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 Transitions
The 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 care 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 care 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 Model
The ITCC created Bridge by integrating ITCC transitional care best practices established in the community, with evidence-based transitional care 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., 2012). The post-discharge assessment can identify these issues and provide a more accurate reflection of the needs experienced by older adults and their caregivers during this transitional period.
Pre- and post-discharge assessments drive the intervention, which consists of setting up relevant community resources, advocating on behalf of the client while making follow-up medical appointments, troubleshooting service breakdowns, providing brief counseling, and facilitating communication between professionals, each in their own “silo of care.” Throughout the intervention, Bridge Care Coordinators provide psychosocial support to older adults and caregivers. At thirty days, the client or caregiver is contacted to ensure connection to longer-term supports and to address any emergent needs.
The ITCC is able to implement and maintain operations through the support of private foundations and an Administration on Aging, Aging & Disability Resource Center (ADRC) Care Transitions grant. Most recently, the ITCC collaborated with an ADRC to receive a Community-Based Care Transitions Program contract. More than twenty partners in Illinois and other states have implemented Bridge.
Evaluating the Bridge Model
Bridge’s efficacy is assessed through evaluating both its process and outcomes.* At each phase, data are collected from clients and caregivers in order to document needs, services provided, satisfaction, and plan-of-care adherence. Preliminary data based on a sample of 315 participants in the first phase of the research found a hospital re-admission rate of 14 percent at thirty days post-discharge, based on reports from clients or caregivers. This rate is considerably lower than the national Medicare rate of 19.6 percent (Jencks, Williams, and Coleman, 2009).
We are in the process of obtaining re-admission data from the Centers for Medicare & Medicaid Services. While we anticipate that the validated admission rate will be higher than patients and caregivers report, this promising outcome is encouraging.
At thirty days, clients reported high levels of satisfaction with Bridge; 97.6 percent would recommend the program to others, and 97.7 percent indicated that the program made the post-discharge experience less stressful. At follow-up, 5.6 percent of clients requested additional assistance from a program specialist to help with new or unmet needs.
Site administrator interviews and surveys capture important information regarding program implementation at each agency and hospital. A stakeholders’ survey completed by hospital administrators, pharmacists, nurses, social workers, and community professionals identified the following as the most beneficial aspects of the Bridge program:
The Bridge Model emphasizes the importance of psychosocial and environmental factors and their integration with medical factors during the post-discharge period. Focusing on this integration exemplifies the patient-centered model, and allows for a comprehensive approach to transitional care.
* Outcomes are based on preliminary data and should not be cited without permission from the first author.
Susan Altfeld, M.A., Ph.D., is clinical assistant professor of Community Health Sciences at the University of Illinois at Chicago’s School of Public Health, Chicago, Illinois. She can be contacted at firstname.lastname@example.org. Kristen Pavle, M.S.W., is associate director of the Center for Long-Term Care Reform, Health & Medicine Policy Research Group, Chicago, Illinois. She can be contacted at email@example.com. Walter Rosenberg, M.S.W., is program coordinator for Health and Aging at Rush University Medical Center, Chicago, Illinois. He can be contacted at Walter_Rosenberg@rush.edu. Ilana Shure, Ed.M., M.S.W., is Aging Resource Center program manager at Aging Care Connections, La Grange, Illinois. She can be contacted at firstname.lastname@example.org.
Editor’s Note: This article is taken from the Winter 2012-2013 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “Care Transitions in an Aging America” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generationssubscribers at MetaPress.
Altfeld, S. J., et al. 2012. “Effects of an Enhanced Discharge Planning Intervention for Hospitalized Older Adults: A Randomized Trial.” The Gerontologist September 7 (e-pub ahead of print). www.ncbi.nlm.nih.gov/pubmed/22961467. Retrieved October 25, 2012.
Bronfenbrenner, U. 1979. The Ecology of Human Development: Experiments by Nature and Design. Cambridge, MA: Harvard University Press.
Brown-Williams, H. 2007. “Dangerous Transitions: Study Shows Discharge Planning Risks.” Aging Today
Graham, C., Ivey, S., and Neuhauser, L. 2009. “From Hospital to Home: Assessing the Transitional Care Needs of Vulnerable Seniors.” The Gerontologist 49(1): 23−33.
Jencks, S. F., Williams, M. V., and Coleman, E. A. 2009. “Rehospitalizations Among Patients in the Medicare Fee-for-Service Program.” The New England Journal of Medicine 360(14): 1418–28. doi:10.1056/NEJMsa0803563.
Kohn, L. T., Corrigan, J. M., and Donaldson, M. S. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press.
Morrow-Howell, N., Proctor, E. K., and Mui, A. C. 1991. “Adequacy of Discharge Plans for Elderly Patients.” Social Work Research and Abstracts 27(1): 6–13.
Parry, C., et al. 2003. “The Care Transitions Intervention: A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care.” Home Health Services Quarterly 22(3): 1–18.
Proctor, E. K., et al. 2000. “Adequacy of Home Care and Hospital Readmission for Elderly Congestive Heart Failure Clients.” Health and Social Work 25(2): 87–96.
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