Bridge Program

The Bridge Program assists patients and their families during the transition from hospital to home. Patients over 65 years of age, currently in the hospital who are managing multiple chronic illnesses as well as complex care needs, are eligible to participate in the Bridge Program.

The Bridge Team, including a doctor, a nurse practitioner and a social worker, work with a patient’s medical teams at the hospital and with his or her care provider in the community, to provide support, medical care and resources during this transition. Specific services include:

• Reviewing discharge instructions and medications
• Coordinating care with visiting nurses (VNA) and patients personal physicians
• Ensuring that other necessary services are in place to support patients as they recover

Home visits by the doctor and nurse practitioner from the Bridge Program are covered by health insurance. Visits by the social worker or care manager are provided free of charge.

Hear what one of our patients had to say about our program:

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