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Benefits of Transitions of Care Management

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Bridge Solutions bridges a critical gap in health care delivery, helping patients make an important transition from the hospital to the home, minimizing declines in health status. The purpose of our services is not limited to providing ongoing care to patients but to optimize patient outcomes following an acute episode of illness. The major goal is to help the patient and family caregivers develop the knowledge, skills and resources essential to prevent future decline and re-hospitalization. At the end of the episode of care, continuity is assured by excellent communication with the primary care providers continuing to follow patients who have made a commitment to their self-management goals.

We agree with the findings of the National Transitions of Care Council that ineffective communication during transitions of care can reduce the quality of care significantly, leading to:

  • Medication errors, both overuse and sub-optimal use of prescription drugs
  • Delay in diagnosis
  • Increased length of stay
  • Re-Hospitalization
  • Patient dissatisfaction & complaints
  • Patient and caregiver confusion about patient’s condition and appropriate care;
  • Lack of follow-through on referrals; and
  • Increased costs because missing test results, discharge summaries, referrals, and medication lists may require patients to schedule redundant appointments or may lead providers to prescribe duplicative medications.

The Transitions of Care Management Services provided by Bridge Solutions are designed to eliminate the issues above by:

  • Improving communication during transitions between providers, patients, and caregivers by acting as the clearinghouse of all patient information and being responsible for coordinating acute, episodic, and chronic care.
  • Viewing the patients, their problems and environments, in a holistic manner, allowing us to design a comprehensive care plan that ensures tracking of progress to goal, is developed with the care team and patient, and includes information on evidence-based referrals, follow-up tests, self-management support, and community resources.
  • Placing emphasis on medication reconciliation, follow-up tests/services, changes in plan of care, involvement of a team during hospitalization, communication between care settings, and transfer of current/past health information from old to new home in a timely manner.

In addition to our Transitions of Care Management Services, Bridge Solutions also provides the following services & programs: Skilled nursing, Physical therapy, Speech therapy, Occupational therapy, Medical social services, Wound care, Cardiac pulmonary care, Diabetic care, Anticoagulant monitoring, Blood pressure monitoring, Infusion therapy, Tracheotomy care, Ventilator care, Catheter care.

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