Aptly named Digital Bridge to Home, this tool is designed to streamline communication between patients, family caregivers, and hospital and primary care healthcare providers during the critical transition from hospital back to the community.
Developed under the leadership of Dr. Carolyn Steele Gray, a Senior Investigator at Sinai Health’s Science of Care Institute and Lunenfeld-Tanenbaum Research Institute, and in collaboration with Trillium Health Partners, the tool addresses a longstanding gap in healthcare. Dr. Steele Gray holds a Tier 2 Canada Research Chair in Implementing Digital Health Innovation at Sinai Health and the University of Toronto and is working with co-leads Drs. Terence Tang (Trillium Health Partners) and Michelle Nelson (Sinai Health). For adults with complex care needs, the journey from hospital to home often leads to confusion, unmet care needs, and higher risks of hospital readmission. The Digital Bridge aims to change that.
Building bridges for better care
Working with technology partner Careteam Technologies, the web-based tool was co-designed with input from patients, caregivers, and healthcare providers, ensuring it meets the unique challenges faced by those navigating care transitions. It focuses on patients with multiple chronic illnesses, social challenges, and frequent hospital visits—individuals who represent a small percentage of the population but account for a disproportionate share of healthcare costs.
“Patients with complex healthcare needs are at their most vulnerable when transitioning out of the hospital,” said Dr. Steele Gray.
“Our goal is to ensure continuity of care, empowering patients and their families while equipping healthcare providers with the tools to offer seamless support.”
The tool centralizes vital information, allowing patients, caregivers, and care teams to stay connected about patient goals, care instructions, follow-up appointments, and home care arrangements. By enhancing communication, the Digital Bridge aims to reduce complications, improve patient outcomes, and support more efficient care delivery.
Implementation testing
The testing phase, now underway, includes onboarding healthcare providers and recruiting patients at Mount Sinai Hospital and Hennick Bridgepoint Hospital. Dr. Steele Gray’s team is training staff to effectively integrate the tool into their workflows.
“The technology is ready, and so are we,” said Dr. Steele Gray. “Our team has worked tirelessly to ensure the tool meets the needs of patients, families, and healthcare teams alike.”
A key focus of the trial is assessing how integrating the tool into daily workflows affects providers. While initial use may require extra time for data entry, the tool is expected to save significant time by reducing the need for repeated questions, phone calls, and other back-and-forth communication.
As Dr. Steele Gray explains, the success of new healthcare technologies like the Digital Bridge hinges on more than just their technical capabilities. Implementation science addresses the deeper challenges of organizational inertia, team dynamics, and resistance to change.
“It’s not enough to simply hand someone a new tool and expect it to work,” said Dr. Steele Gray. “You need to help individuals and teams understand how it fits into their roles, relationships, and workflows. And learn how to adjust tools to better meet everyone where they’re at. Resistance to change is natural, but with strong leadership, trust, and collaboration, we can guide organizations through the transformation process.”
Dr. Steele Gray’s expertise in implementation science has been acknowledged globally, including an invitation to a partner meeting on digital health during the annual United Nations General Assembly in New York in Fall 2024. This prestigious event brought together representatives from the World Health Organization, and other global leaders to explore how digital technologies can enhance integrated care delivery. As the sole Canadian academic healthcare expert invited to present, Dr. Steele Gray showcased the pivotal role of implementation science in advancing healthcare innovation worldwide.
Nurturing new leaders in implementation science
Trainees have been central to the development and implementation of the Digital Bridge. Past postdoctoral fellow (now an Assistant Professor at the University of Toronto) Dr. Hardeep Singh led early co-design efforts, while graduate students Julia Wong and Obinna Ezeani have helped build computational workflows and conducted a usability analysis, respectively. The team is also supported by Bisma Imtaz (a PhD student at the University of Toronto), Ann Zhang (who explored socio-economic variables influencing transitions in baseline data for her Undergraduate thesis work), and Habibeh Zaeem, who has joined the team as Clinical Research student for her postgraduate diploma at Oxford College). Over the years of the project, medical students and other Masters of Health Informatics students have also supported the project to advance their learning as well as support the trial. The experience has provided trainees with invaluable real-world training in implementation science, for which formal programs remain limited in Canada, compared to existing programs in the US and UK.
As the testing phase progresses, the team will evaluate the tool’s impact on patient outcomes, provider efficiency, and overall quality of care. Insights from the trial will inform further refinements to the tool and workflows and help pave the way for broader adoption across Sinai Health and beyond.
“This is not just about technology,” said Dr. Steele Gray. “It’s about transforming how we think about and deliver care. The Digital Bridge is a step toward a healthcare system that prioritizes connection, continuity, and compassion.”
