All Tools and Resources

Care Transitions Intervention® Tools

Patient Activation Assessment® Tool
PDF download (22KB)

What Physicians Need to Know about Transitions Coaches® and The Coleman Care Transitions Intervention®
PDF download (446KB)

Patient Activation Assessment® Guidelines
PDF download (19KB)

Sample Coach Contact Documentation Forms
PDF download (29KB)

Engaging Physicians
PDF download (228KB)

Family Caregiver Activation in Transitions™ (FCAT™) Tool
PDF download (29KB)

Personal Health Record
PDF download (279KB)
Additional Languages: Somali | Spanish

Coach Database
ZIP file download (275KB)

* Please note: The Coach Database this is a zipped file. To access it, click “save” on the pop-up window and save the folder to your hard drive. When the download is complete, click “close” on the pop-up window. Locate the coach.zip folder on your hard drive, right click on it, and select “extract all”). While this database is available for public use, our program does not have the resources at this time to provide technical support on its use.

Care Transitions Measure® Tools


With support from The Commonwealth Fund, The Robert Wood Johnson Foundation, and the Paul Beeson Faculty Scholars in Aging, Dr. Coleman and colleagues designed a 15-item uni-dimensional measure, the Care Transitions Measure (CTM®), to assess the quality of care transitions. The primary objective of this endeavor has been to develop a measure that is both substantively and methodologically consistent with the concept of patient-centeredness, and useful for the purpose of performance measurement and subsequent public report.

The CTM-15®
PDF download (30KB)
Additional Languages: Spanish | Arabic | Chinese | Hebrew |
Japanese | Malay | Russian | Swedish

Instructions for Scoring the CTM-15®
PDF download (91KB)

The CTM-3®
PDF download (30KB)
Additional Languages: Spanish | Finnish |French | Hindi |Italian

Instructions for Scoring the CTM-3®
PDF download (30KB)

CTM® Hospital Specification
PDF download (46KB)

CTM® Frequently Asked Questions
PDF download (263KB)

How To Introduce the CTM® to patients
PDF download (69KB)

The Medication Discrepancy Tool®


The Medication Discrepancy Tool (MDT®) is a tool for identifying and characterizing medication discrepancies that arise when patients are making the transition between sites of care. Discrepancies can be identified at either the patient level or the practitioner/health system level. Specific MDT® items are designed to be actionable and ideally to recognize problems before patients experience harm. It was found that clinicians using the MDT® were able to capture a wide range of transition-related medication problems.

The MDT® was developed to fill the gap in the identification and categorization of transition-related medication problems, to facilitate resolution of these problems by describing appropriate action steps at either the patient or system level, and to lead to a single reconciled list of medications, irrespective of the number of prescribers involved. It is expected to fill an important gap in national efforts to promote patient safety.

The Medication Discrepancy Tool (MDT®)
PDF download (46KB)

The MDT® for Multiple Events
PDF Document (127KB)

DECAF™ Family Caregiver Tool


Greater Recognition for the Integral Role of Family Caregivers: More effective collaboration is needed between family caregivers and health care professionals in order to improve care coordination across settings. During care transitions, family caregivers make important contributions to ensuring quality, safety, and adherence to patient preferences and their roles need to be formally recognized. An important initial step in this regard is to develop a standardized approach to defining the type and intensity of the roles family caregivers contribute to facilitate planning to promote care planning and execution. One potential working definition is the “DECAF” classification developed by our Care Transitions Program®. Modeled after the TNM system used in cancer, each of the letters of DECAFTM refer to a different contribution made by a family caregiver: D= Direct Care Provision, E= Emotional Support, C= Care Coordination, A= Advocacy, and F= Financial. Each category is scored from 0 (no contribution) to 3 (significant contribution) for an overall aggregate score that ranges from 0-15

Executing High Quality Care Transitions: A Call to Do It Right
PDF download (51KB)