8/19/2013 The Bridge Model & Transitional Care from Debr a Mar - PDF document

8/19/2013 The Bridge Model & Transitional Care from Debr a Mar kovitz, L CSW Nursing Homes, Communities, and Hospitals:  Debra Markovitz, LCSW is a social worker at the Rush Health and Aging at A Social Work Approach Rush University Medical Center in Chicago.  She provides transitional care services as a Bridge Care Coordinator to older adults and caregivers. N U R S I N G H O M E S O CI A L W O R K W E B I N A R S E R I E S  Her clinical expertise focuses on older adults, care giving, care coordination, A U G U S T 2 2 , 2 0 13 mental health and the effects of chronic illness and disabilities on patients and caregivers.  She also coordinates the Social Work Age Training Program which is a geriatrics focused educational program for professionals. Learning Objectives: By the end of this presentation, Ilana Shure, MSW individuals will be able to:  Ilana Shure is the Program Manager of the Aging Resource Center, a transitional care program based  Explain the principles that underpin the Bridge on-site at Adventist La Grange Memorial Hospital in Program. La Grange, Illinois.  Ilana supervises master’s-level social workers assisting older adults and their families experiencing  Learn about the processes and skill sets needed for care transitions from hospitals and skilled nursing facilities utilizing the Bridge Model. the Bridge Program.  She provides training to community-based organizations and hospital staff on the Bridge Model, the aging network, aging issues, and community-  Describe the role of Social Work in transitional care. based services for older adults. As a representative for Aging Care Connections to the Illinois Transitional Care Consortium, Ilana serves on the Program Management Team and assists with the  Understand how processes and collaborations are development, implementation, and replication of the Bridge Model. actualized through case examples. Ilana completed both her bachelor’s and master’s degrees in social work focusing on aging and mental health. Agenda The Bridge Model: A Social Work Approach  Social Work Approach to Transitional Care  Partnerships and Collaborations  Bridge Model: Process  The Bridge Model: Context  SNF Partnerships and Process  SNF Case Example  Questions/ Discussion 1

8/19/2013 The Bridge Model: A Social Work Approach to The Bridge Model: A Social Work Approach to Transitional Care Transitional Care  Why transitional care?  Operates systemically to best navigate and problem solve patient needs  Care is fragmented  Communication between providers limited  Older adults particularly vulnerable at times of transitions  Strengths focus looks at patients holistically  Biopsychosocial perspective places equal importance on the social determinants  Person-centered: capitalizes on the “servable moment”- the  New literature highlights importance of social determinants in time in the transition whereby the individual feels empowered successful transitions to accept assistance and make a change  Cognitive decline while in hospital and post-discharge  Journal of General Internal Medicine  Partnerships and collaborations are imperative to transitional  40-50% of readmissions tied to psychosocial problems and lack of community resources care work  Health and Social Work  Social Workers adept at developing and managing partnerships  “Unplanned readmissions largely determined by broader social and  Collaboration is a core activity and competency in Social Work as we are environmental factors… ” trained to think systemically  Journal of the Am erican Medical Association, JAMA (in Readm ission New s ) Collaboration/ Partnership: Concept and Action The Bridge Program: Partnerships and Collaboration  Partnership and Collaboration  Partnership: the state of the relationship or arrangement  Collaboration: the active process of the partnership in action  Collaboration in action…  “… .discussion may be focused on the nature of a social care problem, to determine a course of action, to secure a service for someone in need or to re-establish help that has broken down. A kaleidoscope of factors enter the exchange: the views of service users and carers, service policies and structures, inter-agency agreements, professional cultures and methodologies, power and status, budgets and care resources, time priorities and personal styles. This is collaboration with other professionals and agencies, in action.”  Colin Whittington, 2003 Collaboration in Social Work Practice, edited by Jenny Weinstein, Colin Whittington, and Tony Leiba, Jessica Kinglsey Publishers Ltd, London, England, 2003 Continuum of Collaboration Bridge Program and Value of Partnerships Level Feature  Partnerships are a fundamental component of the Bridge  Isolation  No contact or communication between agencies; inter- Model professional rivalry and stereotyping; goals and interests perceived differently.  Encounter  Some contact between agencies but no meaningful action.  Patients do not live in the hospital or short-term rehabilitation facility  More frequent contact between agencies results in the  They live in homes, communities, long-term care SNF’s  Communication exchange of information; some formal arrangement for liaison  The plan of care is only as good as the receiver’s ability to actualize it and some commitment to joint training.  How does one setting support the other, or not?  Information exchanged between agencies is acted on; there is  Collaboration engagement in joint working; general objectives are shared.  Partnerships and pre-established collaborative processes have a great impact on patient outcomes  Integration  Collaboration throughout the organization, at strategic and operational levels; very high level of trust and respect.  Meaningful partnerships allow for tim ely data transfer, expedited com m unity service provision, and quicker problem solving Working with Older People, by Denise Tanner and John Harris, Routeledge, New York, NY , 2008. 2

8/19/2013 Bridge Care Coordinators Partners The Call for Partnerships  Bridge Care  MANY different disciplines are trying to prevent Coordinators (BCC) as Hospital social workers are readmissions Primary Aging skilled: Care Network Physician  at facilitating and maintaining relationships with interdisciplinary Non- teams Home traditional Health  Hospital Resources Client  Community agencies  Skilled Nursing Facility  Home Health Community  PCP Pharmacy Based  Navigating community Agencies resources, particularly the aging network Skilled Nursing Caregivers Facility Partnership Development Tips The Bridge Model: Process  Recognize the differences between cultures  We come from different perspectives and have different languages  What does MI mean to you?  Address concerns early and troubleshoot problems together  Requires skills, effort and clear intentions  Share both successes and challenges Bridge Model Process Target Population  Must have all of the below Pre-Discharge Post-Discharge 30-day follow- up  60+  Chronic condition • Referral • Assessment • Confirm long-term • Assessment • Referral  Previous hospitalization within support 6 months • Information • Connection structure gathering to providers  Must have at least one of • Collect data • Community • Psychosocial the below resources support  Discharged with home health  Living alone  Discharged to a skilled nursing Outcom e Goa ls: • Decreased readm issions facility • Decreased m ortality  Current practice • Increased physician follow -up  Expanded demand and realistic • Increased understanding of m edications and discharge plan of care pressures • Decreased patient and caregiver stress 3