Have you or a loved one come home from a hospitalization only to need to be hospitalized again within a month? Many experience medical complications after discharge without someone to help coordinate their care. Isabella is proud to have the NewYork-Presbyterian Hospital, Weill-Cornell Medical Center, The Allen Hospital, and St. Luke’s-Roosevelt Hospital Center as partners in offering a way to prevent re-hospitalizations with the new Bridge to Home program.

How does it work?

The Bridge to Home program provides health care professionals who will work with individuals for a period of 30 days following discharge from the hospital. The purpose of the program is to ensure that patients get a high level of care to prevent avoidable re-hospitalization. The Bridge to Home team consists of Social Workers (Bridge Coaches) and Registered Nurses (Bridge Nurses). The team provides advice and assistance in coordinating patient safety at home, helping the patient manage medications, guiding the patient in methods of self-care and connecting the patient to community and healthcare resources.

Who Benefits?

Patients covered by Medicare Fee-For-Service Plans qualify if they have been hospitalized for one of the following conditions:

  • Heart failure
  • Heart attack (acute MI)
  • Pneumonia
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • End-stage kidney disease

What does the 30-day program provide?

The Bridge to Home team will:

  • Meet with the patient before he or she goes home from the hospital.
  • Visit the patient at home within 48 hours after discharge.
  • Ensure there is proper follow-up with primary care physician.
  • Make sure patient knows the purpose of his or her medications and when to take them.
  • Advise the patient of any warning signs they should be aware of.
  • Assist the patient in connecting with community resources to provide follow-up care.
  • Provide access to free home delivered meals.

How does the enrollment process work?

Those interested in the Bridge to Home program should contact the social worker in the hospital who will then get in touch with a Bridge Nurse at the hospital for further follow-up.

The Bridge to Home team will be happy to discuss the program further.

Please call today.
Toll Free: (855) 604-1872
Direct Dial: (212) 342-9566

The Bridge to Home Partnership is funded by the Centers for Medicare and Medicaid Services (CMS)

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