Discharge from hospital to the community can be a challenging transition for patients and caregivers. Through engagement with them, we learned that they often felt unprepared to manage at home. To improve the discharge process, we teamed with patients, caregivers, community care services, interprofessional team members and corporate services to create the Path to Home Passport. The idea and development of this tool was patient and family driven, based on best practices and reviewed by our Patient and Family Advisory Committee. We focused on what was important and meaningful for the patients, keeping them at the center of the care team and discharge planning process. The goal of the passport is to improve the transition process by providing patients with a tool to optimize their preparedness and safety upon discharge.
The final product was a discharge workbook with a pen, a tote bag and a fridge magnet (see picture below). The latest edition of our Passport is divided into four sections: Preparing to go Home, Care Needs When Home, Path to Home Resources and Final Checklist. Patients are given their passport on admission to our hospital and they are encouraged to use the tool throughout their stay while planning their discharge. The Passport can also be used once patients are back in the community at follow-up appointments with their primary care teams.