The Duke Endowment and the North Carolina Healthcare Foundation (NCHF) are pleased to announce the launch of a new initiative, Bridge to Health, which is aimed at improving health for patients with complex care needs. These highest-risk patients often have multiple chronic medical conditions, suffer from substance abuse or mental health conditions rooted in trauma, and have unmet social needs related to homelessness and poverty. Bridge to Health uses a proactive approach designed to engage patients with complex care needs that often cannot be met in traditional outpatient settings. The model provides people with comprehensive, individualized care to improve patient outcomes and decrease the total cost of care by reducing hospital utilization for avoidable health conditions.
The Duke Endowment is providing funding to support six health systems to participate in a pilot program which will optimize the Bridge to Health model by building on collective experience and best practices. The Bridge to Health model was inspired by WakeMed’s Center for Community Health, led by Dr. Brian Klausner and Dr. Theresa Amerson. The Endowment has allocated more than $9.8 million to advance the initiative. The multi‑year investment includes $7.9 million across the six sites – $1.4 million to WakeMed for its role as cohort leader and key advisor and $6.5 million to the five additional health systems as they plan and implement the model over the next four years. The award also includes a $1.9 million investment in technical assistance and evaluation provided by the North Carolina Healthcare Foundation and the Duke-Margolis Institute for Health Policy. Participating health systems are WakeMed Health, Novant Health Forsyth Medical Center, Atrium Health Wake Forest Baptist, Cone Health, ECU Health and UNC Health. These health systems will establish and expand hospital-based transitional (bridging) clinics that are designed to serve the highest-risk patients by stabilizing their acute medical, mental health, and social needs while strengthening collaborative partnerships with primary care providers and community-based organizations to ensure continuity of care.
“We are thrilled to launch the Bridge to Health initiative and partner with NCHF, WakeMed, the participating health systems and Duke-Margolis to learn together, collaborate and refine a care model for patients with acute health and social needs,” said Jay Kennedy, senior program officer with The Duke Endowment’s Health Care program area. “Our goal is to provide a coordinated approach to individualized care for this patient population to help them meet their unique circumstances and support them in achieving long-term stability.”
“We are proud to partner with The Duke Endowment on the Bridge to Health pilot program. This is an exciting opportunity to ensure high-quality health care is accessible to patients across our state who need it most. We are looking forward to the success of this pilot and the participation of six North Carolina health systems,” said Emily Roland, executive director of Program Implementation for NCHF.
The initiative seeks to build a deeper understanding and stronger evidence base regarding the model’s ability to stabilize patients, address unmet social needs, and demonstrate improved health outcomes such as reduced anxiety and depression symptoms, improved blood glucose levels, and decreased unnecessary hospital utilization. This evidence will help advance supplemental payment reform needed to support long-term scale and sustainability. The four-year pilot will include a two-phased approach, with the first year focused on planning and building capacity followed by three years of implementation.
