Bridge-to-Home Collaborative Participating Teams

The Bridge-to-Home Collaborative brings together 16 organizations from across 7 provinces.

British Columbia Team

Providence Health Care, British Columbia

The Medicine Program at St Paul's Hospital delivers inpatient care for a wide variety of patients with complex needs by providing a multidisciplinary team equipped to meet patients' physical, emotional, social and spiritual care needs. Units 7C and 7D will implement the patient-oriented care discharge bundle and measure its effectiveness with patients and families.


Alberta Teams

Edmonton Southside Primary Care Network, Alberta

The Edmonton Southside Primary Care Network will build on their existing post-discharge follow-up developed through the Transitions of Care initiative. The initiative connects patients who have recently been discharged into the community with primary care in a timely fashion.

Project partners: Alberta Health Services (AHS) New Edmonton Hospital Campus Project, AHS Virtual Hospital and AHS Home Living.

Central Zone Primary Care Network Committee (Formerly - Red Deer Primary Care Network), Alberta

The Central Zone PCN Committee will focus on improving transitions from acute care (hospital) to primary care (medical home) for all admitted patients and aligning transition processes across the entire zone.

Project partners: Alberta Health Services, Alberta Medical Association, All 12 Central Zone Primary Care Networks, Patient, family and community advisors

University of Calgary, Alberta

The University of Calgary will adapt and implement the patient-oriented care discharge bundle in all four Intensive Care Units in Calgary to better understand what matters to patients and caregivers about their transitions in care.

Project partners: Alberta Health Services (AHS), Critical Care Strategic Clinical Networks, Family and community advisors


Saskatchewan Teams

Saskatchewan Health Authority, Saskatoon, Saskatchewan

The Saskatchewan Health Authority is moving toward a network of community-based care teams. The team will implement the patient-oriented care discharge bundle to improve service and transitions from St. Paul's Hospital Accountable Care Unit to the Nutana Suburban neighbourhood.

Project partners: Community Health Centre at Market Mall, Acute Medical Team at St. Paul’s Hospital, Family and community advisors

Saskatchewan Health Authority, Northwest Saskatchewan

The Saskatchewan Health Authority, NW teams will implement the patient-oriented discharge bundle on three Connected Care/Hospitalist Care units and within their Community Primary Care areas with a goal of reducing hospital re-admissions.


Manitoba Team

Winnipeg Regional Health Authority, Manitoba

The Winnipeg Regional Health Authority Cardiac Program saw a significant increase in the number of people who inject drugs being admitted for infective endocarditis. The team aims to improve transitions from inpatient to community care by implementing the patient-oriented discharge bundle.

Project partners: Main Street Project, Family and community advisors


Ontario Teams

Toronto Rehabilitation Institute, University Health Network, Ontario

Using lessons learned from the implementation of Patient Oriented Discharge Summaries (PODS) on their Inpatient Stroke and Acquired Brain Injury (ABI) Services, Toronto Rehab will customize the transitions bundle for their Stroke and ABI Outpatient Rehab, that seeks to address the challenging transition of patients and caregivers to living in the community.

Project partners: Patient and Caregiver Partners, Central Neighbourhood House, March of Dimes Canada, Toronto Stroke Networks

Sinai Health System, Ontario

Patients of Chinese descent represents one of the largest ethnic groups served by Sinai Health System. To improve their care transitions, we will address the ethno-racial and linguistic differences that often impact determinants of health and outcomes. The team will adapt and co-design the patient-oriented discharge bundle for cultural appropriateness and implement it for this patient population.

Project partners: Carefirst Seniors & Community Services Association, Yee Hong Centre for Geriatric Care, Family and community advisors

St. Joseph’s Health Care London, Ontario

St. Joseph’s Health Care London will implement the patient-oriented care transition bundle to improve the patient and caregiver experience at Parkwood Institute Main Building and St. Joseph’s Hospital sites. This practice will benefit diverse patient populations served by Rehabilitation, Specialized Geriatric Services, Ambulatory Care and Chronic Disease Outpatient programs. The second year of the project will include a focus on spread and sustainability planning across the organization.

Project partners: South West Local Health Integrated Network (LHIN), Thames Valley Health Team, Community Patient and Caregiver Advisors

The Ottawa Hospital, Ontario

The Ottawa Hospital Rehabilitation Centre plans to pilot the initiative on their ABI rehabilitation inpatient unit to improve care transitions. This will then be spread and adapted for the other three patient groups in the rehabilitation centre (Neuromuscular, Complex Ortho, and Short-term Rehabilitation).

