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Streamlining Transition

from Bridgepoint Rehabilitation Hospital Back to the Community


As part of my master's degree at OCAD University I worked as a design researcher with the Bridgepoint Active Rehabilitation Hospital. The focus of this internship was to improve current hospital services for stroke patients in transition care to support them in having a successful discharge. I was working with four other design research interns and scientific researchers at the Hospital.  


Sep-Dec 2017

My Role



Service Designer

4 team members- design researchers

Job Rutgers, Dr. Kate Sellen,  Dr.Michelle Nelson, Shawn Tracy


I designed, planned, ran, and facilitated interviews and co-design workshops. I analyzed and synthesized data from research into actionable insights and developed guidelines and concepts for future steps of the project.


Navigating health care services are very complex as they are provided in different disconnected settings. Persons with complex care needs such as stroke patients after discharge from hospital are left on their own to navigate this complex system to get the care that they need.

Approach | Methods

It was essential to ensure different actors, including users of healthcare, healthcare providers, and others who are part of this service delivery are engaged in the research and design process.

To design this innovative service process, we used Design Thinking and Inclusive Design approaches to include a diverse group of stakeholders into our processes.


Secondary Research  

Review of current practices, guidelines and best practices, current complexities within transition

Ethnographic Study

Stroke unit

Clinical rounds

Interview & Informal Chat

5- healthcare providers

3-pair of stroke patients and family members

1- volunteer resources manager 


Co-Design 1

15 Participants- stroke unit healthcare providers and staff

Co-Design 2

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

Qualitative Data Analysis & Iterative Design Cycle

Prototype based on data synthesis, test, gather feedback and refine based on the received feedbacks 


Feedback Session 1

4 participants- healthcare providers and scientific researchers

Feedback Session 2

3 participants- scientific researchers and an innovation advisor 

Qualitative Data Analysis & Iterative Design Cycle

Prototype based on data synthesis, test, gather feedback and refine based on the received feedbacks 


Problem Area

Review of literature indicated the following as the main contributing factors for disconnect in transitional care. Lack of:

  • community resources and programs,

  • social support, and/or

  • of coordination between different care providers and services.


Some of the factors that can lead to a poor transition include, but are not limited to:

  • Push for discharge

  • Transitional disconnect

  • Lack of arranging follow-ups

  • Lack of home assessments 

Mapping Current System to Discover Existing Services, Connections and Gaps
Stakeholder Identification

It was essential to define main stakeholders early on to include them in the design process and consider their needs, challenges, and goals. We defined five main user groups for the service, including stroke patients, family members/caregivers, healthcare providers, volunteers, and administrators.

Stakeholders Identification Through Mapping
Stakeholder map - the cool and big one.J
Stakeholder map - the cool and big one.J
Family members/caregivers
Health Administrators
Healthcare Providers
Ethnography Study, Interview & Informal Chat

In this phase we observed the stroke unit as well as clinical round to better understand the context. We moved forward with interviews, engaging the five main stakeholders to understand their needs, challenges, and goals. We also used the interview opportunity to validate the gathered data to date. We used thematic analysis to analyze qualitative data.

Interview Emerged Themes-01.png

Journey Maps/ Four Different Lenses

The following map highlights journeys of four different groups of stakeholders, including patients, caregivers, care providers, and volunteers based on the interviews and ethnography study we had with various stakeholders. This journey map through 4 various lenses identifies unmet patient needs as well as the gaps that exist at different stages of care delivery. It also highlights the existing disconnect between healthcare provider and stroke patient after discharge until the first follow-up.

Stakeholders Persona and Journey Development Through Interviews, Chats and Observation
16 - Preliminary patient journey.jpg
23 - Journey Map Social Worker.jpg
24 - Journey Map Recreational Therapits.

 Icons from: &

Stroke patient & Family/caregiver
Needs and Barriers

 After discharge, stroke patients and their family/caregiver are left on their own to navigate the complex health and welfare system. Based on the place that a stroke patient lives there are different barriers. For instance, if they are living in a condo or a home based on their physical functionality, there can be a huge difference in terms on physical accessibility. Outpatient and supportive programs for stroke patients have no structure in the community. 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.

Patients Flows & the Gaps
home transition (1)-01.png

Causal Loops- System Stress & Leverage Points

Transition complexities are result of a combination of factors. I used causal loops to show how different factors in the system can cause stress and to discover the leverage points. 

Causal loops below present a reinforcing and a balancing loop. Reinforcing loop shows the vicious cycle of variables like push for discharge which means more patients go home. This increases the chance of having new/underlying problem at home which can result in readmission. More patients coming back to the again reinforces push for discharge.

