Practice Innovations

The Bridge Model of Transitional Care

• The Bridge Model is an evidence- and social work-based transitional care intervention designed for older adults discharged from an inpatient hospital stay.
• Read the Model Overview, review a presentation about the model, and visit the Bridge Model's website, www.transitionalcare.org, for more information.

Health Home Connect

• Health Home Connect was developed by the Los Angeles Downtown Women's Center to identify homeless, older adult women and enroll them in Medicaid by linking the Affordable Care Act (ACA) and the US Department of Housing and Urban Development (HUD)’s Coordinated Entry System (CES) housing system.
• Read the Health Home Connect white paper and visit the Downtown Women's Center website,www.downtownwomenscenter.org/healthhomeconnect, to learn more about this initiative. 

Missouri Quality Initiative for Nursing Homes (MOQI)

• MOQI utilizes a combination of interprofessional expertise, including gerontological social workers, to install an information network to share health information between clinicians and hospitals and view clinical care documents to facilitate outcomes.
• Review a PowerPoint presentation about the initiative and visit the MOQI website, http://nursinghomehelp.org/moqi.html, for more information.

Shared Decision Making for Long Term Services and Supports

• Shared decision making is a collaborative, person-directed approach designed for older Veterans—but valuable for all older people—to use in making plans and choices about long term services and supports. 
• View the worksheets for Veterans and family caregivers, and visit the VA Geriatrics and Extended Care website for patient-facing information about shared decision making and descriptions of long term services and supports.