Read the Research

1. Hahn-Goldberg S, L’Espérance A, Comeau B, Harrison A and Fancott. Bridge-to-Home: A Case Study of the Mutually Reinforcing Benefits of Patient Engagement–Focused Quality Improvement Initiatives for Transitions out of Hospital. Healthcare Quarterly 17(1). 2024.
2. Waddell AE, Yue Y, Comrie R, Wong BM, Kurdyak PA. Effects of the Implementation of a Patient-Oriented Discharge Summary (PODS) on Pre- and Postdischarge Outcomes. Psychiatr Serv. 2023 Apr 25:appips20220309. doi: 10.1176/appi.ps.20220309. Epub ahead of print. PMID: 37096357.
3. Pellet, J., Weiss, M., Zúñiga, F. et al. Implementation and preliminary testing of a theory-guided nursing discharge teaching intervention for adult inpatients aged 50 and over with multimorbidity: a pragmatic feasibility study protocol. Pilot Feasibility Study, 71 (2021). https://doi.org/10.1186/s40814-021-00812-4
4. Okrainec K, Chaput A, Rac VE, Tomlinson G, Matelski J, Robson M, Troup A, Krahn M, Hahn-Goldberg S. Raising the bar for patient experience during care transitions in Canada: A repeated cross-sectional survey evaluating a patient-oriented discharge summary at Ontario hospitals. PloS one. 2022 Oct 4;17(10):e0268418. https://doi.org/10.1371/journal.pone.0268418
5. Saragosa M, Jeffs L, Okrainec K, Kuluski K. (2021). Using meta-ethnography to understand the care transition experience of people with dementia and their caregivers. Dementia (London). 14713012211031779. Online ahead of print. http://dx.doi.org/10.1177/14713012211031779
6. Saragosa M, Jeffs L, Hahn-Goldberg S, Abrams H, Soong C, Hart M, Shea B, Okrainec K. (2021). “There was no preamble”: Comparing the transition from hospital to home in different care settings. Canadian Journal on Aging. 40(2): 282-292. http://dx.doi.org/10.1017/S0714980820000380
7. Hahn-Goldberg S, Chaput A, Rosenberg-Yunger Z, Lunsky Y, Okrainec K, Guilcher S, Ransom M, McCarthy L. (2021). Tool development to improve medication information transfer to patients during transitions of care: A participatory action research and design thinking methodology approach. Research in Social and Administrative Pharmacy. S1551-7411(21)00125-X. Online ahead of print. https://doi.org/10.1016/j.sapharm.2021.04.002
8. Hahn-Goldberg S, Huynh T, Chaput A, Krahn M, Rac V, Tomlinson G, Matelski J, Abrams H, Bell C, Madho C, Ferguson C, Turcotte A, Free C, Hogan S, Nicholas B, Oldershaw B, Okrainec K. (2021). Implementation, spread and impact of the Patient Oriented Discharge Summary (PODS) across Ontario hospitals: A mixed methods evaluation. BMC Health Services Research. 21(1): 361. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-021-06374-8
9. Griffiths S, Stephen G, Kiran T, Okrainec K. (2021). “She knows me best”: A qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure. BMC Family Practice. 22(1): 176. https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-021-01524-7
10. Schofield T, Ross H, Bhatia RS, McDonald M, Okrainec K. (2019). Feasibility and performance of a patient-oriented discharge instruction tool for heart failure. BMJ Open Quality. 8(3): E000489. http://dx.doi.org/10.1136/bmjoq-2018-000489 
11. Okrainec K, Hahn-Goldberg S, Abrams H, Bell CM, Soong C, Hart M, Shea B, Schmidt S, Troup A, Jeffs L. (2019). Patients’ and caregivers’ perspectives on factors that influence understanding of and adherence to hospital discharge instructions: A qualitative study. CMAJ Open. 7(3): E478 -E483.
    https://doi.org/10.9778/cmajo.20180208
12. Schofield T, Bhatia RS, Yin C, Hahn-Goldberg S, Okrainec K. (2019). Patient experiences using a novel tool to improve care transitions in patients with heart failure: A qualitative analysis. BMJ Open. 9(6): E026822. https://bmjopen.bmj.com/content/9/6/e026822
13. Hahn-Goldberg S, Jeffs L, Troup A, Kubba R, Okrainec K. (2018). “We are doing it together”; the integral role of caregivers in a patient’s transition home from the medicine unit. PLoS ONE. 13(5): E0197831. https://doi.org/10.1371/journal.pone.0197831
14. Okrainec K, Lau D, Abrams H, Hahn-Goldberg S, Brahmbhatt R, Huynh T, Lam K, Bell C. (2017). Impact of patient-centered discharge tools: A systematic review. The Journal of Hospital Medicine 12(2): 10-17. https://www.journalofhospitalmedicine.com/jhospmed/article/130443/hospital-medicine/impact-patient-centered-discharge-tools-systematic-review
15. Hahn-Goldberg S, Okrainec K, Huynh T, Abrams H, Damba C, Lau D, McGuire R, Yang L, Maxwell J (2016). Implementing Patient Oriented Discharge Summaries (PODS): A multi-site pilot across early adopter hospitals. Healthcare Quarterly; 19(1): 42-8. https://www.longwoods.com/content/24610/healthcare-quarterly/implementing-patient-oriented-discharge-summaries-pods-a-multi-site-pilot-across-early-adopter-ho 
16. Hahn-Goldberg S, Okrainec K, Huynh T, Zahr N, Abrams H. (2015). Co-creating patient-oriented instructions with patients, caregivers, and providers. The Journal of Hospital Medicine. doi: 10.1002/jhm.244: 1-9. https://www.journalofhospitalmedicine.com/jhospmed/article/128293/patient-oriented-discharge-instructions

