The Bridge Model

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Bridge Care Coordinator

The Bridge Model’s Theoretical Framework is rooted in social work professional competencies, including motivational interviewing, the person-in-environment perspective, and Ecological Systems Theory. It consists of social worker–conducted assessments designed to elicit home-going and post-hospital needs, specifically, anticipating that transitional care needs change as the transition from hospital to home occurs and as time in the post-discharge period passes.

• Master’s Prepared Social Worker (MSW/LSCW)

• Perform Assessments
• Provide Interventions

• Different from traditional transitional care models that focus on nurse coaches and nurse practitioners

• Unique in 4 distinct ways

• The actors are different (social workers)
• The assessments are different (social, logistical, coping)

• Administered at three distinct points in the transitional care period

1. Before discharge (initial assessment takes place in the inpatient setting when appropriate)
2. Immediately after discharge, within 2 days of transitioning from hospital to home
3. 30 days after discharge (post-discharge phase of the Bridge model is designed to be entirely video/telephonic)
4. Follow up with patients 1 week post discharge from home health care services

• The interventions are different

• Direct psychotherapeutic support,
• Active linkage to community resources,
• Active coordination among clinical and nonclinical service providers

• The “dose” is different

• Pre-discharge face to-face contact,
• Telephone/Video contact within 48 hours of discharge,
• Telephone/Video contact 30 days after discharge

Responsibilities