Care Transitions Intervention Resources
This video interview segment, produced by the New York State Office for the Aging, discusses the Care Transitions Intervention Coach Model in the context of the the Community Supports Navigator Program.
The Care Transitions Coach Tracking Tool is an excel spreadsheet broken into two sections. The first is a short sample tracking tool for coaches to use to track their patients. The second tab is a longer version that contains several additional fields to be used for analyzing the effect of the intervention.
The Interdisciplinary Team Approach to Improving Transitions Across Geriatric Sites of Care, developed by the University of Colorado Health Sciences Center Division of Health Care Policy and Research, presents a detailed research-based guide to conducting the Care Transitions Intervention.
The Care Transitions Measure is presented as a series of questions to determine the patient's understanding of their care as they transition from the hospital to another setting of care. The measure is presented in both three-question (CTM3) and 15 question (CTM15) forms.
The Care Transitions Measure Scoring Guide, also developed by the University of Colorado, walks providers through the process of evaluating their patients' answers to the questions on the measure. The three question (CTM3) scoring guide and the 15 question (CTM15) question scoring guide are available.
The Discharge Preparation Checklist is a tool to use with patients to ensure they have received all necessary information prior to their discharge.
The Patient Activation Assessment is a tool to measure the patient's level of performance prior to and post Care Transition "Coach" Intervention to determine how prepared a patient is to embark on their transition from the hospital to home, and asks questions related to the patient's knowledge level prior to hospital discharge and then post "Coach" intervention. A list of codes for filling out the Assessment will aid in completing this tool.
The Medication Discrepancy Tool (MDT) is designed to facilitate reconciliation of medications and any identified discrepancies and corresponding drivers across settings. It is intended for use by clinicians at the admission or transfer between care settings.. The information collected from use of this tool should be aggregated and shared with the sending provider where the medication discrepancy originated.
Faith Based Nurse Tools
The Role of the Faith Based Nurse as a Transition Coach is a diagram describing the important role a faith based nurse can play in ensuring quality transitions of care.
The Faith Based Nursing CTI Documentation Tool offers a format in which to capture key clinical and faith-specific information about a patient during their transition of care.
The Faith Based Nurse Emergency Plan Zone Tool is a patient-friendly matrix that helps a patient determine whether they need to call their physician/home health agency or call 911 based on symptoms they might be feeling.