Bridge-to-Home

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.

How Bridge-to-Home contributes to better healthcare in Canada

Evidence shows that transitions may result in adverse events and suboptimal patient outcomes, emergency room visits, or hospital readmissions.¹ In Canada, 1 in 11 patients are readmitted within a month of leaving the hospital, representing approximately $2.3 billion in costs per year.² 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:

• Improve the experience of transitioning from hospital to home/community care for patients and essential care partners.
• Improve the confidence of patients and essential care partners to manage their care as they transition to home.
• Improve provider experience of care.
• Reduce avoidable acute care hospital readmissions.
• Enhance the ability of teams to effectively partner with patients and caregivers in improvement initiatives.

What is the Patient-Oriented Care Transitions Bundle?

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:

• different areas of care
  • acute care
  • outpatients
  • rehabilitation
  • emergency care
  • primary care settings
• different patient populations, such as those in:
  • ICU
  • cardiac care
  • general medicine
  • stroke
  • substance use
  • mental health

Current programming

Bridge-to-Home BC and Yukon collaborative

HEC is partnering with Health Quality BC to deliver the Bridge-to-Home BC and Yukon collaborative. The participating teams are Fraser Health’s Regional Access and Flow team, and a newly formed team from the Yukon consisting of the Government of the Yukon (Community Services) and the Yukon Hospital Corporation.

Past programming

Original Bridge-to-Home Spread Collaborative

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:

• improvements in patient and essential care partner experience of care transitions and their confidence to manage at home
• improvements in their ability to effectively partner with patients and essential care partners in improvement efforts
• improved provider experience of care
• reduced avoidable readmissions

Bridge-to-Home in Quebec

In 2021, HEC partnered with the Centre intégré de santé et des services sociaux (CISSS) de la Gaspésie, a team who participated in the original spread collaborative. HEC supported a “train-the-trainer” model across four regions in Quebec to support teams to implement the patient-oriented care transitions bundle. A series of Bridge-to-Home Quebec workshop recordings developed during this partnership is available to support those interested in implementing this model in other contexts. 

This work was done in partnership with the Quebec Ministry of Health and with funding from the Canadian Partnership Against Cancer (the Partnership).

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?lang=en

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