Tools and Resources

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

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

    DECAF™ Family Caregiver Tool
    PDF download (29KB)

    Sample Coach Contact Documentation Forms
    PDF download (29KB)

    Engaging Physicians
    PDF download (228KB)

    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 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 | French Canadian | 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)

  • Family Caregiver Activation in Transitions™ (FCAT™) Tool

    The FCAT tool™ was developed to foster more productive interactions between health care professionals and family caregivers. Because it was developed with direct input from family caregivers, the items are both relevant to actual experience and are relatively easy to understand. We designed the FCAT tool™ to be administered by a health professional or self-administered by the family caregiver at the point of care at the time of transition or shortly thereafter. The responses could then be reviewed by the care team. Those areas that the family caregiver identified as not feeling confident or prepared through completing the tool would be specifically addressed during discharge preparation instruction.

    The FCAT tool™ and its application to clinical care settings is covered in depth during the Advanced CTI® training. The Advanced CTI® training is designed for Transitions Coaches® that have previously been trained in the Care Transitions Intervention® and have at least three months practice in the field following the CTI® core training. To arrange training and contact our training team, please visit our website at

    The Care Transitions Intervention® training team provides a variety of technical assistance options available to your organization. To explore our offerings and to contact our training team, please visit our website at

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

  • The Medication Discrepancy Tool (MDT®)

    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)

  • Patient Activation Assessment® Tool

    The Patient Activation Assessment®, or PAA®, provides trained Transitions Coaches® with a method of tracking patients’ progress in skill transfer and activation along the Four Pillars® with other fundamental skills learned during their participation in the Care Transitions Intervention® Core training. This tool guides activation as a feedback loop for reinforcing these skills during the follow up phone calls.

    Patient Activation Assessment® Tool
    PDF download (22KB)

    Patient Activation Assessment® Guidelines
    PDF download (19KB)

Click here to view all tools and resources.

Health care services for improving quality care and safety of patients during transitions across care settings