The Goals of the Bridge-to-Home Spread Collaborative
This 17-month spread collaborative will support up to 12 interprofessional teams to implement key domains of the ideal care transition from hospital to home, including discharge planning, timely and relevant information, patient and caregiver education, and post-discharge follow-up. This collaborative will also enhance partnerships within interprofessional teams, including patients and caregivers, hospital, home and community providers and leaders who will work together to adapt, design, implement and evaluate a patient-oriented care transitions bundle that responds to patient and caregiver needs and deepens their involvement as part of the circle of care.
The goals of the spread collaborative are to:
-
Improve the patient and caregiver experience of transitions from hospital to home/community care
-
Improve the confidence of patients (and caregivers) 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 caregivers in improvement initiatives
This collaborative will advance the shared priority of enhancing home and community care by spreading evidence-based innovations that provide patients and families with the knowledge and confidence they need to manage their care at home or in the community.