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Care Transitions

Transitions of Care Management

On average, patients 65 or older with two or more chronic conditions see 7 different Physicians within a year.

group of nurseSenior Citizens whose conditions need complex, continuous care frequently require services from different practitioners in multiple settings. However, practitioners in each setting often operate independently, without knowledge of the problems addressed, services provided, information obtained, medications prescribed, or preferences expressed in previous settings.

The growing national trend for Physicians and other Clinicians to restrict their practices to single settings (e.g., hospitals, skilled nursing facilities, or ambulatory clinics) and not to follow complex patients as they move between settings heightens the potential for fragmentation of care. During transitions, these patients are at risk for medical errors, service duplication, inappropriate care, and critical elements of the care plan “falling through the cracks.” Ultimately, poorly executed care transitions may lead to poor clinical outcomes; dissatisfaction among patients; and inappropriate use of hospital, emergency, post acute, and ambulatory services.

For patients with multiple chronic conditions and complex therapeutic regimens, we emphasizes coordination and continuity of care, prevention and avoidance of complications, and close clinical treatment and management – all accomplished with the active engagement of patients, their family, informal caregivers and in collaboration with the patient’s physicians.

As the Home Health Agency, Bridge Solutions provides Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Workers (MSW) and Home Health Aides (HHA).

Our Clinicians follow patients from hospitals into their homes, and using an evidence-based care coordination approach, provide services designed to streamline plans of care and interrupt patterns of frequent acute hospital or emergency department use and health status decline. Our Clinicians collaborate with Physicians, Nurses, Social Workers, Discharge Planners, Pharmacists, and other members of the health care team in the implementation of services with a unique focus on increasing patients’ and caregivers’ ability to manage their care. Every patient receives an individualized plan of care guided by evidence-based protocols.

Other Helpful Information about Home Health Care and Transitions of Care Management at Bridge Solutions

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