Streamlining Transition from Bridgepoint Rehabilitation Hospital Back to the Community

For Individuals with Chronic Conditions


A Collaborative Project Between OCAD University and Bridgepoint Active Health Care Hospital

A group project with: Filipe de Abreu, Mahsa Karimi, Malin Medin, Sonia Tagari, Teresa Coronel

OCADU Supervisors: Job Rutgers, Kate Sellen

Bridgepoint Leads: Michelle Nelson, Shawn Tracy


The main objective of this research was to understand the complex care needs of stroke patients after discharge from a rehabilitation hospital to the community, finding out the gaps that exist in the current healthcare system, and propose a new system/intervention that creates smoother transition for this population.

In order to achieve the objectives, a series of design research methods involving various stakeholders were used in this study, using the principle of user-centred research and design. 

Research Methodology

To address the complexity in a healthcare system in this project we focused on Design Thinking approach.

Since a multidisciplinary response is required to address the complexity within a healthcare system in this study four different groups of stakeholders have been involved in various stage of the research including stroke patients, caregivers, care providers, and volunteers.  

Methods are as follows:

  • Desk Research

    • Literature Review​

  • Qualitative Research

    • ​Interprofessional Education (IPE)

    • Observation of Clinical Rounds

    • Informal Chats

    • Interviews

Design Process

  • Lunch and Design Session

  • Co-Design Session

  • Feedback Sessions


  • Personas

  • Service Journey Maps

  •  Synthesis Map

  • Concept Prototypes 

  • Service Blueprints

  • Service Design

Synthesis Mapping

Journey Maps/ Four Different Lenses


The structure of our synthesis map has been divided into five primary components (figure below). The first of these on the far-left highlights journeys of four different groups of stakeholders including patient, caregiver, care provider and volunteer based on the

literature and informal interviews we had with various systems stakeholders.

Dyad (Stroke patient & Family/caregiver) Needs and Barriers

The top middle diagram depicts stroke patient needs and barriers in a hospital setting and in the community after discharge and how

these needs and barriers might change in various settings with different structures.

Causal Loops


Directly beside and below this diagram there are a series of causal loops. Causal loops that are below the diagram visualize issues of

the services and stress point in the systems.


Horizon Map

The far-right diagram consists of horizon map that is formed based on the data we gathered from Co-Design as well as validation

and feedback sessions. Within horizon map we are proposing design interventions by considering existing resources and feasibility

of the ideas.


Design Guidelines

The bottom portion of the map contains a set of design guidelines that can be used across the system to improve the system as it currently exists as well as for the future projects.

Current Service Blueprint

The gathered data throughout the research became a base for service design blueprint (figure below). It illustrates the structure of the current system at Bridgepoint and the interactions within this system. This blueprint was a visual tool that helped us to find the gaps within the current system, understand the various people involved in it and discover the necessary touch points we needed to design in order to assist with the recognized gaps.

Future Service Blueprint

The future blueprint, below, introduces interventions in the current system to smooth out the challenges that stroke patient might face in different stages of transition including while they are in the rehabilitation hospital, at discharge, and following discharge when they are back to the community.

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