Partnering with patients to improve transitions in care

by Nadine Morris Carol Fancott, Director | 25 Mar, 2019 | 25 Mar, 2019

Every day, people from across Canada are discharged from institutional care settings. This can be a vulnerable time for patients, especially if they don’t feel they have the information they need to confidently care for themselves after they leave. In particular, transitions from hospital to home can be challenging and pose potential risk for patients at a time of significant stress.

This week, CFHI announced the 16 organizations who will participate in our Bridge-to-Home Spread Collaborative. Through this 17-month quality improvement initiative, CFHI is tackling a long-standing issue in healthcare, one that has been identified by patients and families time and time again. That is that patients and their families or caregivers, often feel ill-prepared when they leave institutionalized care – whether it be from hospital, rehabilitation or from an out-patient setting. And there is evidence to show that poor transitions in care can result in adverse events and poor patient outcomes, emergency room visits, and even hospital readmissions. 123

A transition in care involves any action that ensures the coordination and continuation of healthcare for a patient who is moving between different locations or levels of care. This can happen at many different points in the health system, including the transition to home. Through the Bridge-to-Home Spread Collaborative we are asking the question: How do you make the transition home better for patients and their families or caregivers?

Part of the answer is through the meaningful involvement of patients and families.

From the conception of this program to its design—the innovation we’re spreading was co-designed together with patient partners—to selection of teams, curriculum development; as team coaches and faculty, right through to evaluation—patients and caregivers are involved throughout the multiple layers of this initiative. They are also playing an important role as members on all participating teams.

Teams participating in this Collaborative will work together with patient and family advisors to adapt, design, implement and evaluate a patient-oriented care transitions bundle that will improve their experience of transitions from institutionalized care to home or community care.

The bundle includes:

  1. A patient-oriented discharge summary (known as PODS): PODS is an innovation from OpenLab, a design and innovation lab with University Health Network (UHN). A simple tool that was codesigned by patients and providers in 2014, it is used to engage patients and caregivers in collaborative discharge planning to ensure they consistently get the information they need to transition home. It has been adapted for several different care settings across the spectrum, such as paediatric, rehabilitation, acute, adult care, mental health, and surgery.
  2. Patient and caregiver education: Providing patients and caregivers with the information they need to transition and ensuring they understand the information is critical for success. Teach-back is one educational method that involves patients in their care by asking them to explain, in their own words, what they have learned to manage their care at home.
  3. Welcoming caregivers as partners in care: Family members and caregivers are important allies for quality and safety. Involving them in transition planning, education and support once the transition is underway strengthens their role in helping to support the patient following discharge.
  4. Post-discharge follow-up:  Teams will look at strategies to best support patients and caregivers following discharge that fits within the context of their work.

This initiative has been built around the fundamental principle that when patients can understand and be part of their healthcare, can take control of the information they need, feel confident, and are part of the decision-making process, then they can leave an institutionalized care setting ready to manage their care as they transition to home. That’s a win for everyone!

Learn more about the Bridge-to-Home Spread Collaborative.


1 Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3), 161-167. doi:200302040-00007 [pii]

2 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 [doi]

3 Coleman, E. A., Parry, C., Chalmers, S., & Min, S. J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822-1828. doi:166/17/1822 [pii]