Social Workers Tackle the Root Causes of Hospital Readmission


By Karen W.

hospital social worker

In Illinois, and a growing number of other states, social workers are leading the way in preventing hospital readmissions. By letting social workers do what they do well – focus on the whole person and the whole environment – they are simultaneously improving quality of life and making healthcare more affordable for the population as a whole. The Bridge Model represents one of the big successes.

The Bridge Model goes beyond discharge planning. It has to: The psychosocial problems that will make it difficult to remain in the community often aren’t identified before discharge, but they have a habit of showing up soon after. Originally targeted toward seniors, this enhanced discharge model now serves younger at-risk populations as well.

The model had its foundations in the Rush University Medical Center Enhanced Discharge Planning Program and in a transition program operated through Aging Care Connections; both used social workers in the transition process. In 2008, Rush University convened the Illinois Transitional Care Consortium (ITCC). In 2010, the ITCC received a grant from the Aging and Disability Resource Centers; the award was based on the recognition that practices were evidence-based. The Illinois Department on Aging was a partner in the endeavor (

The Bridge Model, as conceived by Rush and partnering organizations, relies on master’s educated social workers, a group whose scope of practice often includes case management for patients with complex health needs. Bridge Care Coordinators carry out social work assessments to identify the range of psychosocial factors that may impact health success in the community ( They recognize that, while failure to take needed medications can be a significant issue in deteriorating health and readmission, there is far more at play.

The work begins before discharge. A patient may be referred at the hospital level or identified through risk assessments that have been incorporated into the Electronic Medical Record (EMR). The social worker conducts comprehensive assessments. The process involves meeting with an interdisciplinary team.

The care coordinator calls the patient approximately 24 to 48 hours after discharge. The first goal is to build rapport. The next step is to figure out how to meet emerging needs. Transportation difficulties, caregiver burnout, transition-related stress, and difficulty managing medication are among the challenges patients may face.

The social workers may employ psychotherapy techniques to promote follow-through (

The Impetus for Change

While clinical social workers want to improve the lives of the people they work with, their backers are often looking at the bottom line. A 2009 report found that 19.6% of Medicare Fee for Service (FFS) beneficiaries were readmitted to the hospital within 30 days of discharge and 34% were readmitted within 90 days. The authors placed the cost of readmissions at 17.4 billion.

The problem isn’t limited to Medicare – or to Medicaid, though attention given to Medicare and Medicaid admission rates has been a key factor in the push for change.

Recent years have seen many stakeholders working toward innovative solutions and toward quantifying their impact. In some cases, funding has come from governmental organizations such as the Center for Medicare and Medicaid Innovation.

Bridge Model Successes

Mathematica, an independent company that provides evaluation for the Centers for Medicare and Medicaid, reported on the performance of the Rush University Medical System Bridge Program between May and July 2013. Mathematica determined that the program had reduced readmissions by 24.7% — and that each Bridge Care Coordinator had saved the Center for Medicare and Medicaid approximately $245,000 (

The U.S. Department of Health and Human Services, reporting on transitional programs at Rush University Medical Center, noted the following among Bridge Care Coordinator skills: geriatric expertise, clinical skills, and knowledge of resources available at the state, federal, and community levels (

In the 4th quarter of 2015, Rush University Medical Center Bridge had a readmission rate of only 5.67% (

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The Bridge Model around the Nation

The Bridge Model has been replicated in many communities around the United States. Hence a new name: The ITCC is now the Bridge Model National Office. The Bridge Model National Office reports that more than 50 partners have received training.

Illinois has the most sites; a number of other states now boast several. Georgia and Washington are among the states with a high level of activity. In August of 2016, the Bridge Program National Office reported having recently trained 25 professionals at the Southeast Washington Aging and Long Term Care Council (ALTC) Office.

The following programs received grants through the Center for Medicare and Medicaid Innovations Community-based Care Transitions Program:

  • Kenneth Young Center, Rush University Medical Center, Aging Care Connections, Solutions for Care, North Shore Senior Center, PLOWS Council on Aging (Chicago area)
  • Shawnee Health Service (Carbondale, Illinois area)
  • CRIS Healthy Aging Center (Danville, Illinois area)
  • Heights and Hills (Brooklyn area)
  • Tri-County Office on Aging (Lansing, Michigan area)
  • Partners in Care Foundation (San Fernando, California area)
  • Philadelphia Corporation for Aging

Communities adapt the model to meet local needs. The Bridge Model Collaborative is a platform for sharing best practices (