Care Transitions Toolkit

Several evidence-based care transitions models have been shown to ensure coordination of care as patients transfer from hospital to home or related settings, thus avoiding re-hospitalization, duplication of services, conflicting recommendations, medication errors, patient/caregiver distress, and higher costs. Connected health technologies have the potential to support care transitions interventions, including those that improve communications among clinicians, patients, and caregivers; medication adherence and reconciliation; patient monitoring; risk assessment; and other related activities.

These tools were contributed by organizations from across the country, Center for Technology and Aging grantees, and consultants and are intended to be easily adapted into practice. The Center for Technology and Aging Care Transitions Grantees include five state Aging and Disability Resource Centers (ADRCs) that are part of an Administration on Aging (AoA) and Centers for Medicare & Medicaid Services (CMS) initiative to help individuals manage their long-term care support services. Indiana and Texas focused on care transitions program planning and evaluation. California, Rhode Island, and Washington expanded the use of personal health record technologies.

This toolkit provides tools to assist organizations that have already adopted or are in process of adopting a care transitions model and want to augment their programs with connected health technologies. Please visit the Resources Page for more information on Care Transitions Models and their respective websites.

Learn more about Care Transitions grantees and programs. >>

Get Started

Tools are organized under eight workstreams: functional areas that simplify the steps required to successfully deploy a technology. Workstreams are not sequential. They often overlap and segue into one another during the course of the deployment journey. Sub-tasks within workstreams further help you quickly find the right tool for the right task. More is on the workstream homepage.

Click ‘more/less’ next to each workstream for a list of guides and tools relating to that area. Each workstream and sub-task has a corresponding guide. Download the guides first prior to reviewing individual tools to obtain an overview and important considerations for implementing technology.

Click on the tool’s title to find more information about each tool, including their description, target audience, and helpful tips. Click on the ‘download tool’ icon to download the tool. (Note: You must be logged in to download tools.)

Connected Health Technologies to Augment Care Transitions Models

This is a sample of connected health technologies that can be used to augment care transitions models and reflects the technologies used by the CTA Care Transitions Grantees.

California: Network of Care website plus electronic PHR used with the Care Transitions Intervention ®

Rhode Island: ER Card – electronic PHR used to promote effective medication management during care transitions

Washington: Shared Care Plan – paper and web-based PHR used with the Care Transitions Intervention ®

Texas: Care Transitions Coaching System Tool used with the Care Transitions Intervention ®

Indiana: GRACE Team Care™ Technologies for Care Assessment and Evaluation used with the GRACE Care Management Program

Care Transitions Toolkit Workstreams

Program Planning [More/Less]

Program Planning reviews program design and change management.

Technology Management [More/Less]

Technology Management covers technology review, technology selection and technology logistics.

Patient Management [More/Less]

Patient Management consists of patient selection, recruitment/enrollment, engagement and program discharge.

Clinical Management [More/Less]

Clinical Management addresses provider engagement and clinical processes.

Financial Management [More/Less]

Financial Management addresses budgeting and ROI Analysis.

Administration [More/Less]

Administration reviews contracting and compliance issues.

Marketing [More/Less]

Marketing covers program promotion and customer support.

Evaluation & Performance Improvement [More/Less]

Evaluation & Performance Improvement examines program and performance measurements around care effectiveness, cost of care, and care experience.