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Transitioning from the hospital back into the community after facing acute illness or injury can be challenging for patients, families and care partners. Whether it’s returning to health and wellness or living with illness or disability, many social and structural determinants of health shape and influence the experience of leaving the hospital. Support looks different for every person and supporting a smooth discharge process requires a holistic approach.

What is Bridge-to-Home?

Healthcare Excellence Canada (HEC) led the Bridge-to-Home spread collaborative from 2018 – 2020 and focused on improving care transitions from acute care to home and community through the implementation of a patient-oriented care transitions bundle. This bundle consisted of the Patient-Oriented Discharge Summary (PODS), “teach-back” methods for patient and family education, involvement of families/caregivers in discharge processes, and post-discharge follow-up.

We’ve partnered with Healthcare Excellence Canada to spread Bridge-to-Home to health authorities in BC and the Yukon. The Bridge-to-Home BC & Yukon Collaborative is a quality improvement initiative that focuses on care transitions from hospital to home and community. The goals of the collaborative are to:

  • Improve the patient and care partner experience of transitions from hospital to home/community care
  • Improve the confidence of patients (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 care partners in improvement initiative.

This collaborative will advance the shared priority of enhancing home and community care by spreading evidence-based innovations that provide patients and care partners with the knowledge and confidence they need to manage their care at home or in the community.

Learning Modules

The collaborative will offer a combination of interactive webinars (via Zoom) and (potentially) in-person sessions, to share knowledge and techniques on a specific topic into everyday practice. Each period (of project work) helps translate theory into practice. The collaborative will take place over five modules delivered over the course of a year (dependent on COVID-19 pandemic status).

Each module kicks off with a learning session which provides participants with new learning, ideas, connections and/or inspiration on a specific goal for the overall Bridge-to-Home program. The rest of the module is dedicated to time to apply that learning through recommended activities, connecting with other participants and coaching support from the Council and an expert advisory team.

How to Apply

The deadline to apply was September 09, 2022 and the Call for Applications is now closed. 

Please download and review the detailed Call for Applications if you would like to learn more about the program.

Contact us at for more information.

Benefits of Participating in the Collaborative

Health care jurisdictions and accrediting bodies have increasingly focused on the patient experience of care. The Bridge-to-Home collaborative seeks to improve the patient and care partner experience as they transition from hospital to home by implementing a patient-oriented bundle that has been co-designed with patients and care partners to meet their needs.

This collaborative will provide a common framework to strengthen connections between institutional care, patients and care partners, and community/primary care/home care. Interventions will be tailored by each improvement team based on the context and needs of their patients and care partners, and in alignment with organizational priorities.

Working together using an all-teach-all-learn approach, improvement teams will enhance their capacity to partner with patients and care partners and improve transitions using a quality improvement methodology. The collaborative will also enhance capacity for improvement teams to implement future quality improvement projects and to do so with patients and care partners.

Improvement teams will also have access to a range of valuable resources to help organizations spread their improvement beyond their initial site(s). These resources include:

  • Seed funding of up to $40,000 per participating health authority
  • Support to develop partnership models that include patients and care partners for quality improvement
  • Support for the implementation and spread of a patient-oriented transition bundle
  • Support for performance measurement and evaluation
  • Peer-to-peer networking and exchanges
  • Educational webinars focused on patient-oriented care transitions, patient engagement for quality improvement, improvement methodology, and change management
  • In-person and/or virtual workshop(s) to foster cross-team learning (TBC)
  • A network of expert faculty and coaches

Key Dates

Application Process

  • Call for applications: July 2022
  • Pre-Application Calls: August 2022
  • Application deadline: September 9, 2022
  • Notify all teams of acceptance into the collaborative: September 23, 2022
  • Sign tri-partite agreements: September – October 2022

Collaborative Learning Series

  • October 2022: Learning Module 1
  • December 2022: Learning Module 2
  • March 2023: Learning Module 3
  • June 2023: Learning Module 4
  • October 2023: Learning Module 5