Conference Publications

1. Sachdeva M, Jeffs L, Bell CM, Okrainec K. (2020). Socioeconomic disparities affecting the transition from hospital to home: A mixed methods analysis. Abstracts from the 2020 Annual Meeting of the Society of General Internal Medicine. Journal of General Internal Medicine. 35(Suppl 1): S1–S779.
   https://link.springer.com/content/pdf/10.1007/s11606-020-05890-3.pdf
2. Okrainec K, Hahn-Goldberg S, Hyunh T, Zahr N, Abrams H. (2015). Towards the development of patient-centred discharge summaries. Abstracts from the 38th Annual Meeting of the Society of General Internal Medicine. Journal of General Internal Medicine. 30: 45–551.
   https://link.springer.com/article/10.1007/s11606-015-3271-0 

1. Design Report – LHIN pdf
2. Early Adopter Report – LHIN pdf
3. Infographic of Results of Ontario-Wide Implementation pdf 

1. To explore the impact of PODS on understanding and adherence to discharge instructions and unscheduled visits.
2. To explore the contextual roles of process, system & provider engagement needed when providing discharge instructions.
3. To identify patient-level characteristics that might impact the use and effectiveness of discharge instructions.

Visit the clinical trials page here.

Provincial and National Implementation

1. PODS was granted funding through the ARTIC program supported by CAHO and HQO to help implement the tool throughout 25 hospitals in Ontario.
2. The ARTIC community of practice ran from April 2017 through March 2019. 
3. PODS was part of CFHI’s Bridge to Home collaborative, supporting 16 organizations across Canada improving the transition from hospital to home. Learn more here.
4. Through this work, we are evaluating the implementation and impact of PODS in these hospitals as well as what organizational and system factors impact its success.

Patient Oriented Medication Tools

 Medication instructions are an important and often complex part of patient instructions during care transitions. It is recommended to include patient friendly medication lists along with the PODS, but the process of medication instructions is often separate from other instructions provided during care transitions. Therefore, we conducted further design-based research to create medication oriented medication tools. Read more here.