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

System Thinking, Design Thinking, Strategic Design, Service Design, Design Research, Inclusive Design, Design for Health, Experience Design, Long-term strategy development, Visual Design, Graphic Design, Adobe Photoshop, Adobe Illustrator

My Role:

I performed qualitative and design research. I facilitated co-design sessions and communicated system progress and functionality through producing system thinking tools to diverse stakeholders. I analyzed and synthesized data into meaningful insights and developed guidelines and concepts for future steps of the project.

Other OCAD U Researchers: Filipe de Abreu, Mahsa Karimi, Malin Medin, Sonia Tagari, Teresa Coronel


This project addresses the complex care needs of stroke patients in order to smooth transition from Bridgepoint rehabilitation to their home communities.

Transition from hospital to home is imperfect. People who have had a stroke and their caregivers need to adapt to a new life routine and a new set of abilities. Sometimes, navigating access to all the supports and resources they need after discharge can be very confusing or limited. This can cause underlying or unforeseen issues, from physical to social to financial, to become major problems. This is why the transition system needs to be improved to best support patient and caregiver needs.


A service design that starts while stroke patients are at the rehabilitation hospital. This Service is triad-centered (patient, caregiver and health provider). It helps the care team by taking over some of the services that are currently being facilitated by them and expanding those to all the stroke patients at Bridgepoint including:

  • caregiver education and training

  • home assessment

  • making sure that every patient has a family physician 

  • book an appointment with the family physicians within a week from their discharge date.

  • transportation arrangement to get home at discharge.

  • 72 hr follow up calls after discharge

  • connect the patients to sub hubs in the community


Research Methods
Rationale for the Method

Literature scan


Discover Current Practices, guidelines and best practices, Discover current complexities within transition

Ethnographic Observation of Stroke Unit

Clinical Rounds Observation

Observation of Inter-professional Education


Discover elements that support a successful transition as well as barriers for individuals with chronic conditions and complexities

Discover transition system and patient journey touchpoints

Informal Chats


Health Providers-5

pair of Stroke Patients and a family members-3

Volunteer Resources Manger-1

Define need, barriers and goals

Discover gaps

Discover challenges with current services

Two Co-Design Sessions 

Lunch and Design-15

Participants were stroke unit health providers and staff

Co-design session

17 participants including health providers, volunteers, health researchers family member of patients with complexities

Validate data gathered to date from literature scan, observation and interviews

Validate data translation to different stakeholders journeys, personas

Gather additional data about current services and stages of transition and how patients transition journey is like from various lenses

Gather data on current service blueprints and touchpoints

Gathered data on current gaps in the system and framed the problem area

Ideate and develop prototypes to for a streamlined transition that addresses the existing gaps

Data Analysis


Open and thematic coding were used to analyze qualitative methods' data and find themes

Research-based Design Prototyping

& Feedback Session

Feed back session- 4 participants including health providers and health researchers

Refine personas and journey maps

Translate gathered data into service blueprints, touchpoints

Translate data to concept prototypes

iterative design cycle of prototyping transition service

Feed back session a pilot to test the

the service design storyboard prototype

Fine tune the service design prototype based on received feedback

Discovery ( empathize and define)

Problem Area

The problem is that transition system is very complex to navigate and individuals with complex conditions are left on their own to navigate the system after discharge from rehabilitation hospital. Factors that can lead to a poor transition include but are not limited to push for discharge, lack of arranged follow-ups, lack of home assessments. Data from the qualitative research methods including observations and interviews were translated to personas, journey maps and synthesis map. The qualitative research also informed the first prototype of service blueprints. These materials supported next phase of our research with multidisciplinary stakeholders in co-design to present the research project and crosscheck its reliability.

Mapping Current System to Discover Existing Services, Connections and Gaps
Journey Maps/ Four Different Lenses

The following image 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. These journey map through 4 various lenses identifies unmet patient needs as well as the gaps that exist in different stages of care. It also presents the communication gap that exist after discharge until the first follow-up.

Stakeholders Persona and Journey Development Through Interviews, Chats and Observation
journey map.png

Graphic Designed by: Rezvan Boostani | Icons from: &

Stakeholders Identification Through Mapping

Graphic Designed by: Filipe de Abreu & Malin Medin

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

This 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. It illustrates that in a hospital setting daily activities and rehab programs are facilitated by care team. Additionally, shows that after discharge, stroke patients and their family/caregiver are left on their own to navigate complex health and welfare system. After discharge, there is no communication with care provider and based on the place that stroke patient lives there are different barriers like if they are living in the condo or home based on their physical functionality, there can be a huge difference in terms on physical accessibility. Out-patient and supportive programs for stroke patients have no structure in the community and based on the area that stroke patients are living there can be gaps regarding accessibility to the aforementioned programs. Factors including transportation, weather, Comorbidities, unintended consequences, language, money, employment, social links and built environment can impact transition of stroke patients from hospital to community as well.

