Abstract P39: Bridging the Discharge Gap Effectively (BRIDGE)

Background: The transition from hospital-to-home is challenging for many cardiac patients (pts) in the era of shortening length of stay. Early follow up after discharge(d/c) may help reduce ED visits and readmissions. BRIDGE is a nurse practitioner based transitional care model that aims to schedule pts within 14 days of d/c and provide appropriate guideline-based care with the oversight of a cardiologist. Preliminary data has shown this model to be effective. We describe demographic and clinical differences between pts who did/did not attend BRIDGE, and describe interventions. Methods: Retrospective data was abstracted for all pts referred to BRIDGE Jun ‘08 to Aug ’09. Data collected: demographics, disease conditions, additional care during BRIDGE, medications, events within 6 months post d/c. Results: Of 407 pts referred to BRIDGE, 284 (69.8%) attended; with no significant demographic or clinical differences between attendees and nonattendees (except Afib pts). Of attendees, 97 (34.2%) received additional education on disease process, symptoms, and/or when to go to ED. Detailed diet/physical activity counseling was provided to 60 (21.1%) and 72 (25.4%) pts. Diagnostics were scheduled for 19 (6.7%); 65 (22.9%) required referrals for other services; serious medication issues addressed for 43 (15.1%) pts. Conclusion: The BRIDGE model is an attractive concept in transitional care with success in reducing ED visits and readmissions. Demographic and clinical characteristics do not provide rationale for a patient’s decision to attend. Our data suggest that most patients require early post-d/c education, medication counseling, and referrals beyond what was received at d/c. ![Graphic][1] [1]: /embed/inline-graphic-1.gif