Transitioning back to the community after a hospital stay can be a difficult time for patients and family caregivers. In recent years, our work around patient oriented discharge has improved patient experience

measured in our Quality Improvement Plan. Now, we have an opportunity to innovate further as part of the Canadian Foundation For Healthcare Improvement’s Bridge-To-Home Spread Collaborative.

“When we examined data collected through the Measuring Health Equity survey, we discovered that Chinese speaking (Cantonese and Mandarin) patients had poorer outcomes related to care transitions than other ethnic groups,” notes Agnes Tong, Manager of Quality and Patient Safety at Sinai Health System. Examples of outcomes related to transitions include longer lengths of stay and being re-admitted to the hospital within 30 days of discharge.

As part of the national collaborative we will help improve transitions for our Chinese speaking patient population. This project will be a partnership with community organizations Carefirst Seniors and Community Services Association and Yee Hong Centre For Geriatric Care, as well as patient and family partners. Together, we will develop a discharge tool that is culturally appropriate.

“The goal is to have a tool that is in the language of our Chinese patients and caregivers,” says Agnes. The model of care includes collaborating with our community partners prior to transition as a way to ensure patients and their caregivers are aware of what resources are available and that the information can be reinforced when they are the community.

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