Preliminary Map of the Current Service
Preliminary FlowChart of the Gaps
Needs and Barriers

Graphic Designed by: Rezvan Boostani | Icons from: &

Causal Loops- System Stress & Leverage Points

Transition complexities are result of combination of factors. I used causal loops to show how different factors in the system can cause stress also to discover the leverage points. These loops also progress from the purpose of the discharge, to the structural barriers of hospital resources and funding programs for stroke patients as well as social barriers that prevent changes from happening that would make communities more inclusive to the target population. 

Causal loops below presents a reinforcing and a balancing loop. Reinforcing loop shows the vicious cycle of variables like push for discharge that increases candidates to go home which this increases the chance of having new/underlying problem at home and further result in readmission and increase in candidates for rehab and again increase in rehab patients reinforces push for discharge. The balancing loop illustrates how hospital resources can balance or put stress on candidates for rehab as well as push for discharge. Also it further highlights how policy and funding can impact hospital resources. System Policy and Funding can impact successful discharge through financial assistance and community programs.

Causal Loops

Developed &  Designed by: Rezvan Boostani 

Casual Loop-2.png

This Casual Loop illustrates more in detail what elements can reinforce a successful discharge. Home assessment, financial assistance and out-patient rehab programs are the factors that can support successful transition to home. However, there are elements like travel time, human resources, transportation, community programs and funded programs criteria that can simplify or complicate this cycle.

Developed &  Designed by: Rezvan Boostani 

Co-Design 1- Lunch & Design

Since the focus of the study was on complex care needs of patients after discharge it was necessary to have deep understanding of how patients are discharged from the hospital. To achieve that, after literature scan, ethnographic observation and interviews we found it necessary to engage diverse stakeholders to validate the gathered data and to discover if there are missing points. We designed a very informal session around lunch time in stroke unit dining place where we provided lunch and prepared translated data to visual tools for staff to interact with as they dine. This session was very informal and designed in a way that take the least time from stroke unit staff.

  • Validated and identified gaps within the post discharge experience

  • Validated patient journeys 

  • Gathered professional insights

lunch & whatever 06.JPG


Co-Design 2

In second co-design session we engaged health providers, family of patients with complex conditions, volunteers and researchers. Activities were designed to introduce the project, validate the gathered data to date, gather additional data where needed, ideate and develop the idea. Activities include persona creation, mind mapping and idea development. Key insights form this session are what participants defined as important components of a streamlined transition.

co-design 07.JPG
co-design 08.JPG
Key Insights
  • Consistent Communication across Organizations

  • Consolidated Resources and Applications

  • Follow-Up During the Post-Discharge Period between Inpatient and Outpatient

  • Socialization and Community Integration

  • Supports for Caregivers

  • Alleviation of Anxiety and Worry

  • Flexibility and Individuality

co-design 02.JPG


and Prototyping

(Usability Testing)

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. This prototype was used as a visual tool to communicate with scientific board at Bridgepoint about how the system performs and where the intervention and change can happen in the system.

Current Service Blueprints
Current Blueprint.jpg

Graphic Designed by: Mahsa Karimi

Research-Based Design Prototyping Cycle

Based on the themes that emerged from the co-design ideation we started our first cycle of concept prototypes for the possible solution. We used storyboard for the initial prototype and we tested these prototype in a feedback session with health providers and scientific researchers at Bridgepoint. These prototype reflected the main ideas and important factors identified by diverse stakeholders at co-design.

feedback session 01.JPG
Caregiver Education
Caregiver Education.png
Common Profile
Common Profile.png
Caregiver Support
Caregiver Support.png
Volunteer Matching
Volunteer Maching.png
Transition Team
Transition Team.png

Illustrated by: Sonia Tagari


Service Design

Based on the received feedbacks we fine tuned our prototyped and designed a service that streamlines the transition based on the define needs, barriers and goals. This service design addresses the existing gap and starts from rehabilitation hospital.

Final Service Design Prototype.png
Service Design Prototyping

Illustrated by: Sonia Tagari | Edited by: Rezvan Boostani

Continuum of Care
Streamlined Transition Service

We picked one of our personas to introduce the service design and show how this service design makes his transition smooth. Since the beginning we found importance of meeting of triad (patient, caregiver/ family and health provider). This transition service also offers caregiver education during patient stay at rehab. 

The transition team books the follow-up appointment with family physician once they know the discharge date. They make sure that patients receive the home assessment. Transition service also follow-up on the family physician appointment to make sure it took place. patients also receive a follow up call from the transition service.

Service Design- Continuum of Care
Service Design.png
Service Design1.png
Service Design2.png

Graphic Designed by: Filipe de Abreu | Icons from: &

Future Service Blueprints

We used future service blueprint to communicate where and how exactly the interventions we proposed through a service design can take place in the current system. 

Future Blueprint.jpg

Graphic Designed by: Mahsa Karimi

  • LinkedIn - Grey Circle
  • Facebook
  • Instagram