Bridge-to-Home Spread Collaborative

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

Evidence demonstrates that transitions in care may result in adverse events and suboptimal patient outcomes, emergency room visits, or hospital readmissions.1 In Canada, approximately 8.5 percent of adult acute care patients were readmitted to hospital within 30 days of their initial discharge, costing an estimated $1.8 billion2 and accounting for 11 percent of all acute hospital costs.3 While not all readmissions are avoidable, research suggests between nine and 59 percent of readmissions could be prevented.4

The Canadian Foundation for Healthcare Improvement’s Bridge-to-Home Spread Collaborative improves the quality of care – and patient, caregiver and provider experiences of care – during transitions from hospital to their home.

Through this 17-month Collaborative, 16 teams from seven provinces are partnering with patients, family and caregivers and providers to implement a patient-oriented care transition bundle which gives patients and their caregivers the information and confidence they need to transition well from hospital to home.

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

The Bridge-to-Home Spread Collaborative is driving the rapid adoption of an evidence-informed innovation that provides patients, families and caregivers with the knowledge and confidence they need to manage their care at home or in the community.

The goals of the 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 experiences of care
  • Enhance the ability of teams to effectively partner with patients and caregivers in improvement initiatives
  • Reduce avoidable acute care hospital readmissions

The participating teams are collecting data to report on: experiences of patients, caregivers and healthcare providers; confidence of patients and caregivers to manage their care as they transition from hospital to home; and hospital readmissions. Subscribe to our newsletter to see the results of the Bridge-to-Home Collaborative when they are available in 2020.

The Approach

The participating teams are supported by CFHI to implement a patient orientated care-transition bundle. Patient partners have been integral in Bridge-to-Home and are part of steering and evaluation committees and as faculty members and coaches. Teams are supported with an education framework that includes webinars, workshops, peer-to-peer networking and coaching. In addition, up to $40,000 per team is provided by CFHI in seed funding.

Teams are supported to enhance their capability and capacity to partner with patients, family and caregivers. They work in partnership with patients, family and caregivers to adapt the bundle to their local context and ensure a well-rounded discharge process with appropriate follow-up.

The bundle includes:

  • A patient-oriented discharge summary (PODS). The University Health Network’s OpenLab co-designed the PODS tool together with patients and caregivers. It provides patients, families and caregivers with clear information in five areas they have deemed important: medications, activity and diet restrictions, follow-up appointments, symptoms to expect, and information about who to call if there are questions.
  • Techniques, such as teach-back,5 that improve patient and caregiver understanding about the patient’s health condition
  • Ways to actively engage and partner with patients, family and caregivers, including involvement during an admission process, interprofessional rounds or discharge planning
  • Post-discharge follow-up that provides details about the next steps for the patient.

The Collaborative runs from fall 2018 until 2020.


The Bridge-to-Home Collaborative brings together 16 teams from across seven provinces.

Meet the teams and their projects

Tool / Resource

CFHI Quality Improvement Primer: Partnering with Patients, Families & Caregivers in Co-designing Care
Read more >

What We Do

Better Care Closer to Home and the Community


Pulling Back the Curtain: My First Year as CFHI’s Patient Partner
Read more >

When you are leaving the hospital, you are thrust into a situation where you are nervous and vulnerable. Having the correct understanding of my condition and a care action plan is essential for me to confidently manage my care and maintain my quality of life

-Sue Johnson,
Patient Partner (2018)

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. Retried from:!/indicators/006/all-patients-readmitted-to-hospital/;mapC1;mapLevel2;/ 

3 Canadian Institute for Health Information. (2012). All cause readmission to acute care and return to the emergency department. Retrieved from!/indicators/006/all-patients-readmitted-to-hospital/;mapC1;mapLevel2;/