Search Results for: personal health record

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.

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 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.

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.