Continuity of Care

Continuity of Care

To better provide continuity of care for each patient, Bridges Health addresses the following limitations of the health care system:

  • fragmentation of care
  • limited access to care
  • sub-optimal discharge plans
  • poor medication reconciliation
  • inconsistency in care between providers
  • disease-specific approaches vs. whole person approaches
  • fragmented transition between levels of care
    • hospital to home
    • hospital to sub-acute facility
    • ambulatory clinic to home/senior living centers
  • high hospital readmission rates related to lack of care coordination
  • high out of pocket expenses (which is a barrier to access)
  • poor patient social support
  • poor outcomes in the overall health of patients with complex care needs or co-morbidities

Bridges Health has developed strong partnerships with the following entities:

  • Patient’s primary care provider office (the referring provider)
  • Specialty care
  • Skilled nursing facilities and transitional care unit
  • Home Health services
  • OT/PT/RT providers
  • Respite care services
  • Labs
  • Radiology/imaging services
  • Hospital ER and admissions/discharge departments
  • Palliative care and hospices
  • In patient mental health services
  • Outpatient mental and behavioral health services

In addition, Bridges Health is vitally involved in care coordination for patients.  Strong relationships with the following entities help with these aspects of comprehensive care:

  • Aging and disability services
  • Transportation services
  • Adults and  People with Disabilities (APD) and Department of Human Services
  • Food banks and other resources for basic needs
  • Homeless shelters and low income housing

To facilitate a more seamless approach to care, our team participates in daily ‘huddles’ to discuss the optimal care plan for each patient. There is also a great deal of non-visit based care involved: email, phone calls, home visits; use of support groups and educational forums within the clinic and community; integrated behavioral health; nutritional assessment and support; pharmaceutical management; pro-active care based on event triggers in the lives of our patients including anniversaries of deaths, important events, transitions to becoming a caregiver to other family members, etc.

Patients may be accompanied to specialists’ visits, supported with discharge instructions and helped with self-management care. There are weekly connections with the patients’ Community Health Workers or other members of the Bridges team.

Twice monthly MDT (Multi-Disciplinary Team) meetings focus on  both a macro and micro view of how the team is doing in relation to both the patients’ health and wellness goals and resourcing barriers to care that impacts these goals being achieved.

The end result is empowered patients and families. The Bridges team helps patients seek answers to the following questions:

  • What are my conditions? What is not working in my body?
  • What do I need to do about these conditions?
  • Why are these health goals important?
  • Who will partner with me in achieving my goals?

Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. ~World Health Organization, 1948