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Promising Models in Transitional Care

Robyn Golden and Bonnie Ewald
April 27, 2015
Health & Medicine is pleased to share this post from Board Member Robyn Golden and Program Coordinator Bonnie Ewald on our work developing the Bridge Model of transitional care and other interventions to improve health for older adults. In addition to serving on our board, Robyn is director of Health and Aging at Rush University Medical Center in Chicago. Bonnie divides her time between our Center for Long-Term Care Reform and the Chicago Area Schweitzer Fellows Program. This article originally appeared in Aging Todaya publication of the American Society on Aging.

The older adult healthcare system faces complex challenges—among them are spiraling costs at the end of life, bridging fragmented services, ageism, attracting the necessary workforce and supporting family caregivers. The dominant medical model, based on discrete episodes of illness and curative care, largely ignores the big picture of individuals’ lives. As Dr. Atul Gawande recently wrote in Being Mortal (New York: Metropolitan Books, 2014), “Our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer.”

As an alternative to the current system, Gawande envisions one that works with individuals over time, taking into account a person’s self-identified goals, co-occurring medical conditions and the social determinants that affect their health and well-being. In this “refashioned” model, providers and organizations offer coordinated chronic care, and talk openly with patients and their families about goals, values and preferences. Thanks to the Affordable Care Act’s funding for initiatives such as accountable care organizations, Medicaid Health Homes, and Aging and Disability Resource Networks, many states and organizations are shifting toward such models. 

The Rush Model
At Rush University Medical Center, a large academic medical center in Chicago, health-related challenges facing older adults are not abstract policy issues, but are dealt with as stark realities demanding coordinated medical-psychosocial interventions. When individuals are discharged from the hospital they face many non-medical issues, such as who will make sure they connect with a primary care provider and appropriate home- and community-based services (HCBS)? How will care plans incorporate their values and preferences? Who will support them as they adapt to mobility changes and who will provide other psychosocial supports? Who will monitor caregivers to ensure their needs are being met? 

Rush’s Health and Aging department responds by employing a social work team that supports aging individuals as they transition between settings or manage multiple conditions. By evolving our work into standardized models of care, developing an evidence base and disseminating the models to other organizations, we seek to increase our impact and support others in changing their practice to meet the complex needs of their patients, too. We have successfully standardized our social work–centered approaches into the Bridge Model of transitional care and the Ambulatory Integration of the Medical and Social (AIMS) Model of integrating social work services into primary care, each with an evidence base showing reductions in hospitalizations and in emergency department usage.

One key contributor to our success in these efforts—and a strategy that could be employed by other advocates—is developing strong working partnerships between hospitals, community-based providers and advocacy organizations. Working closely with Chicago-area organizations such as Aging Care Connections and Health & Medicine Policy Research Group (a Chicago-based policy center working to support the needs of older adults) has enhanced the development and dissemination of best practices and the evaluation of our model. Together, we have shown that outcomes—such as hospital readmission rates—are significantly improved when social workers are an integral part of the care team, providing behavioral health support and building strong working partnerships between hospitals and HCBS organizations.

Developing such best practices for using social workers is critical because emerging care coordination models emphasize approaches that maximize the contributions of all team members, such as ensuring that all providers can effectively work at the top of their licenses.

New Approaches Work, but Difficulties Exist
Despite our approach’s great potential, working inside a flawed healthcare system has presented a number of difficulties, such as securing data-sharing agreements between hospitals and various HCBS organizations to ensure that medical and social service providers can easily access and share pertinent information. New models’ financial sustainability has also been a problem; while a social work team’s involvement may improve hospitals’ quality metrics (such as 30-day readmission rates or patient satisfaction scores), those outcomes do not always correlate with a clear business case. Furthermore, community partners’ financial stability remains a problem, and organizations across the spectrum struggle to adapt their practice culture by adopting and embracing new approaches to care.

Also, at the macro level, without a payment system that recognizes the value of psychosocial supports and community-based services, the resources older adults need often are missing. Finally, we lack validated metrics to evaluate the quality of various HCBS, making improvements in processes and outcomes difficult. How effective can a care coordinator be if affordable transportation options or quality, timely in-home services are not available?

It is imperative that older adults, their families, and we who work directly with them participate in the development of these new models. Repeatedly, in our work, we see patterns in how healthcare practice affects people’s lives.

Whether the client is a full-time family caregiver struggling to understand medical lingo or a 90-year-old adapting to mobility changes, we see that many health-related needs could be addressed by comprehensive, psychosocial services focusing on increasing health literacy and supporting individuals to live safely at home and in community. Health & Medicine organizes these lessons from on-the-ground partners to make policy recommendations that promote comprehensive health systems and address inequities in health and healthcare. In Illinois, for example, our input has affected the quality metrics by which Medicaid managed care organizations are measured, and has created the blueprint for a new ombudsman program for HCBS recipients.

Together, Rush and Health & Medicine are working toward a state and national system that bolsters HCBS providers, focuses on preventive care, reduces disparities, supports the economic security of older adults and their caregivers, and allows individuals to have a say in their care.

In our two-pronged approach of using innovative care models more responsive to the complex needs of older adults, and advocating for systemic change to improve future service delivery, we aim to create a health environment that truly allows patients’ voices to help guide healthcare practice.