Care Transitions Coaching System


The Care Transitions Coaching System is a Microsoft ACCESS database that is designed for use by certified coaches delivering the Care Transitions Intervention®. The tool allows coaches to enter a new consumer into the system, tracking each contact with the consumer, while also noting or assessing demographic data, patient activation measures, barriers to attaining goals, and other useful information. A publicly available version of the tool, the “Coach database,” was used as a starting point for creation of the Care Transitions Coaching System Tool and is available from the Care Transitions Intervention® Program website at This coaching tool is designed to be used throughout the course of the intervention and to make modifying data and tracking clients quick and easy. Transition coaches generally enter data about their coaching activities and any consumer responses to surveys into the tool after face-to-face interactions and during telephone interactions.


  • Coaches that will use the database to enter and manage information about their Care Transitions Intervention® clients
  • Supervisors of Care Transitions Intervention® programs that will track activity by coach, site of care, or other useful tracking and evaluation measures.

Helpful Tips

  • Review the user guide before entering client information into the Care Transitions Coaching System, which is available in the toolkit:
  • All computers require Microsoft ACCESS 2007 to run this version of the tool.
  • It is recommended that all coaches should save data into the same copy of the tool so data are stored together.
  • The Care Transitions Coaching System Tool should only be used to document activities and not to direct coaching activities.
  • The most favorable outcomes and cost savings from sites using this tool were reported from sites that had limited access to client tracking software and were challenged to develop a tracking system on their own.

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