In 2008, several organizations in the field of aging formed the Illinois Transitional Care Consortium (ITCC). The ITCC partner agencies have decades of experience with a broad range of issues affecting older adults: Rush University Medical Center’s Health and Aging Department addressed transitional care needs throughout Chicago’s metro area with a social worker–led, post-discharge intervention; Aging Care Connections, a community organization in suburban Chicago, staffed social workers as transitional care specialists on site at a partner hospital; and the Health & Medicine Policy Research Group conducted statewide focus groups with older persons and their caregivers to identify consumers’ transitional care needs.

These agencies formed the ITCC to develop the Bridge Model (Bridge)—a social work–based transitional care program that addresses the complex needs of older adults. The ITCC subsequently added a research organization member (the University of Illinois at Chicago’s School of Public Health) as well as community organizations with rural and ethnically diverse populations (Solutions for Care, which serves a primarily Latino populace, and Shawnee Alliance, which serves several rural counties).

In 2010, the Administration on Aging recognized the Bridge Model as evidence-based and awarded ITCC with an Aging and Disability Resource Center Care Transitions Grant. In 2011, ITCC joined the Preventing Readmissions through Effective Partnerships Initiative, a collaboration between the Illinois Hospital Association and Blue Cross Blue Shield of Illinois, to train multiple Illinois Hospitals in the Bridge Model. In 2012, ITCC joined with AgeOptions, the suburban Cook County Area Agency on Aging, and was awarded funding to implement the Bridge Model through the Community-based Care Transitions Program. These opportunities have all helped to refine and further develop the Bridge Model.

In 2013, ITCC renamed itself the Bridge Model National Office (BMNO) in order to reflect the growing national scope of its partners. BMNO launched the Bridge Model Collaborative (BMC) as a platform to connect Bridge Model replication sites to share best practices and learn from each other’s varied implementation experiences. BMNO looks forward to building on its history and working with current and future partners to take advantage of opportunities to better integrate health and community care through a social-work approach.