Bridge-to-Home Spread Collaborative: Partnering with Patients and Caregivers to Improve Quality and Patient Experience through Care Transitions

What is the Bridge-to-Home Spread Collaborative?

Transitions from hospital back into the community can be challenging and pose potential risk for patients at a time of significant stress. Without the right information, patients can feel confused and unsure of what to expect when they leave the hospital.

Bridge-to-Home is a 17-month spread collaborative with a goal to improve the quality of care and patient and caregiver experiences of care during transitions from hospital to home.

Participating improvement teams will implement a patient-oriented care transitions bundle that gives patients and caregivers the information and confidence they need for a safe transition from hospital to home. Patients and caregivers will be active partners throughout this quality improvement initiative.

The patient-oriented care transitions bundle includes:

  • A patient-oriented discharge summary (known as PODS) which includes clear information on medications, activity and diet restrictions, follow-up appointments, expected symptoms (including worrisome symptoms that need further attention) and contact information for providers if the patient has more questions.
  • Patient and caregiver education
  • Involvement of caregivers as part of the circle of care
  • Post-discharge follow-up

The Bridge-to-Home Spread 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.

Sue Johnson, Patient Partner


Participating teams

The Bridge-to-Home Collaborative brings together 16 organizations from across 7 provinces.
Find out where they are from and learn more about their projects.


Key Dates

Key Dates

Last Updated: March 2019