Bridge Program

The BRIDGE Program

Modeled after Evidence Based Programs proven to Reduce Hospital Re-admissions

At Seasons of Change we are passionate about helping individuals.  An article in Forbes Magazine 9/23/2013 identified preventable medical errors occurring in the hospital as the third leading cause of death in the United States. The conclusion of an article in the Journal of Patient Safety dated September, 2013 called for “increased vigilance in medical care to address the problem of harm to patients who come to a hospital seeking only to be healed”.  A 2013 article in The Atlantic entitled The Hospital is No Place For the Elderly asks the question, "Medical treatment for aging, chronically ill patients is costly and often ineffective. Can they get better care at home?"

The BRIDGE program was developed to help decrease the number of unnecessary re-hospitalizations that your senior may experience.

The Aging Life Care Professionals at Seasons of Change developed the BRIDGE Program to provide an opportunity for the senior to “Bridge” safely and effectively from their hospital stay to their home. Not only is it the goal to return the senior home successfully but to provide the framework and support to keep the person safe at home for the first 30 days after a discharge as this is the time frame when there is an increased incidence of repeat hospitalizations.  

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Think of the BRIDGE Program as a “safety net” where the goal is to prevent unnecessary readmits to the hospital in the first 30 days after discharge.  The key is early and immediate intervention.

The BRIDGE Program consists of:

A total of 3 VISITS  to the senior depending on when the process begins. Ideally the first visit occurs at the hospital prior to discharge so the BRIDGE Coach may gain access to the senior and their records (with the senior’s or POA’s permission), this allows the BRIDGE Coach to set post-discharge goals.  

2 - 3* SUBSEQUENT VISITS occur in the home, with family present if so desired, to work to achieve the four goals as outlined above. Home visits are scheduled:  60 – 75 minutes for the first home visit and 30 - 60 minutes for the remaining visits to ensure that all areas are covered and the senior is actively engaged and working towards the goals. The senior is encouraged to make a list of questions or concerns to share with the coach at these visits. During these visits the BRIDGE Coach will conduct a safety evaluation of the home, make recommendations for change and advise as to safety strategies to further ensure the senior's safe transition. 

*2 home visits if initial visit occurs in the hospital, 3 home visits if service does not initiate with hospital visit

*The copyrighted Comprehensive Health Record is delivered with the first home visit.  The coach will encourage and instruct the senior in its completion. Educational materials as appropriate will also be provided for ongoing education for the senior and the family and/or caregiver.  

The BRIDGE Coach is accessible by phone throughout the program period for questions and concerns by the senior.  

BRIDGE Coaches are Licensed Nurses or Social Workers who have spent time in their careers  dealing with the senior population.  Professionals who know and understand medication regimens and the challenges that seniors have to overcome to remain at home safely and successfully.

The BRIDGE Program addresses Four Specific Areas to achieve its goals:

1.MEDICATION MANAGEMENT:  

Seniors must understand the medications they are taking, how to take them, when to take them and why they are taking them. Further, they must be aware of medication changes present at discharge, must understand the reason for these changes and ensure to fill these new prescriptions. The BRIDGE Coach will ensure that this goal has been met and provide education to the senior where needed to achieve success in this area.

2. FOLLOW UP WITH ALL IDENTIFIED PHYSICIANS:

Upon discharge from the hospital, certain physicians have been identified which the patient needs to follow up with. Oftentimes the discharging senior fails to make these follow up appointments for various reasons, and while the hospital may schedule an appointment for the senior with their Primary Care Physician, they may not schedule appointments with the designated specialists.  Seniors successfully avoid repeat hospitalizations when they properly following through with their physicians. The BRIDGE Coach will ensure that follow up appointments have been made and if not will attempt to schedule these appointments when in the senior’s home with the senior’s permission. The coach will also ensure that the senior has means of transportation to these appointments at this time.  

3.  RED FLAG INDICATORS:

 Depending on the disease processes which have been diagnosed, the senior should have been educated in the hospital as to what signs and symptoms to look for.  Unfortunately the senior and their family are typically overwhelmed with more paperwork and information than they can possibly comprehend.  The BRIDGE Coach will go over the discharge paperwork and the indicators specific to the disease process with the senior in their home using the "teach back" method.  As material is presented to the individual the coach asks the senior to explain the educational instructions in their own words.  The coach can then determine how well the individual understood the instructions or education provided by their response and can effectively cover those areas where the individual demonstrates a lack of understanding.

4.COMPREHENSIVE HEALTH RECORD (CHR)*:

A thorough health picture of an individual is secured with an accurately completed CHR. This document, when accurately completed, contains data on an individual including their demographic information, insurance information, diagnosis, medications, providers, and more. It should be taken to all physician visits, and to all planned or unplanned future hospitalizations to decrease the potential for errors and increase the senior’s success rate. The BRIDGE Coach will supply the individual with his or her own CHR to complete.  

*The CHR is a copyrighted document and may not be reproduced without express written permission by Seasons of Change LLC

Save all paperwork that the individual is discharged from the hospital with to enable the BRIDGE coach to go over this paperwork with the individual. It is important to keep all paperwork that an individual receives from the hospital, doctor visits, and so on. The CHR is the perfect place to store all of these documents.

Current literature indicates that the risk for repeat hospitalization and unnecessary ER visits in the initial 30 day period can be reduced by 20% to as as much as 56% for the individual who successfully completes a program such as Seasons of Change BRIDGE Program. Further, the same individual can anticipate reduced costs in hospital charges as the BRIDGE Coach provides an onsite professional to reach out to with questions and concerns. In our practice we have become aware of individuals who have taken themselves to the Emergency Room for a visit seeking answers to questions or needing coordination of services because they have no one else to turn to for assist, before Seasons of Change became involved in their situation. These are issues in which a BRIDGE Coach can assist them. 

 

Contact Seasons of Change to speak to an Aging Life Care Specialist to see how the BRIDGE Program will benefit your currently hospitalized or newly discharged senior.  The BRIDGE Program is also effective transitioning the senior from Skilled Unit to home.