Project partners: Peter Moir, Sarah Kaplan, Susan Johnson, Christina Myers (CBI Health/TRAC), Suzanne McKenna (Champlian LHIN ABI Coordinator), TOH-Rehab Centre (Clinical staff, managers, discharge coordinator), Family Practitioner, Family and community advisors

Lakeridge Health, Ontario

Lakeridge Health recognizes the need to improve patient experience in the Emergency Department (ED). The team will implement the patient-oriented discharge bundle to address concerns related to experience of care, care transitions and care planning in the ED.

Project partners: Lakeridge Health is partnering with Central East, Local Health Integration Network Home and Community Care; Central East Local Health Integration Network, Patient and Family Advisory Council; Community Care Durham

South West Continuous Quality Improvement Collaborative (CQIC), Ontario

The CQIC is a regional partnership that will implement the patient-oriented discharge bundle in community and hospital-based mental health and addiction programs across Southwestern Ontario. As part of the B2H Collaborative, three hospital partners: Grey Bruce Health Services (GBHS), Huron Perth Health Alliance (HPHA), and Woodstock Hospital (WH) will also implement the bundle in other service units. GBHS will define a discharge process for its new pediatric unit and strengthen the discharge process for withdrawal services along with rolling out to the acute inpatient unit; HPHA will improve discharge planning processes with clients and community partners in inpatient mental health, medicine and surgical services; and, WH will enhance an existing tool to improve discharge processes in its medicine and mental health services. Additional implementation support for this work is provided by the Ministry of Health and Long-Term Care through the Centre for Addiction and Mental Health’s Provincial System Support Program.

Project partners:

  • Addiction Services of Thames Valley
  • Alexandra Marine and General Hospital
  • Canadian Hearing Society
  • Canadian Mental Health Association, branches in Elgin, Grey Bruce, Huron-Perth, Middlesex & Oxford
  • Choices for Change: Alcohol, Drug & Gambling Counselling Centre
  • Grey Bruce Health Services
  • Huron Perth Healthcare Alliance
  • Mission Services of London, Quintin Warner House
  • Oneida Nation of the Thames
  • Woodstock Hospital
  • Family and community advisors

Quebec Teams

Centre intégré de santé et de services sociaux de la Gaspesie

CISSS de la Gaspesie will focus on the transition between acute care and post-treatment follow up in the community by community care teams for patients undergoing cancer treatment. The team will work to improve the experience of patients, families and caregivers in their care transition and treatment through diverse resources adapted to their needs. The team will create an educational kit, establish a network of patients/clients/family/caregivers and improve communications between the CISSS and the community care teams.

Project partners:

  • Dr Marie-Pascale Pomey, Centre of Excellence on Partnership with Patients and the Public, University of Montreal Hospital Research Centre (CRCHUM)
  • Grand Gaspé Family Medicine Group (Groupe de médecine familiale du Grand Gaspé)
  • Maria Family and University Medicine Group (Groupe de médecine familiale et Universitaire de Maria)
  • OGPAC, Gaspesian cancer organization (Organisme gaspésien des personnes atteintes de cancer)
  • Family and community advisors

Centre intégré de santé et de services sociaux des Laurentides

CISSS des Laurentides will implement the patient-oriented discharge bundle to support transitions for seniors with comorbidities requiring complex care. The bundle will be implemented in four medical unites at the St-Eustache Hospital. The units were chosen due to the issues related to transitions of care in this population (E.g., high rehospitalization rate, communication on medication and care) and a planned training on interdisciplinary partnership and care.

Project partners :

  • Nursing and Clinical Ethics Department (Direction des soins infirmiers et de l'éthique clinique)
  • Senior’s Autonomy Support Department (Direction soutien à l'autonomie des personnes âgées)
  • Multidisciplinary Services Department (Direction des services multidisciplinaires)
  • Professional Services Department (Direction des services professionnels)
  • Performance, Continuous Improvement and Quality Department (Direction de la performance, de l'amélioration continue et de la qualité)
  • Family and community advisors

Newfoundland and Labrador Team

Western Health, Newfoundland

Western Health recognizes the need for patient-oriented transitions to meet the unique needs of the patients admitted to the medicine and surgery units at Western Memorial Regional Hospital. The team plans to implement the patient-oriented discharge bundle to improve the quality of care, increase confidence in the transition to home, and increase discharge satisfaction levels of the medical surgical patients and their caregivers.