The Central Texas Aging, Disability & Veterans Resource Center (CTADVRC) is revamping the Care Transitions program in Central Texas. Currently, two programs are offered to discharging patients to help facilitate the move from hospital to home:  Care Transition Intervention (CTI) through each of our partner hospitals and the Bridge Model which will be administered by the CTADVRC.

Walter Rosenberg, Rush University Medical Center, leading the training session.

If a patient discharging from one of our partner hospitals does not want to participate in CTI (which includes a home visit), the CTADVRC will then implement the Bridge Model.  This alternative program is a social work intervention plan that includes assessment of patients’ emotions, thoughts, and behaviors along with their social and cultural surroundings.  These assessments are then followed by four phone calls and additional support to meet any identified needs.

Two Bridge Transition Coaches will be located at the CTADVRC with one of those coaches being an employee of Baylor Scott & White Hospital.  Donna Parker, CTCTP Program Manager with the Central Texas Council of Governments said, “This additional care transition program will help us reach a 30% decrease in hospital readmissions as well as reduce mortality rates and costs for at-risk older adults.”

Walter Rosenberg, Rush University Medical Center, answering questions during training.

In order to implement this new program, the CTADVRC hosted a Bridge Model Training Course at the Central Texas Council of Governments. This training, recognized as evidenced-based by Centers for Medicaid and Medicare (CMS) and Administration for Community Living (ACL), emphasizes collaboration among hospitals, community-based providers, and the Aging Network in order to ensure a seamless continuum of health and community care across settings. The one-day, interactive training session geared toward site leadership and clinical staff also includes post-training support and ongoing learning sessions.

Richard McGhee, Director of the Area Agency on Aging said, “It is incumbent upon us as good stewards to make sure our clients have the best care that science has to offer.”

For more information, contact Donna Parker, CTCTP Program Manager, Central Texas Council of Governments, donna.parker@ctcog.org or Richard McGhee, Director, Area Agency on Aging, richard.mcghee@ctcog.org . For more information on the Bridge Model, please visit www.transitionalcare.org or contact info@transitionalcare.org .