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Care Transitions Program Toolkit


Through this 4-week program, patients with complex care needs receive specific tools, are supported by a “transition coach,” and learn self-management skills to ensure their needs are met during the transition from hospital to home.

The tool kit includes the following:

  • Intervention tools
    • Protocol manual
    • Discharge preparation checklist
    • Personal health record
    • Sample transition coach charting form
    • Coach database
    • Frequently asked questions
  • Instruments
    • Care Transitions Measure (CTM© TM)
    • Medical Discrepancy Tool (MDT©)
  • Introductory and training video 
    • Care Transitions InterventionSM DVD
Links to the Tool:
This tool is available at:


University of Colorado, Health Sciences Center

Funding Sources

Paul Beeson Faculty Scholars in Aging; Robert Wood Johnson Foundation; The Commonwealth Fund

QualityTool Topic



  • Release Date: 07/2006
  • Original Summary: 10/2007
Disclaimer: The inclusion of a tool in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality or Westat of the tool or of the submitter or developer of the tool. Read more.

Last updated: September 12, 2008.