The Community Memorial Foundation has always supported the Bridge Model and continues to be a valuable partner in its development. We were pleased to see the success of Bridge highlighted in the Feb. 16th Grantmakers for Health Bulletin article on the evolution of the Aging Well Neighborhood at Adventist LaGrange Memorial Hospital, entitled, “The Health Care Neighborhood: Philanthropy’s Role in Aging Well.”

“The Bridge intervention at the Medical Center has significantly reduced all-cause readmissions. In 4th quarter 2015, the Bridge readmission rate was 5.67 percent, outperforming the national average by nearly two-thirds (USDHHS, 2014).”

Thank you Community Memorial Foundation!

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From March 20–24, 2016, nearly 3,000 professionals will meet in Washington, D.C. to engage with each other on a multitude of issues affecting our older adult population. Every year we meet as a community at the Aging in America Conference to share ideas and knowledge, learn from the experts, gain new perspectives and get reinvigorated to do our best work.

BMNO was delighted to hear that we will be featured in the American Society on Aging, Managed Care Academy Boot Camp 2: Transitional Care within Population Health – Integration, Process, Performance and Finances on Tuesday, March 22nd.

For more information about our presentation, please visit our featured blogpost, link here.

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We were delighted to be featured on the PerfectServe Connected Clinician blog on November 19th, 2015. Walter Rosenberg and Jessica Grabowski highlighted the Bridge Model and wrote about, “Engaging patients and lowering readmissions by focusing on transitional care.” Check out the article here.

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• Earlier this year, the National Coalition on Care Coordination released a report “Building the Business
  Case: Community Organizations Responding to the Changing Healthcare Environment for Aging Populations,” which explains that in order to best meet the needs of older adults and other vulnerable populations, it is imperative that community-based organizations and the healthcare sector develop collaborations.
• The Administration for Community Living is now hosting the second cohort of its learning collaborative and technical assistance for business acumen (more details can be found here). Many resources for community-based organizations are available here, such as webinar slides about legal considerations to consider when partnering with a managed care organization, and a tip sheet “Assessing Health Plans’ NCQA HEDIS Performance”.
• The SCAN Foundation has hosted Linkage Lab, a similar learning collaborative for community-based organizations in California. Case studies of organizations and other lessons learned from the first Linkage Lab cohort can be found here, and several relevant educational modules are available at no cost here.

Innovative programming that is person centered and works to integrate medical and social services is an essential part of what community-based organizations can offer to payers and providers. It is imperative that community-based organizations are able to offer effective programming and create a value proposition of those programs, and launching a Bridge Model program is tool to support you in this. For more on Bridge replication, please email [email protected].

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This webinar, “Working with Transient Populations” will be scheduled for January 26th 2016,1:00-2:00pm Central Time (2:00pm EDT, 11:00am PDT). Invited presenter, Marifel Sison, Hospital Liaison & Case Manager Supervisor from Ascencia, a homeless services agency in LA , will lead a discussion about general strategies and challenges to conducting outreach with people who are homeless and how a community-based organization like Ascencia partners with hospitals to provide transitional care. This presentation will provide hospital-community partnerships with important information and strategies to meaningfully engage with hard-to-reach populations.  We hope you’ll join us!

Registration for the webinar today, follow link here!

Please email [email protected] with any questions.

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• Evidence-based self-management programs
• Partnering with patient-centered medical homes to receive referrals
• Collaborate with hospitals on completing their Community Health Needs Assessments, which non-profit hospitals are required to do to maintain tax-exempt status
• Partner with regional Accountable Care Organizations
• Take advantage of CMS’s State Innovation Models Initiative as an opportunity to connect with providers
• Increase business acumen in order to negotiate sustainable partnerships with payers and hospital systems (For more on this, we recommend reading the National Coalition on Care Coordination’s recent report “Building the Business Case: Community Organizations Responding to the Changing Healthcare Environment for Aging Populations”)

Another opportunity is for CBOs to play a leadership role is in Medicaid managed care initiatives that many states are undertaking. Approximately 70% of Medicaid beneficiaries across the country are enrolled in a managed care plan for Medicaid health services, and that number will continue to rise. Moreover, 18 states have managed Medicaid long-term services and supports (LTSS) initiatives for older adults and adults with physical disabilities. AARP Public Policy Institute and Truven Health Analytics recently completed “Care Coordination in Managed Long-Term Services and Supports”, a study that analyzes the status of care coordination in managed LTSS efforts in those 18 states. Some states require that managed care organizations contract with existing community-based providers to meet LTSS needs – and other states do not require that.

Illinois is one state that has moved toward managed LTSS, and the AARP/Truven report dives deep into a case study of approaches managed care organizations are taking in IL and how community-based organizations are engaging with them to best meet needs. (See numbered pages 13-19 for the Illinois case study.) While IL does not require the managed care organizations contract with CBOs, Illinois CBOs are engaging a variety of tactics to partner with them. One such approach is the Coordinated Care Alliance, which brings IL aging and disability community-based organizations together to offer a more uniform service package to managed care partners. Many of the community-based organizations who are active in partnering with managed care organizations, such as Aging Care Connections, are implementing the Bridge Model as a community-focused solution to reducing hospitalization rates and improving connections with LTSS.

Health reform has created many opportunities for partnerships between community agencies, health systems, and payers to best meet needs of community members and to curb increasing costs. How will the community-based organizations in your region respond?

