The Bridge Model

The Bridge Model is a person-centered, social work-led, interdisciplinary model of transitional care. Bridge 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. It does not add another layer or silo of care, but rather connects existing silos to assist older adults and their caregivers who are transitioning across the continuum of care. Bridge is the only widely-replicated model of transitional care that is explicitly social worker led. Bridge is recognized as an evidence-based model of transitional care by the Administration on Community Living and by the Agency for Healthcare Research and Quality (AHRQ).

The model emphasizes six principles, including social determinants of health, community-specific focus, and hospital-community collaboration. Bridge Care Coordinators apply a thorough social work assessment to address the many biopsychosocial factors that may challenge clients and their caregivers in their transition home and back into their communities.


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