A woman with glasses and a blue cardigan talking to an elderly man in a gray t-shirt in a kitchen.
Logo for Bridge Back Community Transition Program with a bird outline and text

BridgeBack is designed to reduce barriers to safe and timely discharges. Bridge Guides specialize in helping seniors and high-need adults move from hospitals, nursing homes, and other acute settings into stable community living. We handle the details that delay discharges - housing, paperwork, benefits, and transportation so you can focus on care.

Transition Services

Housing navigation and landlord coordination

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ID Recovery 

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Benefits applications support (SSI/SSDI, Medicaid, etc)

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Transportation and appointment support

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External Service provider referrals and coordination

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Pre and post discharge emotional support (CPST, PSR, Peer Support)

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Modern glass building of a hospital with a large medical cross symbol on the facade.

FACILITY BENEFITs

Discharge planning and care coordination assistance.

Reduce hospital readmissions and failed discharges.

Facilitate compliance with discharge planning regulations.

Ensure follow-through post-discharge with consistent case manager communication.

Prepare residents for community living before discharge to support smoother transitions.

Build a bridge from institutional care to community-based recovery pathways.

Two elderly people, a man and a woman, walk together on a sidewalk in a park. The man uses a cane and the woman pulls a rolling walker. The image is in black and white.

Member BENEFITs

Personalized coaching to build real-world independence.

Establishes a trusting, relatable relationship.

Reduces stress during transition by ensuring continuity of care.

Prevents relapse, crisis, or hospitalization.

Helps maintain mental health stability in the community.

Enhances community integration and confidence.

Strengthens emotional and social stability post-discharge.

Value Based Outcomes

Projections Based on Available Research and Industry Reporting

Integrating CPST, PSR, and Peer Support during discharge planning can reduce 90 Day Readmission Rates by up to 70%

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Integrating CPST, PSR, and Peer Support during discharge planning can reduce Facility Costs by up to $7,500 per patient.

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Patients enrolled with enhanced supports experience an average of 50% greater improvement in mental health symptoms.

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Patients enrolled with enhanced supports are 65% more likely to follow up on outpatient appointments.

Resources

Barnett, J. T., Conner, K. O., Cadet, T., & Brown, M. J. (2018). The impact of peer support on the risk of future hospital readmissions among older adults with a medical illness and co-occurring depression. Social Sciences, 7(9), 156. https://doi.org/10.3390/socsci7090156

Busch, A. B., Epstein, A. M., McGuire, T. G., Normand, S.-L. T., & Frank, R. G. (2015). Thirty-day hospital readmission for Medicaid enrollees with schizophrenia: The role of local health care systems. Journal of Mental Health Policy and Economics, 18(3), 115–128.

Faheem, S., Lyons, M., Moody, M., Sharp, S., & White, J. (2025). Impact of clubhouses in reducing psychiatric readmission risk. Cureus, 17(3), e80559. https://doi.org/10.7759/cureus.80559

Hutchison, S. L., MacDonald-Wilson, K. L., Karpov, I., Herschell, A. D., & Carney, T. (2023). Peer support to reduce readmission in Medicaid-enrolled adults with substance use disorder. Journal of Substance Abuse Treatment, 144, 108901. https://doi.org/10.1016/j.jsat.2022.108901

Macias, C., Rodican, C. F., Hargreaves, W., Jones, D. R., Barreira, P., & Wang, Q. (2006). Supported employment outcomes of a randomized controlled trial of ACT and clubhouse models. Psychiatric Services, 57(10), 1406–1415. https://doi.org/10.1176/ps.2006.57.10.1406

O’Connell, M. J., Sledge, W. H., Staeheli, M., Sells, D., Costa, M., Wieland, M., & Davidson, L. (2018). Outcomes of a peer mentor intervention for persons with recurrent psychiatric hospitalization. Psychiatric Services, 69(7), 760–767. https://doi.org/10.1176/appi.ps.201700266

Sledge, W. H., Lawless, M., Sells, D., Wieland, M., O’Connell, M. J., & Davidson, L. (2011). Effectiveness of peer support in reducing readmissions of persons with multiple psychiatric hospitalizations. Psychiatric Services, 62(5), 541–544. https://doi.org/10.1176/ps.62.5.pss6205_0541

Tyler, N., Wright, N., Panayiotou, M., Waring, J., & Johnson, M. (2019). Interventions to reduce psychiatric hospital admissions: A systematic review of service user and carer views. BMC Psychiatry, 19(1), 283. https://doi.org/10.1186/s12888-019-2252-6

Weisbrod, A. (2020). Reducing readmissions: Transitional care programs for mental health patients. American Journal of Psychiatry Residents’ Journal, 15(4), 12–15.

Westat. (2015). An assessment of innovative models of peer support services in behavioral health to reduce preventable acute hospitalization and readmissions. Office of Disability, Aging and Long-Term Care Policy, ASPE, U.S. Department of Health and Human Services.

Yoon, J., Chang, E., Rubenstein, L. V., & Chaney, E. F. (2010). Impact of mental health collaborative care on psychiatric hospitalization in a randomized trial. Medical Care, 48(1), 68–76. https://doi.org/10.1097/MLR.0b013e3181bd4cdf