What Is the Bridge to Home Program?
The Bridge to Home Program is a structured transitional care program for home health eligible patients who are at high risk of hospital readmission following discharge from an inpatient facility.
It goes beyond standard home health visits by bundling skilled clinical services with enhanced personal care support, early clinical assessment, and consistent between-visit contact, all delivered through a physician-approved plan of care built around each patient’s individual needs.
The program recognizes a clinical reality that discharge paperwork alone cannot address: many patients arrive home still in the early stages of recovery, not yet able to manage daily activities independently, and without the clinical oversight that their condition still requires. The Bridge to Home Program fills that role, connecting patients to the right level of care at the right time, and supporting a continuum that does not end at the hospital door.
What the Bridge to Home Program Includes
In addition to core skilled services, physical therapy, occupational therapy, speech therapy, nursing, and social work, the Bridge to Home Program provides:
- Clinician visit within 24 hours or RN/Therapist visit with in 24 hours
- Admission Assessment Within 48 Hours
- Up to 7 Home Health Aide Visits in the First Two Weeks
- Assistance with Bathing, Dressing, and Linen Changes
- Access to High-Quality Nursing and Therapy Services
- Mobile Safety Device Options for 24/7 Monitoring
- Check-In Calls Between Visits
No Primary Care Physician? We Can Help With That Too.
One of the most significant barriers to safe recovery at home is not having a primary care physician or having one but being unable to get there for appointments.
If your loved one does not have a Primary Care Physician, or if getting to PCP appointments is genuinely difficult given their current condition, our team can arrange for a visiting doctor group to come to their home within a short time.
This service removes one of the most common obstacles to the physician oversight that safe home recovery requires. You do not need to have a PCP already established to begin receiving care, and you should not have to go without physician involvement because getting there is not currently possible.
Contact our intake team at (855) 415-5744 to learn more about this option.
Program Benefits
The Bridge to Home Program is designed to deliver four outcomes that matter most to patients and families in the post-discharge period:
- Peace of mind
- Reduced risk of hospital readmission
- Improved long-term outcomes
- An easier transition home
What to Expect When the Program Begins
Registered Nurse/Therapist visits the home to assess your loved one’s current status, review discharge instructions, and identify any immediate clinical concerns.
Within 48 hours, the admission assessment is completed. The care team determines the specific services and personalized plan of care.
Throughout the program, skilled nursing, therapy, and aide visits follow the established plan of care.
As recovery progresses, the plan of care is adjusted to reflect your loved one’s improving function and evolving needs.
Our on-call clinical team is available 24 hours a day, 7 days a week, including nights, weekends, and holidays. A concern at 10 p.m. does not have to wait until morning.