Personal Health Record
A patient-centered record that consists of the essential care elements for facilitating productive interdisciplinary communication during the care transition. A PDF of the PHR that can be downloaded and personalized is available at caretransitions.org/patient_tools.asp
Discharge Preparation Checklist
A structured checklist of critical activities that patients should complete before leaving the hospital or nursing facility. A PDF of the checklist is available at caretransitions.org/patient_tools.asp.
Medication Discrepancy Tool ©
A tool designed to help the Coach reconcile the patient’s medication regimen, by identifying any significant medication problems (e.g. adverse drug events, patient non-adherence, patient lack of understanding of medication regimen) and developing a plan for problem resolution.
A guide for practitioners, researchers, or policy makers on improving interventions and transitions between sites of care. The manual provides an overview, general structure, and guiding principles of transition coaching. A PDF of the manual can be found at www.caretransitions.org/documents/manual.01-05-04.pdf
Sample Transition Coach Charting Form
A sample form for the Coach to chart intervention activities during hospital visits, nursing home visits, and home visits. A PDF of the chart is available at www.caretransitions.org/documents/ChartingForm.pdf
Care Transitions MeasureTM
A five-part tool kit designed to assess the quality of care transitions for the use of performance measurement and public reporting. This tool was designed to provide a consistent measurement, and is applicable across multiple sites of care. The measures toolkit is available at www.caretransitions.org/measures.asp
Care Transitions Intervention video
The training video shows the Transition Coach and a patient in various settings, highlighting transitional care issues and scenarios and illustrating the key facets of the intervention. The video can be ordered, free of charge, in VHS or DVD format at http://www.caretransitions.org/downloadvideo.asp
The Care Transitions InterventionSM Website
Includes great deal of information about the model, including tools, FAQ, and case studies. The website also provides PDFs of many relevant articles, a selection of which is provided below. http://www.caretransitions.org
Frequently Asked Questions
A list of answers to top questions about the implementation and operation of The Care Transitions Intervention, including cost, average caseload for Coaches, and time and duration of intervention activities. FAQs can be found at www.caretransitions.org/CTI_FAQ.asp
The Care Transitions Intervention
Coleman E, Parry C, Chalmers S, Min, S. The Care Transitions Intervention: Results of a Randomized Controlled Trial. Arch Intern Med. 2006;166:1822-1828.
Preparing Patients and Caregivers to Participate in Care Delivered across Settings: The Care Transitions Intervention
Coleman E, Smith J, Frank J, et al. Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. J Am Geriatr Soc. 2004;52:1817-1825. Abstract Available only.
One Patient, Many Places
HMO Workgroup on Care Management, “One Patient, Many Places: Managing Healthcare Transitions” (AAHP Foundation, Washington, DC, February 2004).
Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care
Coleman E, Berenson R. Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care. Ann Intern Med. 2004;141(7):533-536. Abstract Available only.
Development and testing of a measure designed to assess the quality of care transitions
Coleman E, Smith J, Frank J, et al. Development and testing of a measure designed to assess the quality of care transitions. International Journal of Integrated Care, 2002, (2).