PRP041: Building a Digital Bridge to support patient-centred care transitions from hospital to home

Jason Nie, MSc; Terence Tang, MD, FRCPC; Michelle Nelson, PhD, MA; Hardeep Singh, PhD, MScOT; Alana Armas, MSc; Mayura Loganathan, MD; Carolyn Steele Gray, PhD, MA


Context: Care transitions from hospital to home can be a time of vulnerability for people with complex care needs. Incomplete information transfer or poor communication between the various clinicians (in hospital and primary care) and organizations involved can impede access to needed support and resources. Establishing digitally supported communication that enables person-centred care and self-management can offer advantages for patients transitioning from hospital to home. Objective: To support effective transitions from hospital to home for people with complex care needs through the design, development and implementation of a digital communication platform – the Digital Bridge to Home. Study Design: Iterative co-design with patients, caregivers, hospital and primary care providers will inform development of the Digital Bridge transition workflow, followed by a non-randomized pragmatic evaluation of impact and outcomes. Embedded ethnography will be included to capture contextual and process data to inform the implementation assessment and development of a scale and spread strategy. Setting: Two hospital systems in Ontario, Canada that provide acute, rehabilitation and primary care. Population studied: Patients ≥60 years of age with ≥3 chronic conditions transitioning from hospital to home (n=300). Intervention: Digital Bridge builds on the foundation of two validated technologies; Care Connector, designed to improve inter-professional communication in hospital, and the electronic Patient Reported Outcomes (ePRO) tool designed to support goal-oriented care planning and self-management in primary care settings. Outcome Measures: Care Transitions Measure-3 to assess transition quality; Relational Coordination to evaluate communication and relational aspects of teamwork. Results: It is anticipated that Digital Bridge will improve transition quality and communication across hospital and primary care, leading to greater shared situational awareness during care transitions. Expected Outcomes: It is expected that i) patients will experience improved care transitions and health-related quality of life, 2) clinicians will experience greater efficiency in their coordination of care efforts, and potentially fewer errors and missed information, 3) standardize care transition practices across organizational boundaries, and 4) reduce unnecessary readmission or emergency department visits by patients post-discharge.
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Edmond Ramly, PhD 11/24/2020

Wonderful work! Curious to learn more about your iterative co-design process and barriers and facilitators you encountered in engaging your diverse set of stakeholders

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