Built for Area Agencies on Aging and community organizations

Prevent avoidable readmissions in the first 30 days after discharge.

Bridge30 is the operational workspace your CHWs, coaches, and supervisors use to follow up with high-risk older adults — every call, visit, and outcome tracked end to end.

No credit card required. HIPAA-oriented architecture. BAA available.

38
Avg. enrolled clients per coach
100%
Tracked 30-day outcomes
4.2 hrs
Time saved per episode

Everything your team needs to run a real readmission prevention program.

Configurable workflows, structured assessments, and outcome reporting — without spreadsheets, paper packets, or duct-taped tools.

Client & caseload management

Centralized client records with risk tier, episode timeline, caregiver, payer, and full activity history.

Standard assessments

Readmission risk, ED utilization, medication reconciliation, social needs, and self-management readiness.

Risk scoring & alerts

Configurable weighted scoring with Low / Medium / High tiers and supervisor escalations for high-risk cases.

Encounter logging

Phone outreach, home visits, care coordination, transportation, and caregiver coaching — all timestamped.

Outcome reporting

30-day readmission, ED revisit, PCP follow-up, and timely first-contact rates by staff and program.

HIPAA-oriented controls

Tenant isolation, role-based access, audit trail, and consent capture built in from day one.

Workflow

A clear 30-day journey for every enrolled client.

Bridge30 ships with a strong default workflow that mirrors how high-performing AAAs already operate, then lets your administrators tune statuses, automation, and risk weights to match your program.

  • Manual referral entry with discharge details
  • Eligibility and consent capture in one flow
  • Auto-opened 30-day episode with risk tier
  • Tasks generated by risk and assessment results
  • Encounters logged across every touchpoint
  • Closure with outcome tracking for reporting
Episode timeline
Active
Welcome call completed
18 min · CHW Maria L.
Day 1
Home visit + medication review
52 min · Caregiver present
Day 3
PCP follow-up confirmed
Dr. Patel · scheduled 4/30
Day 7
Self-management check-in
No red flags reported
Day 14

Built for every role on the team.

From intake to supervisor oversight, each role gets a focused, secure view of the work that matters.

CHWs & Coaches

Daily caseload, tasks due, quick encounter capture, and one-tap follow-up scheduling.

Supervisors

Productivity snapshots, high-risk monitoring, overdue queues, and review approvals.

Administrators

Branding, program length, risk weights, automation, user invitations, and exports.

Ready to run a tighter, more accountable program?

Spin up your organization in under five minutes. We'll seed your account with realistic demo data so your team can explore before going live.