BridgeConnect – Streamlining AAA Referrals

Role: Program Manager

When the pandemic disrupted normal discharge workflows, social work teams across Western Pennsylvania struggled to connect patients with Area Agencies on Aging (AAA). In-person coordination was limited, and communication gaps were leaving vulnerable patients without critical post-discharge support.

To close this gap, I created a new referral process within CarePort Care Management that directly linked hospital teams to local AAA offices. By embedding the process into our existing discharge system, social workers could easily identify and refer patients for community services like home assistance, transportation, and nutrition support—without additional manual steps.

I also introduced a tasking system within CarePort to help track referrals, ensuring that every patient was followed through from discharge to service completion. What began as a single-site pilot quickly expanded to five counties across Western PA, with other regional hospitals adopting the model due to its success and simplicity.

Impact: BridgeConnect became a vital tool for improving transitions of care for older adults. It strengthened relationships between hospitals and community agencies, reduced care gaps, and ensured that patients leaving the hospital had the resources and support they needed to recover safely at home. The model remains active across multiple health systems today.