Transitioning from the hospital back into the community after facing acute illness or injury can be challenging for patients, families and care partners. Whether it’s returning to health and wellness or living with illness or disability, many social and structural determinants of health shape and influence the experience of leaving the hospital. Support looks different for every person and supporting a smooth discharge process requires a holistic approach. 

What is Bridge-to-Home?

Healthcare Excellence Canada (HEC) led the Bridge-to-Home spread collaborative from 2018-2020 and focused on improving care transitions from acute care to home and community through the implementation of a patient-oriented care transitions bundle. This bundle consisted of the Patient-Oriented Care Discharge Summary (PODS), “teach-back” methods for patient and family education, involvement of families/care partners in discharge processes, and post-discharge follow-up.

Health Quality BC partnered with Healthcare Excellence Canada to spread Bridge-to-Home to health authorities in BC and the Yukon. The Bridge-to-Home BC & Yukon Collaborative was a quality improvement initiative that focused on care transitions from hospital to home and community. The goals of the collaborative were to: 

  • Improve the patient and care partner experience of transitions from hospital to home/community care.
  • Improve the confidence of patients (care partners) to manage their care as they transition to home.
  • Improve provider experience of care.
  • Reduce avoidable hospital readmissions.
  • Enhance the ability of teams to effectively partner with patients and care partners in improvement initiative.

The shared priority of enhancing home and community care was advanced through the collaborative by spreading evidence-based innovations that provide patients and care partners with the knowledge and confidence they need to manage their care at home or in the community.

About the Program

Running from October 2022 to October 2023, the Bridge-to-Home BC & Yukon Collaborative provided a common framework to strengthen connections between institutional care, patients and care partners, and community/ primary care/ home care. Interventions in the patient-oriented care transitions bundle were tailored by each participating improvement team based on their context and the needs of their patients and care partners, and in alignment with organizational priorities.

The collaborative offered a combination of learning sessions, learning activities, coaching support, connection with other organizations, and access to an expert advisory team. The learning sessions provided participants with new learning, ideas, connections and/or inspiration on a specific goal for the overall Bridge-to-Home program. The collaborative also enhanced capacity for improvement teams to implement future quality improvement projects and to do so with patients and care partners.

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