Bridging the Divides at Christiana Care Health System

Rationale / Objectives

Bridges began in July 2012 and is part of a three-year grant funded for $10 million by the Center for Medicare and Medicaid Innovation. The goals of the program are to improve the delivery of evidence-based care tailored to each individual patient, resulting in better health, better health care and lower costs.

Project/Program Description & Major Achievements

Bridging the Divides (Bridges) is a care management program focused on helping 2,200 patients with ischemic heart disease transition successfully from hospital care and improve their long-term health. Christiana Care Health System works closely with community doctors and specialists to support patients in the Bridges program for at least one year after they are discharged from the hospital. A core component of the program is improving the technology infrastructure to make data from clinical sites more available to the providers caring for each patient. The new system incorporates data from many places that patients receive care, including:

  • Inpatient and outpatient electronic medical records from primary care and specialty physicians
  • Statewide lab and hospital use information from the Delaware Health Information Network (DHIN)
  • This program is supported by a Health Care Innovation Award from the Center for Medicare and Medicaid Innovation.

Results from the initial pilot included: enhanced patient satisfaction, including 91% of patients receiving the right amount of follow-up after discharge and 88% were more optimistic about their future; a streamlined care management process with improved workflows resulting in a 50% reduction in the number of process steps required for a care manager to access and process program participant readmissions; a 43% reduction in overdue tasks; improved depression scores were also achieved. The Bridges program resulted in an annual cost savings of $1.75 million.

Lessons Learned

  • Program development needs to be sequential, not concurrent – IT platform needs to start first because it has the longest lead time
  • Excellent care management is hard to do
  • Patients don’t yet understand the role of aggressive care management
  • Must understand the right metrics to measure
  • Address socioeconomic and psychosocial factors
  • Predictive analytics may be superfluous
  • There is a need to expand the program into additional high-risk populations to measure larger numbers of patients

Further Description

Christiana Care Health System, headquartered in Wilmington, Delaware, is one of the country’s largest health care providers, ranking 21st in the United States for hospital admissions. Christiana Care is a not-for-profit major teaching hospital with two campuses and more than 250 Medical-Dental residents and fellows. Christiana Care is recognized as a regional center for excellence in cardiology, cancer and women’s health services. The Bridges care management team is known as Care Link Services and includes social workers, nurses, a pharmacist, a health ambassador, a care management supervisor and a physician adviser. As a cardiac patient plans to transition home or into a rehab, the Care Link team explains medication, schedules future doctor appointments and makes sure other services are in place.

At home, daily readings of weight, blood pressure and oxygen saturation may be collected. The readings alert Care Link Services to potential problems. Ongoing data collection helps the care team to ad­just treatments as needed. The system also has analytic capabilities to look at data points that are common for patients when they are readmitted. Predictive analytics are used to identify patients who are more likely to experience readmissions, develop complications and need a higher level of care. An electronic portal was recently introduced so that patients and families can use for direct e-mail communication with Care Link Services. Bridging the Divides is fully integrated with the Delaware Health Information Network.

Major Achievements

Metric Result Detail 
% of patients receiving the right amount of follow-up after discharge


See: The Evolution of Population Health Management
% of patients who were optimistic about their future 88%  
% reduction in the number of process steps for care manager to access and process participant readmissions 50%  
Annual cost savings $1.75M  

Future plans include: expanded clinical programming; assuming various risk-based contracts (MSSP, PMPM relationships); the majority of care will be risk-based with effective care delivery models that empower providers and enhance patient/member satisfaction.