Ilana Shure, manager of the Aging Care Connections Aging Resource Center, La Grange, provided training on the Bridge Model of Transitional Care in Philadelphia last week.  Walter Rosenberg of Rush University Medical Center joined Ms. Shure representing the Illinois Transitional Care Consortium to provide training to the Philadelphia Corporation on Aging, one of the country’s largest area agencies on aging, and HealthInsight, a Utah Quality Improvement Organization. 

Aging Care Connections helped develop the Bridge Model and was the first in the nation to use the concept of a community-based aging specialist on-site at the hospital to secure at-home services prior to discharge.  The Aging Resource Center (ARC), established by Aging Care Connections at Adventist La Grange Memorial Hospital, offers older adults and their families the opportunity to explore and secure community resources and services prior to discharge from the hospital and local skilled care facilities.  On-site assessment for services, connection to information about community resources, and follow-up in the community are provided through the ARC Program to ensure a smooth transition back home.  In most cases, the wait for delivery of home-based services, such as bathing and housekeeping assistance, adaptive equipment, transportation, caregiver support and respite, home delivered meals, and benefits assistance, has been cut from 14 days to an average of two days.

Since its inception in May, 2007, the ARC has assisted more than 2,036 older adults and their family members manage the transition back to their homes after hospitalization or a stay in a skilled nursing facility.  The ARC co-developed the evidence-based Bridge Model and continues to use this nationally-recognized transitional care model to provide the highest quality care to its clients.

Transitional care is at the forefront of the nation’s healthcare providers’ attention due to the Affordable Care Act which seeks to reduce re-admission to hospitals.  The Bridge Model has demonstrated success with outcome-based research relating to reducing re-admissions.  Hospitals must partner with community-based social service agencies to provide services ensuring a smooth, seamless transition back to the community from an acute care setting.

The Illinois Transitional Care Consortium (ITCC) is a consortium of community-based organizations, hospitals, a research university, and a health care policy-advocacy organization.  ITCC developed the Bridge Model, a social-work based model of transitional care that serves older adults being discharged home after a hospital stay. 

The Illinois Transitional Care Consortium partners are: Aging Care Connections, Solutions for Care, Shawnee Alliance for Seniors, Rush University Medical Center, University of Illinois at Chicago School of Public Health and Center for Health and Aging Research, and Health & Medicine Policy Research Group.