The Impact of the Bridge Model of Transitional Care on Medicare Super Utilizers: Preliminary Findings

Background/purpose: Hospitalization is a sentinel event for older adults and adults with disabilities because it is frequently associated with increased disability and may mark a transition from independent living to either community-based or institutionalized long-term care. Transitions from hospital to home are vulnerable exchange points that are prone to patient safety issues and stressful for patients and their caregivers, particularly for adults with multiple chronic conditions and complex needs. Some of these older adults incur high medical costs from recurring, preventable inpatient or emergency department visits. Known as super utilizers, they have become the focus of many delivery system innovations. A transitional care intervention designed to address the complex social and medical needs and to improve care continuity may reduce service utilization and cost among super utilizers.

Bridge-Super Utilizer (Bridge-S) is a social work-based transitional care program aimed at reducing readmissions for older adults with 5 or more inpatient admissions in the past year. Bridge-S uses master-prepared social workers called Bridge Care Coordinators (BCCs) to provide support to both clients and family caregivers as they go through transitions. Bridge-S features a comprehensive needs assessment, application of psychotherapeutic skills, and a standardized protocol to develop collaboration between hospitals and community-based organizations.

This study aims to assess the impact of the “Bridge-Super Utilizer”—a social work-based transitional care program for super utilizers.

Methods: We employed a retrospective quasi-experimental design using hospital administrative data. The setting was an urban teaching hospital in the Midwest. Super utilizers eligible for the intervention had 5 or more admissions to the study site in a rolling 12-month look-back period, with an admission between June 1, 2014 and May 31, 2015. Subjects included 456 super utilizers who received the intervention and a matched comparison group of eligible patients who did not receive the intervention due to limited program capacity. Patient were matched using propensity score matching based on demographic, clinical characteristics, and utilization outcomes during the 6-month period before the intervention. OLS regression analyses were conducted on the matched sample to examine the between-group differences on health services utilization during the 6-month period after the intervention. Health services utilization outcome measures include number of 30-day readmissions and readmission rates, 30-day emergency department visits, and missed outpatient appointments within 7 and 14 days of index discharge.

Results: The intervention group had an average of 18% lower 30-day readmission rates, 1.25 fewer inpatient admissions, 0.8 fewer emergency department visits, and 0.7 fewer missed outpatient appointments compared to matched comparisons after the intervention.

 

Conclusions and Implications: Holistically addressing patients’ social and medical needs during care transitions may reduce subsequent readmissions and emergency department visits among Medicare super utilizers.