Care transitions occur when patients move between health care providers or settings, including home, in order to have their care needs met.  The current health care system poses many challenges for older adults with multiple chronic diseases and complex care needs who are particularly vulnerable to breakdowns in care. Research shows that nearly 20% of hospitalized Medicare beneficiaries are readmitted within 30 days of discharge. 1, 2  The Medicare Payment Advisory Commission (MedPAC) estimates that 75 percent of these readmissions are potentially preventable, especially by incorporating best practices into care.3


Fortunately, there is an expanding body of evidence that provides a better understanding of what is needed to ensure safe and effective transitions from one health care provider or setting to another  Home health providers are uniquely positioned to help reduce avoidable rehospitalizations and improve the quality of care by focusing on improving the care transitions process during critical transitions of older patients. Important aspects of care transitions include medication management (click here for CHAMP's Medication Management Toolkit), patient coaching, education, and support for self-management, communication between and among clinicians, patients and family caregivers, and discharge planning and risk assessment.




1. Jenck S., Williams M., Coleman E. Rehospitalizations among patients in the Medicare Fee-for-Service Program.  New England Journal of Medicine 2009, 360: 1418-1428.  Accessed January 18, 2013

2. Wier L.M., Barrett, M.L., Steiner, C., Jiang, H.J.  AllCause Readmissions by Payer and Age, 2008.  HCUP Statistical Brief #115.  June 2011.  Agency for Healthcare Research and Quality, Rockville, MD.  Accessed January 18, 2013.

3. Medicare Payment Advisory Commission.  2007.  Report to Congress: Promoting Greater Efficiency in Medicare.  Washington, DC.  MedPAC. Accessed January 18, 2013.


Geriatric Care Transitions Toolkit

To support homecare professionals in facilitating safe and effective care transitions for older adults to and from home healthcare, CHAMP selected and organized evidence-based tools from our Resource Library into this online Geriatric Care Transitions Toolkit. This Toolkit contains:

  1. Clinically-focused and validated tools to help you identify patients at increased risk of experiencing poor transitions;

  2. Intervention tools for homecare professionals, patients and their caregivers, that facilitate effective transitions and improve patient outcomes;

  3. Tools to help you, your patients, and their caregivers improve cross-setting communication; and

  4. Guidelines and evidence-based best practices that provide an overview of the evidence for improving quality and safety during transitions between care settings. 

This toolkit was designed to give you and your team quick and easy access to best practice resources to achieve successful transitions for older adults, thus reducing their risk of potentially preventable rehospitalizations. CHAMP included a comprehensive list of tools (mostly items in the public domain), so we do not expect individual users to want/need every item in the Toolkit. To download and print tools individually, simply click on the name of the tool.

1. Evaluation and Screening Tools


For Homecare Professionals
Care Transitions Measure (CTM-3)® - This three-item instrument evaluates the quality of preparation for patients to participate in post-hospital self-care activities. The CTM-3 is a subset of the more comprehensive CTM-15 and includes three key areas that patients identified as critically important for successful care transitions (also available in French).

Transitions_resizedCare Transitions Measure (CTM-15)® - This 15-item tool assesses the quality of care during transition from the patients' perspective.  The items are rated on a four-point response scale ranging from strongly disagree to strongly agree.  The CTM-15 was developed at the University of Colorado for the Care Transitions Program®.

Home Health Agency Performance Self-Assessment Survey: Patient Transitions and Family Caregiving - This survey helps home care staff evaluate and improve how well they work with family caregivers in planning transitions. A companion survey for family caregivers is also available.  They were developed by the United Hospital Fund's Next Step in Care program.

The Medication Discrepancy Tool (MDT)® - This tool facilitates medication reconciliation for patients transitioning between care settings.  It was developed at the University of Colorado for the Care Transitions Program®.

Transitional Care Model Screening Criteria and Risk Assessment - This one-page checklist is useful for identifying older patients who are at increased risk of rehospitalization when transitioning from hospital to home.  It was developed as part of the Transitional Care Model (TCM).

2. Intervention Tools


For Homecare Professionals
Best Practice Intervention Package (BPIP) - Cross Settings I and II and III - These Best Practice Intervention Packages (BPIPs) from the second phase of the Home Health Quality Improvement National Campaign contain evidence-based tools and resources focused on improving care across provider settings, and on more efficiently managing patients in all provider settings.  The materials are free but log-in is required.

Care Transitions Toolkit - This guide helps organizations implement care transitions improvement efforts.  It includes links, tools, and strategies developed and used by Medicare Quality Improvement Organizations (QIOs) participating in the Centers for Medicare & Medicaid Services (CMS) Care Transitions Theme.

IPRO Discharge Criteria Flyer II - This tool provides a checklist of critical information to include when transitioning patients between care settings. It was developed by IPRO, the Medicare Quality Improvement Organization for New York State.

