NTOCC WebinarDemonstration of NTOCC's Transitions of Care Evaluation Software

originally presented on
Friday, April 13, 2012 (3:00 PM - 4:00 PM EDT)

Watch the recent demonstration of the new web-based Transitions of Care Evaluation Software. Ed Davidson, PharmD, MPH, creator of the program and long standing NTOCC Advisors Council member, walks through the program, provides tips for individuals and organizations, and answers attendee questions regarding this tool.

Watch the Recorded Webinar

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register nowWEBINAR: Coordinating TOC Across Multiple Care Settings

Wednesday, February 4, 11a CST
Continuing Education: Nursing 1.2 hours , CCMC 1.5 hours, NASW 1.5 hours
Speakers:Jessica Grabowski, Walter Rosenberg, Bonnie Ewald

National readmission rates are holding steady and the influx of new post-ACA patients is starting to significantly burden the healthcare system. With hospitals under the microscope more than ever before, novel and underused approaches to transitional care are emerging as possible solutions to this potential utilization crisis. In this webinar, we will make the case for how social work is uniquely poised to serve a critical role in this environment due to the comprehensive lens it brings to patient assessment and intervention. We will specifically discuss the Bridge Model of transitional care, a social work-based transitional care intervention designed for older adults discharged from an inpatient hospital stay.

This webinar will describe the important role that social workers and hospital-community partnerships play in transitional care. We will highlight the six guiding principles of the Bridge Model and will explore in detail the continuous quality improvement process that sites undergo. Initial successes of the model have led to 50+ organizations around the country replicating Bridge, and we will share recent findings on the impact of Bridge on healthcare outcomes.

Learning Objectives

  1. Describe the unique role of social worker in transitional care
  2. Explain the core components of the Bridge Model
  3. Define the continuous quality improvement process of the model
  4. Discuss the impact of Bridge on healthcare outcomes

About the Speakers
Jessica Grabowski, LSW, is the Program Manager of the Aging Resource Center at Aging Care Connections. At Aging Care Connections, a Care Coordination Unit in La Grange, IL, she oversees The Bridge Model of transitional care which is on-site at Adventist La Grange Memorial Hospital and six surrounding skilled nursing facilities.  Jessica supervises master level social workers offering older adults and their families the opportunity to explore and secure community resources and services prior to discharge from the hospital and skilled facilities.  At the hospital and skilled nursing facilities, she provides in-service training to staff on the aging network, aging issues, and community-based services for older adults.  Jessica is a part of the management team for the Bridge Model National Office (BMNO).  She assists in the development and replication training of the Bridge Model.  She received her MSW from University of Chicago and BA from Indiana University.

Walter Rosenberg is the Manager of Transitional Care at Rush University Medical Center where he runs the transitional care team, oversees business planning of the department, conducts program development and evaluation, manages the departmental budget, and provides clinical social work services.  He serves on the Readmission Steering committee and the Impact and Innovation team.  Walter is also the Program Manager at the Bridge Model National Office (BMNO).  As the BMNO representative for Rush, Walter heads its model development, quality improvement, and community partnership efforts, and is a lead trainer for its Bridge Model of transitional care.  Walter serves on the advisory board for the Dominican University Graduate School of Social Work, and he received his MSW and BA from the University of Illinois at Chicago.

Bonnie Ewald is a Program Coordinator for Health & Medicine Policy Research Group, a non-profit health policy center that promotes policy and program development that improve the health status of all people in Illinois. In this role, she administers the Bridge Model National Office, develops various forums on health systems reform for providers and stakeholder groups, and mentors individuals in a variety of outcome-driven community work. Bonnie received a BS from the University of Wisconsin at Madison.


WEBINAR: Using Mobile Technology To Predict Hospitalization Risk Using Community Workers: Resetting The Standard For The Least Expensive Care Transitions

Wednesday, Feb. 18, 11 a.m. CST
Speakers: Andrey Ostrovsky
Registration - Coming soon!

The session will breakdown the costs of traditional care transitions models to highlight limitations to their sustainability. Dr. Ostrovsky will then share research showing alternative approaches to care transitions that use workforce innovation that has led to a more cost-effective approach to reducing readmissions. He will also share new research showing how mobile technology can empower community workers and nurses to predict 30-day hospitalization risk.


-List at least two opportunities to improve health for vulnerable populations through the Affordable Care Act
-Understand the limitations of the current digital health innovation ecosystem
-List at least two approaches to care transitions


Andrey Ostrovsky, MD, is a practicing physician and social entrepreneur who leads Care at Hand's executive management and strategic vision. He has led teams at the World Health Organization, United States Senate, and San Francisco Health Department toward health system strengthening through technology. Andrey has contributed to legislation at the city and national level to advance care delivery for vulnerable populations. And he serves on several boards and committees for Foundations as well as Federal and State Committees shaping standards and measures for interoperability, quality, and innovation in healthcare. He is a published researcher in public health informatics, quality improvement, healthcare innovation, social entrepreneurship, and care coordination. 

Andrey holds a Medical Doctorate and undergraduate degrees in Chemistry and Psychology Magna cum Laude, and is a member of Phi Beta Kappa. Andrey is completing his pediatrics residency training in the Boston Combined Residency Program at Boston Medical Center and Boston Children's Hospital and is a clinical instructor at Harvard Medical School.

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