For Hospitals | MyBridgeLink | BridgeCare Health Network

For Hospitals

We Partner with Your Team to Resolve Discharge Barriers

We collaborate with hospitals, families, and community providers to prevent delays and accelerate safe, timely discharges. MyBridgeSuites provide efficient, worry-free placement, while MyBridgeCare agencies deliver the clinical support needed—ensuring continuity of care and reducing hospital costs and bed pressures.

Agencies within our network maintain Rapid Ready teams capable of activating staff for same-day hospital discharge. This response time exceeds industry standards for intake—particularly for complex cases and weekend transitions.

All MyBridgeLink network members are carefully vetted to align with clinical standards, responsiveness expectations, and commitment to patient-centered care.

▶ From Hospital to Home: The Process

Barrier Returning Home

▸Delays in placement at new assisted living apartments
▸Change in condition — unable to return on weekends
▸Family unable to promptly establish plan for care
▸Dementia care requiring 24/7 or 1:1 supervision

Awaiting Approvals

▸Pending insurance prior authorizations
▸Pending county approval for Medical Assistance
▸Pending county review for OBRA-Level II PASSAR
▸Pending county assessment for Elderly Waiver

Pending Legal Issues

▸Guardian or conservator needed
▸No healthcare directive or agent
▸No power of attorney
▸Displaced due to real estate issue / sale of home

Respite Care & Palliative

▸Patient exhausted TCU benefits / no coverage
▸Needs time to stabilize before community placement
▸Caregiver / spouse hospitalized or not able to support right now
▸Hospice / Palliative / Comfort — supporting families by allowing time to process end-of-life plans in a comfortable setting, or waiting for a preferred Residential Hospice Home to have a bed available.

Clinical Capability Tiers for Placement & Care Coordination

Tier 1 – Lower Acuity / Transitional (Short-Term Recovery & Support)

Patients who are medically ready for discharge but require short-term support to safely transition home.

Pre/Post Orthopedic Surgery Recovery
Short-term recovery support including mobility assistance and therapy coordination.
COVID+ (awaiting TCU placement)
Isolation-capable placement while awaiting next level of care.
Catheter / PureWick Management
Routine urinary management requiring basic clinical oversight.
Skilled Care Services (as ordered)
RN, PT, OT, SLP, HHA, MSW services to support recovery, rehabilitation, and discharge planning.

Tier 2 – Moderate Acuity (High Support + Coordinated Services)

Patients requiring consistent support, often with a mix of clinical and non-clinical care.

End-of-Life Care with Hospice
Comfort-focused care in coordination with hospice providers, supporting both patient and family.
Dementia with 1:1, 24/7 Supervision Needs
Continuous supervision for safety, redirection, and behavioral support.
Bariatric Care (up to 500 lbs)
Specialized support including mobility assistance, equipment needs, and caregiver safety.
Home Infusion Therapy
IV medication administration (e.g., antibiotics, hydration) with nursing oversight.
Daily Wound Care / Wound Vac
Skilled wound management including dressing changes and negative pressure therapy.

Tier 3 – High Acuity (Advanced Clinical Support Required)

Patients requiring complex, high-skill clinical oversight and coordination.

Trach Care
Ongoing tracheostomy management requiring skilled nursing, suctioning, and airway monitoring.
TPN (Total Parenteral Nutrition)
IV-administered nutrition requiring central line care, monitoring, and infection prevention.
Dialysis (transport to clinic as needed)
Patients requiring routine dialysis treatments with coordination of safe transport and post-treatment support.
NG Tube / PEG Feeding
Enteral feeding management requiring skilled oversight for nutrition delivery, tube care, and monitoring.

❌ NOT SUPPORTED (Outside Current Care Model)

Require specialized infrastructure, supervision, or regulatory environment

• Active Chemotherapy (Oncology Care)

Requires oncology-directed treatment, specialized infusion environments, and hazardous drug handling not aligned with residential care settings. Typically managed through oncology infusion centers or specialized programs.

But we can support:

▸Patients between chemo cycles
▸Post-treatment stabilization
▸Waiting for next oncology step

• Trach Care (Complex / Unstable)

Advanced airway management requiring continuous skilled nursing and rapid clinical escalation capabilities.

