Case Studies

Bridge Model of Transitional Care


The Bridge Model improves transitions of care by utilizing master’s-educated social workers in a care-coordinator role. The model emphasizes care continuity and interdisciplinary teamwork.  During the pre-discharge phase, Bridge Care Coordinators collaborate with discharge planners, participate in interdisciplinary rounds, review the medical record and conduct bedside visits with patients. After discharge, BCCs conduct a comprehensive biopsychosocial assessment and intervene until all identified gaps in care have been addressed.  Intervention consists of case management and care coordination activities, complemented by psychotherapeutic techniques that target patient engagement. BCCs connect post-discharge providers, advocate on behalf of their patients, ensure that medical and community-based services are provided as planned and frequently work directly with family caregivers.

This model is extremely adaptable, with approximately 60 replication sites nationwide. Readmission reduction rates are consistently above 20 percent. In addition, the model decreases mortality, patient/caregiver burden and stress, and improves physician follow-up.

The group holds frequent informational webinars at no charge. View the list of upcoming webinars or visit the website.

The Bridge Model was recently recognized by the Agency for Healthcare Research and Quality in its publication “Hospital Guide to Reducing Medicaid Readmissions.” In section 6, “Provide Enhanced Services for High-risk Patients,” the Bridge Model is listed as a model example of ways to address Medicare patients’ social, logistical, financial, clinical and behavioral health needs.

Read the latest success stories of the Bridge Model

For further information, contact:

Rush University Medical Center, Health & Aging Department, Chicago

Walter Rosenberg, Manager of Transitional Care,

Additional Resources

Webinars December 13th, 2017

Equity of Care Webinar SeriesPart 2: Aligning Diversity and Inclusion, Community Engagement, Busi......

Webinars November 20th, 2017

Equity of Care Webinar SeriesPart 1: Aligning Diversity and Inclusion, Community Engagement, Busi......

Webinars November 17th, 2017

Transportation and the Role of Hospitals This AHA webinar on “Transportation and the Role of Hos......