Digital Bridge: Using Technology to Support Patient-centered Care Transitions From Hospital to Home

When older adults have many health problems, they often go in and out of the hospital frequently. The time spent moving from the hospital back to home can be very difficult. Patients can feel vulnerable and overwhelmed, and sometimes they end up back in the hospital soon after being discharged. This often happens because there isn't clear or timely communication between all the different healthcare workers involved, or with the patient and their family.

Our study, called 'Digital Bridge', wants to improve this process. We're creating a digital tool that connects the different communication systems already used in hospitals and by GPs. This 'bridge' helps doctors, nurses, patients, and their families talk to each other more easily and share important information. The aim is to make sure everyone involved is on the same page, helping patients get the right support and care both while in hospital and for up to six months after they go home.

We're working closely with patients, families, and healthcare staff to design this Digital Bridge, making sure it really meets everyone's needs. We'll be testing it in hospitals in Toronto and Mississauga, Canada, to see if it improves how patients experience going home, their quality of life, and how well healthcare teams work together. Ultimately, we hope this technology will make the process smoother, reduce how often people need to return to hospital, and help them manage their health better at home.