• Behavioral Health / Acute Psychiatric Needs

Requires licensed behavioral health environment and specialized staffing.

• Substance Use Detox / Withdrawal Management

Requires medically supervised detox programs.

👉 All referrals undergo clinical review to ensure appropriate care alignment and safety.

🔄 Strategic Positioning: Where BridgeCare Fits

BridgeCare fills the gap for patients who are:

✔️Medically ready for discharge
✔️Unable to go home safely
✔️Delayed due to placement or coordination barriers

BridgeCare does NOT replace:

•Hospitals • SNFs • Oncology treatment centers

👉 Instead, it accelerates movement between them

"BridgeCare supports patients who are medically ready for discharge but remain in the hospital due to placement barriers. We provide rapid placement and coordinated care for appropriate patients, while aligning higher-acuity needs with the right clinical partners or care settings."

Agency Partnerships We Coordinate

Skilled Home Care — RN, PT, OT, SLP, HHA Private Duty — RN, CNA, HHA Contracted Social Workers Primary Care Providers & Clinics Assisted Living Care Providers Hospice Agencies Specialty Nursing Relocation & Moving Companies

Reduce Discharge Delays — Starting This Month

Discharge medically ready patients within 24 hours and free up critical bed capacity.

📅 Schedule Strategy Call →

Start Referral

For same-day placement and availability checks.

Contact Central Intake →

Billing Overview

BridgeCare Health Network may enter into payment agreements with hospitals to facilitate timely discharge when patient or family financial access is delayed. Under such agreements, BridgeCare bills the hospital directly for an initial 5-day stay, ensuring continuity of care without delay.

	MyBridgeSuites	Skilled Nursing Facility	Direct Home Discharge
Daily Rate	Base rate All-inclusive lodging & coordination	$400–$650/day median (semi-private to private)	$0–$840+/day (varies by hours of aide support needed)
Admission Speed	Same day	1–5+ days (bed availability & auth)	24–72 hrs (home health setup)
Insurance / Medicare	Private pay No auth delays, no 3-day rule	Medicare days 1–20 at 100% Days 21–100: $194.50/day copay Requires 3-day qualifying hospital stay	Medicare covers skilled visits only (not 24/7 aide support)
Room / Accommodation	Private* / Shared Room Home-like environment	Semi-private standard Private available at higher daily copay	Home environment (may not be medically set up)
Minimum Stay	5 days	30–90 days preferred by most facilities	None
24/7 Care Coordination	Yes Agency staff coordinated by BridgeCare	Yes Facility staff; stretched ratios common	No Family/patient must manage all scheduling
Medical Equipment Included	Yes Hospital bed, lift recliner, commode, bed alarm & more	Yes Standard facility equipment	Must source or rent Typically 48–72 hr delivery wait
Therapy / Rehab Access	Coordinated via home health agency Onsite PT, OT, SLP through agency partners	On-site PT/OT/SLP Typically 1–2 hrs/day	Skilled visits 2–3x/week; Start of care often delayed Medicare-covered home health
30-Day Hospital Readmission Risk (highest risk is in first 7 days)	Lower 24/7 coordination & monitoring	~15–20% national avg (CMS, varies by diagnosis)	~20–25% national avg (AHRQ; higher without 24/7 support)
Family Coordination Burden	Low BridgeCare manages staffing & coordination	Low Facility handles day-to-day	High Family coordinates all care, equipment & visits
Prior Authorization Required	No	Yes Can delay discharge 24–72+ hrs	Partial Skilled visits require physician order
	*no additional cost

MyBridgeLink
Earlier Discharges. Better Outcomes. Costs Contained.

We Partner with Your Team to Resolve Discharge Barriers

Reduce Discharge Delays — Starting This Month

Start Referral

Billing Overview

BridgeCare vs. SNF vs. Direct Home Discharge

MyBridgeLinkEarlier Discharges. Better Outcomes. Costs Contained.

We Partner with Your Team to Resolve Discharge Barriers

Reduce Discharge Delays — Starting This Month

Start Referral

Billing Overview

BridgeCare vs. SNF vs. Direct Home Discharge

Same Day Admission Inquiry

MyBridgeLink
Earlier Discharges. Better Outcomes. Costs Contained.