Patient PASS (Preparation to Address Situations after discharge Successfully): A Transition Record - This one-page tool offers an easy reference to help patients safely transition to home. It was created as part of Project BOOST (Better Outcomes for Older Adults through Safe Transitions)

The Transitional Care Model (TCM)  - This nurse-led intervention was designed to help improve post-discharge outcomes for chronically ill high-risk older adults. The TCM was tested and refined over 20 years by a multidisciplinary team based at the University of Pennsylvania. (Click here to watch a brief video blog by Dr. Mary Naylor, a developer of the TCM, describing the model and how it can benefit home care clinicians).

Transitions_Helping doorWhen Home Care Ends: What Then? Elements for Home Care Providers - This one-page handout is a quick reference for health care providers in working with family caregivers before a patient is discharged from home care. It was developed for the United Hospital Fund's Next Step in Care Program.

For Paraprofessionals
Home Health Aide Action Steps to Reduce Hospitalization - This tool helps home health aides implement key strategies to help patients avoid hospitalizations.

For Patients/Caregivers
A Family Caregiver's Planner for Care at Home  -  This tool helps family caregivers better understand and keep track of the services and supplies that will be provided under the home care plan (also available in Chinese, Russian and Spanish).  It was developed for the United Hospital Fund's Next Step in Care Program.

My Emergency Plan - This teaching tool helps patients or their caregivers recognize warning signs that may indicate a condition is worsening and whether call their home health agency or 911 if they become symptomatic.  It was developed by the West Virginia Medical Institute.

My Medicine List - This tool from the National Transitions of Care Coalition (NTOCC) provides an easy way for patients and caregivers to keep track of and review medications with healthcare professionals (also available in French and Spanish).

Tips to Prevent Medication Discrepancies - This list of practical tips from Florida Medical Quality Assurance, Inc. (FMQAI) can be used for educating providers and patients about preventable medication errors.

Your Discharge Planning Checklist - This six-page discharge planning list from the Centers for Medicare & Medicaid Services (CMS) is for patients preparing to leave a hospital or other healthcare setting.  It prompts patients and caregivers to ask questions about key discharge planning topics.

Your Personal Health Record - This handout helps to facilitate communication and ensure continuity of care planning across providers and settings.

3. Communication Tools


For Homecare Professionals
Ask Me 3™ - This program helps foster effective communication with patients. It encourages patients to ask three simple questions during every medical encounter, and providers to answer them.

Continuity Assessment Record & Evaluation (CARE) Instrument - This internet-based instrument developed by CMS provides an electronic means for a variety of health care providers to rapidly and accurately communicate critical patient information during transitions between care settings. 

CommunicationReview of the SBAR (Situation-Background-Assessment-Recommendation) Technique  - This set of slides briefly summarizes SBAR, an easy-to-remember technique for communicating information requiring action (such as between a home care nurse and a hospital physician referring a patient for services).

SBAR (Situation-Background-Assessment-Recommendation) Worksheet - This one-page worksheet summarizes the four steps of SBAR, an easy-to-remember technique for communicating information requiring action (such as between a home care nurse and a hospital physician referring a patient for services). It can be printed and filled in to help plan an upcoming communication.

Teach-Back Summary Sheet - This one-page handout summarizes an effective communication technique for managers and clinicians to ensure that the information they provide is understood. It was developed for CHAMP's Techniques for Improved Clinical Coaching course.

For Patients/Caregivers
Empowered Patient Coalition SBAR (Situation-Background-Assessment-Recommendation) Form - This version of the standardized communication tool helps patients and advocates relay vital information to health care professionals.

Talking With Your Doctor: A Guide for Older People - This resource was designed to help patients communicate more effectively with their doctor and other health care providers. It includes worksheets to help patients/caregivers prepare for important discussions, including life changes, medications, and other concerns.


4. Guidelines/ Best Practices


Best Practices Evidence Brief: Care Coordination, Management and Transitions - This brief reviews chronic conditions among older home care patients and evidence-based ways to improve care coordination. It describes models for transitions of care and includes ways home care nurses and therapists can implement effective care management interventions with their older patients. It was developed by the Visiting Nurse Service of New York's Center for Home Care Policy & Research as part of a National Framework for Geriatric Home Care Excellence.

How-to Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations (2012) - This resource guide, developed by the Institute for Healthcare Improvement (IHI), supports home health care agencies in improving their care delivery processes in the first 24-48 hours of admission.  It includes tools to test and implement three key promising changes for improving the transition to home.

Improving Care Transitions and Reducing Hospital Readmissions: Establishing the Evidence for Community-Based Implementation Strategies (2010) - This article summarizes implementation strategies for improving care transitions and provides supporting evidence on reducing hospital readmissions.

Seven Essential Intervention Categories - This is a collection of essential care transition intervention strategies.  It is categorized into seven main topics with examples to aid providers in adopting the strategies.  It was developed by the National Transitions of Care Coalition (NTOCC).

To find more free Transitions tools to use with your staff, your patients, and their caregivers, visit the CHAMP Tools page and select "Transitions" from the topics drop-down menu.