Bridging the transition from hospital to home

Carolyn’s latest project, a collaboration with Trillium Health Partners, aims to develop a digital tool to help older adults with chronic health conditions make smoother transitions back home from the hospital. The Digital Bridge to Home project will enable improved flow of information between members of the clinical team and with patients.  

“We know that older adults with complex health needs are more likely to experience frequent admissions to the hospital as the transition back home is challenging,” says Carolyn.

The Digital Bridge will help patients, family caregivers and care teams stay connected about medications, care instructions, follow-up appointments and home care arrangements, all important parts of care transition. Carolyn emphasizes that this tool will also be designed to empower patients with complex health needs to take an active role in managing their health.

“The focus of this tool will be on supporting the patient in identifying and working towards their own health goals,” says Carolyn. “Goal-oriented care provides patients with a more integrated care experience. Ultimately, this could lead to better outcomes and a better quality of life for patients with chronic conditions.”

The team is using two existing digital tools as the base for this work. Trillium Health Partners’ Care Connector application enhances communication between health care professionals in the hospital. On the community side, Carolyn has designed an app called electronic Patient Reported Outcomes (ePRO) that enables the patient, family caregivers and primary care providers to communicate about health goals and track progress.

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The team will integrate these two apps to create their new tool. They will co-design the integration with patients, family caregivers and health care professionals to ensure that the app addresses everyone’s needs.

Getting support for a new digital tool can be a challenge, but Carolyn says COVID-19 is making people more open to using technology in health care. “We started this project before the COVID-19 pandemic and it was paused for several months. Now we are recruiting our advisory committee members and the energy and desire we’re seeing is much greater than before. People see the potential in virtual care and are now interested in other ways technology can support care.”

Carolyn and her colleagues will test the new app with patients and family caregivers at both Trillium Health Partners and Bridgepoint Active Healthcare. They hope to one day implement it on a broad scale.