Causal Loops of System Stress Points

This Casual Loop illustrates more in detail what elements can reinforce a successful discharge. Home assessment, financial assistance and outpatient 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.

Causal loop--01.png
Journey Map-Patient-working--01.png


Co-Design 1- Lunch & Design

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 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. In this session we:

  • validated and identified gaps within the post discharge experience,

  • validated patient journeys, 

  • gathered professional insights.

lunch & whatever 06.JPG

Co-Design 2

In this session we engaged healthcare providers, family of patients with complex conditions, volunteers, administrators, and researchers. Activities were designed to introduce the project, validate the gathered data to date, gather additional data, ideate, prototype, and test. Activities include validating stakeholders' needs, painpoints, goals as well as mind mapping, ideation, prototyping, and testing. Key insights from 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

  • Centralized information on resources

  • Follow-up during the post-discharge period

  • Integration of community resources

  • Supports for caregivers

  • Support plans for the alleviation of anxiety 

  • Flexibility and individuality

co-design 02.JPG
co-design 06.JPG


Usability Testing & Feedback

The gathered data throughout the research was translated to the Bridgepoint's current service blueprint (figure below). This blueprint illustrates the structure of the service delivery at the Bridgepoint including the relationship of different stakeholders and components relevant to a certain touchpoint. This blueprint was used as a visual tool to communicate with executive board at the Bridgepoint Rehabilitation Hospital about current service delivery issues and where design intervention can take place.

Current Service Blueprints

The magnified area shows one of the main areas of disconnect in the current service delivery.

Current Service Blueprint-01.png
Iterative Design Cycle
Feedback Loops

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

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


Service Design

Based on the received feedbacks we fine tuned our prototypes and redesigned a service that streamlines the transition based on the defined needs, painpoints and goals by diverse stakeholders. This service design using the principle of person-centered care addresses the existing gaps within care delivery and starts with interventions from rehabilitation hospital.

Service Design Prototyping
Final Service Design Prototype.png

Continuum of Care

A Streamlined Transition Service

We picked one of our personas to introduce the service design and show how this service design makes his transition smooth through storytelling to Bridgepoint Rehabilitation Hospital executive board. Since the beginning, we found importance of meeting of triad's (patient, caregiver/ family, and healthcare provider) needs. 

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

Our service design intervention proposes a triad-centred transitional plan: patient, caregiver, and healthcare provider. Elements of this streamlined service include:

  • Caregiver education 

  • Home assessment

  • Find family physician 

  • Book an appointment 

  • Make transportation arrangements

  • Make 72-hour follow-up calls 

  • Connect patients to community services 

Service Design2.png
Future Service Blueprints

We used future service blueprint to communicate where and how exactly the design interventions can take place. The magnified areas show the areas that the proposed service can intervene to improve experience for all the stakeholders.

future bluepprint-01.png


  • Presented the "Continuum of Care" streamlined transition service design to the executive board at Bridgepoint Rehabilitation Hospital & OCAD University Design for Health Program director and instructors

  • Project presentation was a great success Bridgepoint Rehabilitation hospital started to apply some of the interventions

  • The project presentation secured a partnership between Bridgepoint Rehabilitation Hospital and OCAD University 


I presented a poster of the project at GTA Rehab Network Best Practices Day 2019 and I won 3rd place of the People's Choice Awards. This is a link to this conference website and the award. 


I also presented the project at Cahspr Conference 2019 in an oral session on the "Cancer, Chronic Disease Management".

Benefits of the proposed Service Design

Our proposed Service Design intervention can address a small aspect of the huge transition dilemma for diverse stakeholders with:

  •  Alleviating some of the stress on healthcare providers by effective home assessments

  • Mitigating some of the strain on the patient and caregiver by providing follow-up support

  • Preparing both patients and caregivers for their new life routines through education

  • Removing some of the possibilities for readmission by providing more community resources 

Next Steps

We used horizon map to communicate how the proposed design interventions can take place in the years ahead. 

The streamlined transition service from the rehabilitation hospital back to the home communities can be implemented by further including the patients’ and caregivers’ inputs within the proposed plan.

To move forward with the proposed design interventions, it is beneficial to test it through a pilot practice to ensure it is inclusive of all stakeholder groups' perspectives.

Horizon Map-01.png

Personal Learning

  • Ways of communication with diverse stakeholders in a hospital setting, academic setting, and community programs 

  • Health & welfare system general overview, hierarchy, terms

  • Hospital system performance

  • Service design approach

  • System thinking tools

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