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

Our Digital Bridge is an integration of the Care Connector and ePRO technologies that will support care transitions by: 1) inviting PCPs to access Care Connector while the patient is in hospital, allowing for asynchronous communication via the messaging feature for proactive discharge planning, 2) facilitating the inclusion of inter-professional recommendations in the discharge module (e.g. diet and mobility) typically missing from traditional physician generated discharge summaries, 3) electronic generation of PODS for use in patient-centred discharge teaching, 4) providing patients electronic access to PODS post discharge to facilitate use of information at home, 5) adoption of digital enabled goal-oriented process to engage patients and families in discharge process, and 6) providing ongoing self-management support for patients using ePRO for the vulnerable period 6 months post discharge.