Digital Bridge to support patient-centered transitions from hospital to home

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

This project will test a digital communication system that connects hospital teams, primary care, patients, and caregivers to help older adults with multiple chronic conditions have smoother transitions from hospital to home.

Quick facts

• Phase: NA
• Study type: Interventional
• Enrollment: 640 (estimated)
• Ages: 60 Years and up
• Sex: All
• Sponsor: Mount Sinai Hospital, Canada (other)
• Locations: 1 site (Toronto, Ontario)
• Trial ID: NCT04287192 on ClinicalTrials.gov

What this trial studies

The project will develop and test a "Digital Bridge" that links communication technologies already used in hospitals and primary care to improve information flow among clinicians, patients, and family caregivers. Investigators will co-design the tool with users and implement it for patients aged 60 and older who have three or more chronic conditions and are admitted to participating medicine or rehabilitation services. Participants will be enrolled at admission and followed from discharge to six months post-discharge to track communication, care coordination, and health outcomes. The intervention aims to support timely, person-centered communication across settings to reduce gaps that contribute to post-discharge vulnerability and readmission.

Who should consider this trial

Good fit: Ideal candidates are English-speaking community-dwelling adults aged 60 or older with three or more chronic conditions who are being discharged home from participating hospital medicine or rehabilitation services.

Not a fit: Patients discharged to other acute care facilities, long-term care, palliative or complex continuing care, those who cannot use or access English-language technology, or who cannot be contacted after discharge are unlikely to benefit.

Why it matters

Potential benefit: If successful, this could reduce avoidable readmissions and improve care coordination and patient and caregiver experience after discharge.

How similar studies have performed: Previous transitional-care and digital communication interventions have shown mixed but sometimes positive effects on readmissions and patient experience, while fully integrated cross-setting digital solutions remain relatively untested.

Eligibility criteria

Inclusion Criteria:

* Patients with anticipated discharge home will be recruited at the time of admission to one of the services (i.e medicine or rehab) in the study. Patients aged 60 and over, with CCN defined as presenting with 3 or more chronic conditions from the 16 most prominent in the population, which is an established method to identifying patients with CCN. As the technology is only currently available in English, patients (or a caregiver) must be able to speak and read English. Patients with mild cognitive impairment will not be excluded if able to provide informed consent, and engage with the intervention (independently or with caregiver aid).

Exclusion Criteria:

* Previously participated in the study (in case of re-admission); discharge destination is another acute care facility, palliative care unit, complex continuing care, or long term care; died in hospital, cannot be contacted by telephone after discharge; unable to respond to survey question for any reason and lack of availability of family members and/or other caregivers willing and able to provide assistance.

Where this trial is running

Toronto, Ontario

• Sinai Health — Toronto, Ontario, Canada (RECRUITING)

Study contacts

• Principal investigator: Carolyn Steele Gray, PhD — Sinai Health System
• Study coordinator: Carolyn Steele Gray, PhD

Conditions: Older Adults With Complex Care Needs