The post CBOs engaging in health reform and managed LTSS initiatives appeared first on Bridge Model of Transitional Care.

• Tuesday, June 30, 12pm ET: “The Bridge Model”, hosted by Post-Acute Care Center for Research (PACCR). For more details and to register, click here.
• Thursday, July 9, 4pm ET: “Bridging the Gap in Care Coordination: A Social Work Based Approach to Transitional Care”, hosted by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization. For more details and to register, click here.
• Wednesday, August 12, 1pm ET: “The Bridge Model of Transitional Care: Integrating care across settings”, hosted by PerfectServe, Inc. For more details and to register, click here.

The post Upcoming Informational Webinars about Bridge appeared first on Bridge Model of Transitional Care.

There are many approaches to addressing medication errors, and they often vary on protocol such as post-discharge follow-up frequency, how home health is involved, and how pharmacists are utilized. Whether a program is designated by the Centers for Medicare and Medicaid Services (CMS) as qualifying as a Medication Therapy Management Program for Part D, or is starting smaller and incorporating medication reconciliation practices into its post-discharge intervention, it is imperative that transitional care programs try to offer some type of support to reduce medication errors.

However, it is a challenge to discern the specific impact of such interventions. In its recent article “Does Medication Management Really Reduce Readmissions?”, HealthLeaders Media highlights the mixed evidence base for the use of Medication Therapy Management (MTM) on reducing 30-day hospital readmissions. After sharing findings from a few MTM publications, the HealthLeaders author concludes:

Evidence supports the benefit of programs that offer three essential elements: comprehensive review of each patient’s medications, health literacy and follow-up services.

The topic of a recent Bridge Model Collaborative webinar (one perk of being a Bridge Model replication site) was “Approaches to Medication Management”. During the webinar, Bridge Model implementation sites in California, Chicago, and Philadelphia shared with the group how they help address medication errors. While sites develop their own protocol based on their own partnerships and opportunities, the Bridge sites shared common themes:

• Relying on the relationships with patients and families to reveal underlying psychosocial concerns that were impacting their ability to follow their medication plan
• Promoting health literacy with patients and family caregivers and practicing skills such as reading discharge instructions and asking medical providers for more information
• Troubleshooting medication access challenges with financial supports or other follow-up services
• Engaging medical providers – such as home health RNs, primary care providers, or pharmacists – to complete a medication reconciliation and address medication-related concerns

While it may seem challenging for a social work-driven intervention to help reduce medication errors, Bridge Model implementation sites have been effective in this arena by focusing on health literacy, improving access to medications, and collaborating with medical providers – all in order to ensure patients and their families are best supported during a care transition.

The post Medication Management: What’s the best approach? appeared first on Bridge Model of Transitional Care.

In early April, BMNO trainers traveled to Belton, Texas to train two Area Agencies on Aging: the Central Texas Aging, Disability & Veterans Resource Center at the Central Texas Council of Governments and the Area Agency on Aging at the Heart of Texas Council of Governments. The Central Texas Council of Governments highlighted their care transitions program and the Bridge Model training in a recent blog post.

At the end of May, our trainers will return to Georgia for our third training with Georgia Area Agencies on Aging – the first with one AAA in 2012, the second with 5 AAAs in 2014, and now returning to train new staff from previously-trained sites and to train a few new AAAs as well. Many thanks to the Georgia Division on Aging Services for being so supportive of Georgia Aging Network organizations in developing their service lines to include transitional care programs!

We welcome these new Bridge Model replication sites to the Bridge Model Collaborative, and we look forward to all of the insight and new ideas that they will bring to the Bridge community!

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The Bridge Model is one approach to care that aims to bridge medical and social services, which traditionally have been fragmented and not efficient in working together to best meet the needs of their patients/clients. Bridge’s culturally-sensitive, team-based approach works to best support clients and caregivers in achieving what is important to and important for them as they transition home from the hospital. Broad research shows that individuals of low socioeconomic status are more likely to be readmitted to the hospital within 30 days of a hospital discharge, and our experience with the Bridge Model indicates that leveraging community-based social supports is a key aspect to preventing such readmissions.

While we’ve seen promising results in terms of the impact of the Bridge Model on preventing frequent hospitalizations, we are acutely aware of how much Bridge programs rely on publicly-funded services (which are on the chopping block in many states), on volunteer-based services, and on the ingenuity of social workers who work tirelessly to find resources to meet the needs of their clients.

The question then is, What if there aren’t any quality community-based services available? Many payers and health systems are realizing that it is worth it financially to invest in services and resources that can help prevent more expensive medical needs down the line – such as repairs to crumbling stairs, paying for a homemaker that can help grocery shop and cook healthy foods, or providing transportation to primary care appointments.

The New York Times recently highlighted a few such initiatives in its March 22, 2015 article “Health Care Systems Try to Cut Costs by Aiding the Poor and Troubled”. The article highlights a couple specific cases where health systems and payers engage social supports, and discusses the implications of them:

They raise a new question for the health care system: What is its role in tackling problems of poverty? And will addressing those problems save money?

“We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,” said Ross Owen, a Hennepin County, MN health official. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.”

Now health systems around the nation are trying to buy the boots, metaphorically speaking.

With the ACA and state-based health reforms increasingly asking hospitals and payers to invest in “the boots”, care models such as the Bridge Model that emphasize inclusion of psychosocial factors, hospital-community partnerships, and team-based care will have an important role to play.

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