Bridge-to-Home aims to improve care transitions from hospital to home for patients, essential care partners, and providers. Transitions from hospital back to home can be challenging and pose risks during a time of significant stress, especially for patients and their essential partners.
Bridge-to-Home improves the quality and safety of transitions for patients, essential care partners and providers by working with participating teams from across the country to implement a patient-oriented care transition bundle.
Evidence shows that transitions may result in adverse events and suboptimal patient outcomes, emergency room visits, or hospital readmissions.1 In Canada, While not all readmissions are avoidable, research suggests between nine and 59 percent of readmissions could be prevented.3
Recognizing this, Bridge-to-Home drives the rapid adoption of an evidence informed innovation that provides patients, families and essential care partners with the knowledge and confidence they need to manage their care at home or in the community, especially during transitions.
The goals of Bridge-to-Home are to:
The bundle consists of the Patient Oriented Discharge Summary (PODS), ‘teach-back’ methods for patient and family education, involvement of patients and essential care partners in the discharge process and post-discharge follow-up.
The bundle is highly adaptive and fits the context of:
The first iteration of Bridge-to-Home launched in 2018 and ran through 2020. It brought together 16 teams from across seven provinces to implement the patient-oriented care transitions bundle. The teams were composed of healthcare leaders and staff, patients and families from across .
Participating teams reported:
1 Burke, R. E., Kripalani, S., Vasilevskis, E. E., & Schnipper, J. L. (2013). Moving beyond readmission penalties: Creating an ideal process to improve transitional care. Journal of Hospital Medicine, 8(2), 102-109. doi:10.1002/jhm.1990
2 Canadian Institute for Health Information. [Online] All Patients Readmitted to Hospital. Retrieved from: https://yourhealthsystem.cihi.ca/hsp/inbrief.#!/indicators/006/all-patients-readmitted-to-hospital/;mapC1;mapLevel2;/
3 Canadian Institute for Health Information. (2012). All cause readmission to acute care and return to the emergency department. Retrieved from: https://publications.gc.ca/collections/collection_2013/icis-cihi/H118-93-2012-eng.pdf